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Nursing theories as guidance for autonomy support in activities of daily living: a scoping review

BMC Nursing volume 24, Article number: 479 (2025) Cite this article

Abstract

Background

Supporting others with self-care activities lies at the core of nursing practices. While supporting autonomy within essential care is important, there remains a lack of knowledge on what autonomy comprises and how nurses can demonstrate autonomy-supportive behavior. In order to find guidance, we consulted nursing theories that have shaped the profession. This study aims to explore in what way autonomy is described within the nursing theories and how they describe what nurses could/should undertake to demonstrate autonomy-supportive behaviors within activities of daily living.

Methods

A scoping review was performed, in adherence to the Johanna Briggs Institute methodology for scoping reviews, adhering to the EQUATOR guidelines, using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews, PRISMA-ScR, in order to report the scoping review results. Nursing theories were identified through textbooks, PubMed and expert feedback during the period of April to July 2023. No publication year restrictions were applied. Theories (writings that informed, under pinned, or described nursing care) were included if published in English or Dutch. Data extraction was carried out, performing a content analysis using inductive coding to identify categories of autonomy-supportive behavior.

Results

Of 25 nursing theories identified, nine met the inclusion criteria. While none provided explicit definitions of autonomy-supportive behavior, autonomy was described as encompassing being oneself, having freedom and control over one’s life, expressing and making choices, and engagement in carrying out actions. Six categories of autonomy-supportive behavior were identified: being aware of one’s own behavior, respecting individual uniqueness, fostering interpersonal connections, facilitating open communication, allowing the other person to choose the best action, and collaborative guidance and assistance.

Conclusion

This review explored how autonomy is defined in prominent nursing theories and how nurses can foster autonomy in activities of daily living. Despite its central role in healthcare, no consistent definition of autonomy or autonomy-supportive behavior was identified. While nursing theories provide valuable insights, these remain largely theoretical and lack practical applicability. Further research is needed to translate these concepts into actionable strategies for everyday practice.

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Introduction

The term autonomy originates from the ancient Greek auto, meaning “self,” and nomos, meaning “law,” and is a core principle in healthcare [1, 2]. Throughout history, philosophers have engaged in debates regarding the essence of autonomy, leading to the acknowledgement that providing a precise or comprehensive definition is challenging [3,4,5]. Autonomy is often linked with self-determination, freedom of choice, and being able to enact those choices [6,7,8,9]. In healthcare, particularly within nursing, McCormack [6, 7] has explored the concept of autonomy, defining it as the ability of individuals to make independent decisions regarding their care (decisional autonomy) and to act on those decisions (executional autonomy) within their social context. This study adopts McCormack’s perspective on autonomy as its guiding framework.

As individuals age, they often face multiple health conditions and other age-related challenges, leading to an increased reliance on others for managing and performing activities of daily living (ADL) [5, 10]. Nurses hold a pivotal role in providing this essential assistance, positioning them uniquely to foster and support autonomy among those they care for.

In ADL care such as bathing, dressing, and eating, nurses have the chance to support autonomy while managing the difficulties brought on by illness or disability [5, 11]. However, nurses may also inadvertently limit the autonomy of older people by relying excessively on their own past experiences or presuming preferences without consultation [12, 13]. As nursing theorist, Dorothea E. Orem describes within her nursing theory, “Some nurses forget … that nursing is provided for persons” [14]. As such, den Ouden et al. [13] have observed that nurses, although well intentioned, take over the control of more than 51% of the ADL care from older people. Research suggests that caregivers’ support for the autonomy of people correlates with improved physical and psychological well-being [15], while actions undermining autonomy can have a negative impact on self-care and individual identity [16]. It is therefore important to assist nursing staff to enhance older people’s autonomy in their daily care interactions, ensuring that individuals maintain a sense of control and agency over their personal decisions and routines.

The focus on autonomy within nursing practice is in line with wider developments within healthcare policy and practice [17, 18]. Autonomy is mentioned within the 2021 International Council of Nurses Code of Ethics for Nurses [19], is embedded within nursing education for future nurses, and is stated within quality frameworks in Europe [20,21,22]. The quality frameworks in the Netherlands state that autonomy is one of the key principles needed in order to deliver personalized care and support. Despite its prominence in healthcare discourse, ongoing debates persist regarding how autonomy is interpreted and operationalized [5, 17, 23,24,25]. There remains a lack of knowledge regarding what autonomy within ADL care encompasses and how nurses can support autonomy within these care activities [4, 5]. Historically, nursing theories have played a vital role in shaping care practices, fostering a sense of purpose, facilitating professional communication, and providing a theoretical framework for nursing practice [26, 27]. Therefore, a theoretical basis is sought for guidance within the complex dimensions of autonomy-supportive behavior.

Given their central role in guiding nursing practice, we aim to explore in what way autonomy is described within the nursing theories and how they describe what nurses could/should undertake to demonstrate autonomy-supportive behaviors within ADL care.

Method

We used a scoping review methodology to explore how autonomy and autonomy-supportive behavior are described in nursing theories. This approach enabled a broad exploration of nursing theories, streamlining the review process to support policy development and the implementation of targeted interventions for autonomy-supportive practices.

Research aim

Our aim is to explore in what way autonomy is described within the nursing theories and how they describe what nurses could/should undertake to demonstrate autonomy-supportive behaviors within ADL care.

Design

A research protocol was developed in adherence to the Johanna Briggs Institute (JBI) methodology for scoping reviews [28], adhering to the EQUATOR guidelines [29], using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews, PRISMA-ScR [30], in order to report the scoping review results. The PRISMA-ScR checklist is added in the PDF document: Additional File 1 – PRISMA-ScR-Checklist.

Search Methods

To answer the research questions, we subsequently included nursing theories through a search within nursing theory textbooks, an extended search within Internet search engines, and two expert checks.

Searching textbooks for nursing theories

The differences between conceptual models, theories, and frameworks have often been unclear, as they vary in terms of purpose, degree of abstraction, and practical application [27, 31]. Because of this, the research team decided that the focus in this study should be on writings that informed, under pinned, or described nursing care (described as nursing theories within this paper). This could range from frameworks to developed and tested theories.

To establish a theoretical foundation, we began our search by exploring prominent nursing theories, including “Grand Nursing Theories,” which offer the broadest scope for addressing a wide range of concepts and propositions encountered in nursing practice [31].

A comprehensive search to identify which nursing theories are considered “Grand Nursing Theories” (‘leading’ as used from now on), was conducted using Internet search engines. This search did not provide us with a uniform list of leading nursing theories. We did, however, find guidance on websites such as Nursology and Nurselabs. Based on the information shown on these websites, the research team then decided to merge the most common nursing theories into a uniform list of nursing theories. The search was continued within nursing theory textbooks, as they have historically been documented within lengthy writings and books, which may not always be readily accessible through academic databases such as PubMed. To facilitate this, we collaborated with an expert from our university library (Maastricht University, the Netherlands) and conducted a thorough review of nursing theory textbooks [32,33,34,35,36], exploring the diversity and scope of both contemporary and historical nursing theories.

Inclusion and exclusion criteria

To identify relevant nursing theories, nursing textbooks that outlined “leading nursing theories” were examined. Theories that were consistently mentioned across these textbooks were selected for inclusion. To ensure a comprehensive overview, no exclusion criterion was applied based on publication year. Nursing theories were included if they were published in English or Dutch, as these were the languages accessible to the research team.

The research assistants (EM and EvD) coordinated their efforts to review the identified theories. Each research assistant was assigned specific theories to examine. The principal researcher (MBG) reviewed all theories. If autonomy or a synonym of autonomy was referenced within a nursing theory, the theory was included in the study. Conversely, theories mentioning the search term only in the context of professional autonomy were excluded.

To ensure consistency and accuracy, the principal researcher and the research assistants held two meetings to discuss their findings. During these discussions, any discrepancies were resolved, and consensus was reached on the final selection of nursing theories.

Extended search

In order to determine if any nursing theories were missing, we conducted a targeted extended search on Internet search engine PubMed using the following search string: (“nursing theory” OR “nursing theories” OR “leading nursing theories”) AND (“autonom*” OR “self-efficacy” OR “self-determ*” OR “independ*” OR “self-management” OR “self-reliance”). We have used a filter for language: English and Dutch.

This search provided us with Mudd et al. [27], which explored nursing theories for their description of the Fundamental Care Framework. Within their data-extraction, Mudd et al. used subcategories for analysis: (1) Patient participating in their care as a respected and autonomous individual, (2) Nurse and patient share power, and (3) Nurse supporting patient to be in control. Since the research questions and the methodology aligned, the research team decided to compare the list of nursing theories as compiled in paragraph 2.3.1 and added the remaining theories (not already mentioned in our textbook search) as selected by Mudd et al. [27] in the abovementioned categories to strengthen our search. Figure 1 shows the selection process of nursing theories.

Fig. 1
figure 1

Study selection process – following the PRISMA-ScR model [30]

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Expert check

As a final step, an expert check was conducted by two Dutch academics specialized in the field of nursing history, theory and autonomy in nursing care. They were asked to examine the list of the nursing theories included, to identify any potentially relevant theories that might have been missed.

Data extraction

Some nursing theories were available in PDF format [6, 7, 37,38,39,40,41,42,43,44,45]; however, most of the original, full-text theories were only available in book form [46,47,48,49,50,51,52,53,54,55,56,57,58,59,60]. The full texts of the original nursing theories were scanned using Adobe Scan and then saved in PDF format.

We aimed to include nursing theories describing autonomy. As autonomy is a broad concept, we included synonyms of autonomy, as used in the search string, such as self-efficacy, self-determination, independence, and self-management, resulting in the following search terms: “autonom*” OR “self-efficacy” OR “self-determ*” OR “independ*” OR “self-management” OR “self-reliance.” To include nursing theories written by Dutch nursing theorists, we included the Dutch translations of the aforementioned search terms. These synonyms were derived after consultation between the research team, the working group, and expert checks.

The nursing theories were analyzed for their mention of search terms and the found search term(s), and the context in which the search term was mentioned within each nursing theory, were added in an Excel form that included the following categories: “author,” “autonomy and/or synonym,” and “context.” After the screening on the mention of search terms, the principal researcher and the research assistants each assessed the context of the found search terms. The principal researcher and the research assistants each separately analyzed the search terms and the context of the search terms. The context (ADL care) of the search term was analyzed. As leading theories focus on the entirety of the nursing profession, search terms were included if the context in which it was mentioned was also applicable within ADL care. The findings were discussed in one meeting with the research team until a consensus was reached about the inclusion/exclusion of certain nursing theories.

Data analysis and synthesis

The search terms, and the context of the search term (ADL care) within each nursing theory, were analyzed in order to identify what autonomy entailed according to the nursing theories. A content analysis was performed. The principal researcher and one research assistant each independently coded (inductive coding) what autonomy entails according to the nursing theory. This was done in Atlas.ti 23. Codes were compared in several meetings until consensus was reached. Themes that described what autonomy entailed (according to the included nursing theories) were selected through axial and selective coding.

In order to select autonomy-supportive actions from the nursing theories, we conducted a content analysis focusing on extracting actions that contribute to the promotion of autonomy. Using the nursing theories’ descriptions of autonomy (or a synonym of autonomy), actions were derived by scanning the entire nursing theory. The data extraction (inductive coding within Atlas.ti 23) was performed by the principal researcher and one research assistant, using the same method as for the analysis of “autonomy.” The extracted codes were grouped, which led to a thematic summarization of the actions that the nurses need to perform to be autonomy-supportive within essential care.

Results

Theory selection and characteristics

Twenty-five leading nursing theories were identified for screening (as shown in Fig. 1). Most of these theories (21) were developed in the United States, four in Europe: an Irish theory by McCormack [6, 7, 41], a Dutch theory by van den Brink-Tjebbes [59] an English theory by Roper, Logan and Tierney [61], and an Icelandic nursing theory by Halldorsdottir [37].

Chronologically, the theories were developed from 1952 [53] to 2012 [42]: one nursing theory in the 1950s [53, 54], five in the 1960s [38,39,40, 52, 58, 62], four in the 1970s [13, 55, 59, 63], seven in the 1980s [46, 47, 50, 56, 57, 60], five in the 1990s [37, 43, 44, 48, 49, 64], two in the 2000s [6, 7, 41, 45, 65] and one in the 2010s [28].

The most frequently mentioned search term within the nursing theories was “independ*” (18x), followed by “autonom*” (14x). Search terms such as “self-efficacy” and “self-reliance” did not appear within the nursing theories, nor did the Dutch translations of these search terms. Nursing theories that did not mention any of the search terms were excluded (n = 3). If a search term only was cited within the context of professional autonomy, the theory was also excluded (n = 2). The remaining nursing theories were assessed for their applicability within the right context (ADL care and long-term care). This resulted in nine remaining nursing theories. This selection process is depicted in the PDF document: Additional file 2 - Selection of Nursing Theories and Reason for Exclusion.

The nine nursing theories included in the analysis were by McCormack [6, 7], Orem [14], van den Brink-Tjebbes [59], Peplau [53], Travelbee [58], Wiedenbach [66], King [47], Watson [60] and Schoenhofer & Boykin [43]. These nursing theories describe the multifaceted nature of nursing. The significance of centering the care around the care-dependent person and the need for an interpersonal relationship between caregiver and the person is central in the theories of McCormack [6, 7], Peplau [53], Travelbee [58], Wiedenbach [66], Watson [60] and Schoenhofer & Boykin [43]. The nursing theories of Orem [14], van den Brink-Tjebbes [59] and King [47] focus on the goal-oriented aspects of care: supporting the person to achieve in(ter)dependent care.

Autonomy

Four of the nine included nursing theories describe, and use, the term “autonomy”, without providing a definition of autonomy within the document: McCormack [6, 7, 41]; Peplau [53], Travelbee [58] and Watson [60]. The nursing theories that did not include the term “autonomy” but did elaborate on synonyms, were developed by and Orem [14], van den Brink-Tjebbes [59], Wiedenbach [66], King [47] and Schoenhofer & Boykin [43].

The term “independent” is used in the nursing theories of Wiedenbach [66], King [47], and Schoenhofer & Boykin [43]. Orem [14] uses “self-determined,” and van den Brink-Tjebbes [59] is a Dutch nursing theorist and uses the Dutch variation of “independent” and “self-direction” (“zelfstandig” and “regie”)

The coded nursing theories showed that the concept of autonomy in ADL care is broad, comprising four categories: 1) being oneself; 2) having a sense of freedom and control over one’s life; 3) being able to express and make choices; and 4) deliberate engagement in carrying out actions. The PDF document, Additional file 3 - Categories Derived From Codes Mentioned Within Nursing Theories, shows which codes are derived from which nursing theory.

Being oneself

The nursing theories of Watson [60] and Schoenhofer & Boykin [43] emphasize the importance of preserving individual uniqueness and the freedom to be oneself. This individuality lies within the way one conducts oneself to others. Watson’s Human Caring Science stresses the importance by stating the following: “Perhaps the greater danger to one’s humanness in modern society is the loss of one’s self and the loss of one’s capacity and freedom to be oneself” [60].

Schoenhofer & Boykin elaborate on this perspective by emphasizing that the essence of caring lies not in the care activities themselves, but in the individual:

Caring is lived within the moment, and is constantly unfolding … nursing activities are not directed toward healing in the sense of making whole, wholeness is present and unfolding. There is no lack, failure, or inadequacy which is to be corrected through nursing as persons are whole and complete [43].

In alignment with this viewpoint, McCormack’s Person-Centered Care Framework [6, 7] elaborates on the significance of incorporating the patient’s perspective within the care process. McCormack & McCance [41] introduce the term “authentic consciousness,” which involves considering the entirety of a person’s life, encompassing their beliefs, values, views, and experiences. This approach underscores the importance of recognizing and valuing the holistic aspects of an individual’s life in the context of providing care.

Having a sense of freedom and control over one’s life

Watson’s Human Caring Science theory [60] stresses the importance of self-actualization within her nursing: the wish to be autonomous and free from the demands and expectations of others. As Watson states: “Self-actualization includes an inner freedom and control over one’s life to the extent that people are ruled by the laws of their own characters rather than by the rules of society” [60].

In King’s nursing theory, presented as “A theory for nursing: Systems, concepts, process” [47] the importance of individuals exerting power over their environment is described. When an individual’s control over their surroundings is diminished, through alterations in personal space, it changes to their sense of independence.

The ability to express and make choices

Peplau’s Interpersonal Relations in Nursing theory [53] emphasizes creating an environment where individuals can express their wants and needs and participate in collaborative decision-making. The nursing theory of Travelbee [58] and the Person-Centered Care Framework of McCormack [6, 7] also highlight the importance of freedom within the decision-making process.

Travelbee articulates the concept that even when the available choices are not ideal, individuals still retain the freedom to choose and make decisions for themselves. In Travelbee’s perspective, this inherent freedom to choose is a crucial aspect of the Human-to-Human Relationship model in nursing.

McCormack introduces the term “decisional autonomy” within the Person-Centered Care Framework, defining it as the capacity and freedom to choose. They further elaborate on this concept by asserting, “Just because an individual does not have the capacity to carry out a decision does not mean that they do not have a right to be involved in the decision-making itself.” [6]. This underscores the importance of respecting an individual’s right to participate within the decision-making process, irrespective of their ability to execute those decisions, aligning with the principles of person-centered care.

Deliberate engagement in carrying out actions

All theories included describe the importance of actively involving individuals in caregiving. While individuals may need nurse support to achieve certain care objectives, the nurse’s objective is to serve as an extension of the individual, guide them toward interdependence or independence in care rather than fostering dependence. As Orem [14] describes within the Self-Care Deficit theory, individuals actively participate in their own care by consciously taking actions that contribute to their overall health and well-being.

McCormack’s Person-Centered Care Framework [6, 7] introduces the significance of involving the patient within the care process. The concept of “executional autonomy” is introduced, referring to the ability and freedom of the other person in carrying out and implementing choices.

Autonomy-supportive behavior

From the included nursing theories, we distilled actions presented as six categories of autonomy-supportive behaviors within essential care: 1) Being aware of your own behavior; 2) Respecting individual uniqueness; 3) Fostering interpersonal connections; 4) Facilitating open communication; 5) Allowing the other person to choose the best action; 6) Collaborative guidance and assistance. The PDF document, Additional file 3 - Categories Derived From Codes Mentioned Within Nursing Theories, shows which codes are derived from which nursing theory.

Being aware of your own behavior

When providing care, it is important for nurses to be aware of their own behavior in the caregiving process [43, 53, 60, 66]. The first step of this awareness lies within the nurse being conscious of their philosophy and values and how they affect their behavior within the caring process [60]. It is necessary to be aware of the ever-changing dynamics of the nurse-patient relationship that takes place within the caregiving process, in which the other person is dependent on the nurse for essential care, and the power the nurse carries within dependent care [66]. Respect for the other’s freedom and worth is crucial [41, 66]. It is important to have a nonjudgmental attitude toward the other [60] and to adjust the nurse’s behavior to the other [53].

Respecting individual uniqueness

Seven nursing theories describe actions that nurses could use in order to show that they respect the other’s individual uniqueness [14, 41, 43, 53, 59, 60, 66]. According to Schoenhofer & Boykin [43], respecting uniqueness begins with viewing the person as human. This is followed by recognizing the uniqueness of the individual [59, 60, 66] and their values [41]. Peplau [53] describes this in the Interpersonal Relations in Nursing theory as follows: “The nursing process is educative and therapeutic when nurse and patient can come to know and to respect each other, as persons who are alike, and yet, different, as persons who share in the solution of problems” [53]. This includes recognizing the freedom of the other by respecting their dignity within the communicative processes [53, 60].

Fostering interpersonal connections

Establishing an interpersonal connection is essential for effective cooperation [14, 41, 43, 47, 53, 58, 60, 66]. The nurse may achieve an interpersonal connection by getting to know the other [60], by relating to the other as a thinking, feeling person [13], and by entering the world of the other [43]. The start lies at gaining an understanding of what is meaningful and important for the other person: their value base [41, 60]. Gathering information during interactions helps nurses align with the other person’s values and beliefs [53, 59, 66]. The information gathered may help the nurse to act in accordance with the values and beliefs of the other [41, 66]. The ultimate goal is to get to know each other well enough to face the problem at hand in a cooperative way [53].

Gathering insight into the way the other person views the situation helps the nurse in understanding the situation as it is seen by the other person [53] and how they, for example, perceive their illness [58]. As Schoenhofer & Boykin [43] describe within their nursing theory: “In order to know the other, the nurse must be willing to risk entering the other’s world and the other person must be willing to allow the nurse to enter his or her world.” [43]. Truly entering the other’s world involves being aware of your own feelings before tuning into their experiences [43, 53, 60].

Facilitating open communication

Five of the nine nursing theories address “facilitating open communication” [47, 53, 59, 60, 66]. The different nursing theories describe that communication can be achieved by offering the other person room for communicating, by listening to the verbal cues of the other [47], and by observing their body language in order to recognize a need for help [59, 66]. Watson’s Human Caring Science theory [60] highlights the importance of demonstrating actively listening through appropriate responses to (non)verbal cues. Quoting Peplau [53] on the importance of communication:

Only the patient knows what his needs are and he is not always able to identify them … Paying attention to the needs of patients, so that personalities can develop further, is a way of using nursing as a “social force” that aids people to identify what they want … Progressive identification of needs takes place as nurse and patient communicate with one another in the interpersonal relationship [53].

Allowing the other to choose the best action

Eight of the nine nursing theories mention autonomy-supportive actions that encompass giving space to the other person in order to allow them to choose the best actions for themselves [14, 41, 43, 47, 53, 59, 66] at any given time [60]. McCormack & McCance [41] state that “[nurses need to] move beyond a focus on technical competence, [which] requires nurses to engage in authentic humanistic caring practices that embrace all forms of knowing and acting to promote choice and partnership in care decision-making.” [41].

In order to achieve the promotion of choice, it is recommended that the nurse not only provide information [41] but also clarify what this information entails and how this could be of importance for the other person [58,59,60, 66]. By presenting information in this way, the nurse can aid the other person in identifying what they want [53].

As described in paragraph 3.3.4, Facilitating Open Communication, open communication is crucial for understanding preferences and planning actions [53, 59]. This collaboration within the decision-making process is achieved through promoting choice and by negotiating decisions [14, 41, 47].

Collaborative guidance and assistance

Six of the nine nursing theories address “guidance and assistance” [14, 41, 53, 59, 60, 66]. These theories detail tasks like providing guidance, support, and teaching to help individuals meet their care needs. As Orem [14] describes within the Self-Care Deficit Theory: “The relation of nurse to patient is complementary. This means that nurses act to help patients act responsibly for their health-related self-care by making up for existent health-related deficiencies in the patients’ capabilities for self-care ….” [14].

In order to permit the other person to be an active participant within the care, the nurse can facilitate this through information giving [41, 53] and through actively encouraging the other to participate [53, 59]. The aim is to enable individuals to use their capacities and to function cooperatively within the caregiving process [13, 53]. This involves clarifying goals, responding to cues for help, and validating that the help that was provided has fulfilled its purpose [53, 66].

Discussion

This study aimed to explore in what way autonomy is described within the nursing theories and how they describe what nurses could/should undertake to demonstrate autonomy-supportive behaviors within ADL care. The nursing theories included generally do not define autonomy, and when they do, the definitions vary. A concept analysis of codes within the nursing theories showed categories of autonomy, such as being oneself, having a sense of freedom and control over one’s life, being able to express and make choices, and deliberate engagement in carrying out actions. The concept of autonomy-supportive behavior is also not described as such. Drawing from all nine nursing theories included, we identified six categories that outline the actions nurses could/should take to promote autonomy-supportive behaviors in ADL care: 1) Being aware of your own behavior; 2) Respecting individual uniqueness; 3) Fostering interpersonal connections; 4) Facilitating open communication; 5) Allowing the other person to choose the best action; 6) Collaborative guidance and assistance.

Within literature, autonomy is described as a broad, complex, multifaceted, and relational concept [4, 5, 67,68,69,70]. Terms such as self-governing, self-directing, freedom, independence, self-determination [4], and self-initiated behavior, freedom and individuality [67, 68] are used to outline autonomy. Agich [68] presented an ethical framework for autonomy in old age, in which he emphasizes that autonomy involves aligning with what individuals truly identify with. Rather than putting together a specific definition of autonomy, and considering the different viewpoints, this study acknowledges that autonomy is a broad philosophical concept consisting of being oneself, having a sense of freedom and control over one’s life, being able to express and make choices, and deliberate engagement in carrying out actions.

In recent years, calls to respect individual autonomy have grown alongside a paradigm shift from the traditional medical model of healthcare to a more person-centered approach to care [71,72,73]. This study focuses on autonomy-supportive themes within the nurse-patient relationship, recognizing that autonomy in caregiving involves understanding and engaging with the individual’s preferences and actions [69]. Literature consistently underscores the significance of active involvement in decision-making processes and engagement with caregivers [4, 5, 70]. Under the influence of this change to person-centered care, more focus is given to the autonomy within ADL care [17, 74]. Besides the healthcare shift towards more person-centered care, there is also a shift toward more interprofessional care, family-centered care, and transmural care [75,76,77]. Different people are involved within the essential caregiving process, which increases the importance of the care triad between resident, formal caregiver(s), and informal caregiver [78]. While this study focuses on nurses, it is important to acknowledge that autonomy-supportive behavior is not a concept limited solely to nurses and caregivers; instead, it is an interprofessional concept that influences and is influenced by other disciplines and volunteers, as well as by family and other individuals. While this study focuses on nurses, the findings may be relevant to a wider audience. Recognizing the roles of other disciplines, family members, and others can help nursing staff engage in collaborative learning and reflection. Furthermore, it is essential for other healthcare professionals, including physicians, to acknowledge the significance of the contributions of nurses and to integrate their insights into the holistic care plan [79]. The findings of this scoping review on supporting autonomy could help facilitating shared decision-making, particularly in situations where individuals, such as those with dementia, may be unable to make decisions for themselves [80,81,82].

While healthcare has increasingly shifted toward person-centered care, and the complexity of care has risen, the development of nursing theories has stagnated. The most recent nursing theory included within our data-analysis dates to 2012, highlighting a significant concern about the current trajectory of the nursing profession. Hughes [83] emphasizes the growing dominance of quality frameworks, which may be contributing to this stagnation. Nursing theories have faced criticism for being perceived as lacking practical applicability [26], indicating a potential disconnect between what nursing students learn in academic settings and what they encounter in clinical practice [27, 84].

Concluding, there is a lack of rigorous studies to evaluate whether widely cited nursing theories truly address essential questions regarding the relationships between individuals, their health, and the core principles of nursing. This raises concerns about overreliance on such frameworks, which may push nursing towards a more medically oriented model, potentially undermining the person-centered, holistic approach that is central to modern care. Without critically assessing how these theories define and guide nursing’s scope of care, the discipline risks failing to develop strong theoretical foundations that are well-suited to its unique role in healthcare.

Strengths and limitations

A notable strength of our study is the comprehensiveness of our search which allowed us to include a wide range of nursing theories without restricting publication dates. This approach enhanced the comprehensiveness of our findings.

However, several biases may have affected our results. First, there is the possibility of data collection bias, stemming from our decision to focus on nursing theories, which may have caused the exclusion of frameworks and. Including frameworks could have provided different insights. Additionally, bias may have been introduced during data analysis using specific keywords. Given the age of the nursing theories included in our analysis, different word choices could have produced varied results. Furthermore, condensing extensive nursing theories into search terms and brief texts may have introduced confirmation bias, emphasizing information that supported our research questions.

To mitigate biases, we employed three distinct methods for including nursing theories and sought expert review of both the theories and our methodology. Despite these measures, some bias may still have affected our selection process. Additionally, summarizing extensive nursing theories into concise keywords raises questions about whether we fully captured the essence of the theories.

Implications for practice, education, and research

Even though the nursing theories did not provide us with the concrete answers we were aiming for, we did find guidance within the complex dimensions of autonomy-supportive behavior with the distilled four themes of autonomy and six themes that describe autonomy-supportive behaviors. This study offers insights into the concept of autonomy and autonomy-supportive behavior within the essential caregiving process. It sheds light on the theoretical underpinnings of autonomy-supportive behaviors, providing an understanding of their components. However, further research is needed to deepen our understanding of the six identified themes of autonomy-supportive behaviors. While this study outlines the theoretical framework, it leaves open questions about how these behaviors manifest in real-world nursing care settings.

Additionally, there is a need to explore how care recipients experience these behaviors when performed in practice. Understanding the practical application of autonomy-supportive behaviors and their impact on both caregivers and the other person is crucial for refining caregiving practices and enhancing the quality of care provided.

The identified themes of autonomy and autonomy-supportive behaviors serve as valuable theoretical foundations for guiding future nursing education. However, it is important for educational programs to first emphasize the practical application of these concepts, to bridge the gap between theory and practice. Future research should focus on closing this gap, contributing to the development of more effective, person-centered care approaches.

This need is particularly relevant given the decline in the publication of nursing theories over the years, as the focus in nursing has shifted from these theories to quality frameworks for guiding practice. While these frameworks provide structure, they are often less detailed in addressing the nuances of autonomy-supportive behaviors, leaving a gap that theoretical knowledge could fill. This shift away from theory is partly due to the perception that nursing theories are lengthy and challenging to apply in daily practice. Consequently, there is a risk that nursing priorities become overly aligned with the goals of these frameworks, which may not always prioritize autonomy support within the caregiving process.

Although quality frameworks emphasize autonomy, they often lack detailed explanations of what this entails; creating a gap that could be filled with theoretical knowledge of nursing theories. However, without updates to suit modern caregiving practices, older nursing theories risk becoming outdated and less practical.

Therefore, research should aim to develop theories that clearly describe and focus on supporting autonomy in nursing practice. This will help bridge the gap between theoretical knowledge and practical application, ensuring that nursing practice remains effective and person-centered.

Conclusion

This scoping review aimed to explore in what way autonomy is described within the nursing theories and how they describe what nurses could/should undertake to demonstrate autonomy-supportive behaviors within ADL care.

Through reviewing the leading nursing theories, we identified that even though autonomy is a key concept within healthcare practice, there is no uniform description of what autonomy encompasses, or mention of what autonomy-supportive behavior is. Nevertheless, nursing theories do provide guidance for autonomy and autonomy-supportive behavior within ADL care.

These findings provide an initial insight but are not yet operationalizable. Future research should aim to further develop and refine the categories to make them more applicable in practice.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

We extend our gratitude to the librarians who provided invaluable assistance in locating and accessing critical data for our study. This expertise was instrumental in shaping our research. We also acknowledge ZonMW for their financial support, which made this study possible.

Funding

The scholarship resulting in this article was conducted with funding received from ZonMW (10040022010005).

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Authors and Affiliations

  1. Living Lab in Ageing and Long-Term Care, Department of Health Services Research, CAPHRI, Faculty of Health, Medicine and Life Science, Maastricht University, Duboisdomein 30, Maastricht, GT, 6229, The Netherlands

    Melissa Botana Gronek, Michel Bleijlevens, Stan Vluggen, Esmee Moonen, Aileen Van Dijk, Petra Erkens, Sandra Zwakhalen, Jan Hamers & Judith Meijers

  2. Zuyderland Medisch en Zorgconcern, Zuyderland Care, Parklaan 10, Sittard, KG, 6131, The Netherlands

    Melissa Botana Gronek & Judith Meijers

  3. Zuyd University of Applied Sciences, Academy of Nursing, Nieuw Eyckholt 300, Heerlen, DJ, 6419, The Netherlands

    Stan Vluggen

  4. Land van Horne, Werthaboulevard 3, Weert, HZ, 6001, The Netherlands

    Esmee Moonen

  5. Envida, Abtstraat 2a, Maastricht, LS, 6211, The Netherlands

    Aileen Van Dijk

  6. MeanderGroep Zuid-Limburg, Mickelersstraat 2, Landgraaf, PP, 6372, The Netherlands

    Jan Hamers

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PE acquired the funding. MBG, MB, SV, JH and JM designed the study. MBG, EM and AvD performed the data collection. MBG, MB, EM, AvD and JM analyzed and interpreted the data. MBG, MB, SV, PE, SZ, JH and JM prepared the manuscript. All authors approved the final version for submission.

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Botana Gronek, M., Bleijlevens, M., Vluggen, S. et al. Nursing theories as guidance for autonomy support in activities of daily living: a scoping review. BMC Nurs 24, 479 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-02990-5

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