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Chapter 2: Literature Review
(1967). The researchers found that nurses use three distinct strategies for solving
ethically difficult care situations: negotiation, explanation and restraint. The nurses
related the strategy of negotiation with autonomy and stated that this was their
preferred strategy for respecting patient autonomy. It is recognised that this research
was only undertaken in care homes that fulfilled the Norwegian quality regulations.
However, both of these studies (Davies, Ellis and Laker, 2000; Slettebo and Bunch,
2004) identify negotiation strategies as integral to operationalising autonomy.
Slettebo and Bunch (2004) state that patients in nursing homes sometimes give
accounts of episodes in which they feel their autonomy and/or self-respect is violated
as a result of the care they receive from nursing staff. They suggest that further
research needs to be undertaken that explores the meaning of autonomy for older
people in residential care and the ways it can be truly operationalised.
Proot et al. (2002) stated that the majority of studies regarding patient autonomy are
based upon theoretical reflections and not on empirical evidence. Proot et al. (2002)
explored autonomy in stroke rehabilitation. Their aim was to pinpoint which
dimensions of autonomy are identified by care providers and to determine which
factors, in their opinion, influence patient autonomy during the stroke rehabilitation
process in nursing homes. A qualitative research method was adopted and grounded
theory was used to explore the care providers’ views. Twenty-seven members of
multi-disciplinary teams from three nursing homes in The Netherlands were
interviewed. The interview guide was designed from a previous study and from a
literature review. It was piloted prior to use. Detailed description of the analysis was
provided. It was found that autonomy exists in dimensions and that it can be
constrained or facilitated by patient factors and environmental factors. The
dimensions of autonomy include self-determination, independence and self-care, and
these change during stroke rehabilitation. Patient factors were also revealed to
influence autonomy before a stroke (life history, activity rate, character and multi-
morbidity) and after a stroke (disabilities, multi-morbidity, emotional state and
expectations of the nursing home and of the future). The environmental factors that
affect patients’ autonomy include the approach and strategies of care providers and
families, and the nursing home. Proot et al. (2002) explain that the dimensions of
autonomy, the patient factors and the environmental factors are related to each other.
Strategies that Proot et al. (2002) identified for facilitating autonomy included