The operationalization of autonomy in qualitative studies of persons living with dementia: A scoping review

The operationalization of autonomy in qualitative studies of persons living with dementia: A scoping review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The operationalization of autonomy in qualitative studies of persons living with dementia: A scoping review Avery Jesse Beavers, Erin Leigh McKenzie, Andrew Douglas Heslop Stumpf This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7190181/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 22 You are reading this latest preprint version Abstract Background The concept of personal autonomy is fundamental to person-centred care, particularly for persons living with cognitive impairments due to conditions such as dementia. Many empirical studies investigating autonomy in persons with dementia do not provide consistent and theoretically grounded definitions of the term “autonomy,” leading to a problematic lack of conceptual clarity. Objective The aim of this study is to identify and assess definitions of autonomy in qualitative research that considers the phenomenon of autonomy in persons living with dementia. Methods A scoping review was completed in PubMed, Embase (Ovid), Scopus and APA PsycNet. Keywords included terms within the content areas of dementia and autonomy. Inclusion criteria were as follows: mentions of autonomy, participant population with cognitive impairment, adult participants, and qualitative methodology. Included studies were assessed according to whether descriptions of autonomy (if provided) addressed important dimensions of autonomy, namely decisional autonomy, executional autonomy, and authenticity. Results Among 65 eligible articles, the majority (77%, n = 50) provided no definition of autonomy. Of those that did define autonomy, only 5 (8%) addressed all three dimensions of decisional autonomy, executional autonomy, and authenticity, while 6 (9%) addressed two dimensions, and 4 (6%) addressed only one dimension. Conclusions Autonomy is inconsistently and incompletely defined in empirical literature on dementia, with most studies lacking careful theoretical grounding. This conceptual ambiguity hampers research synthesis, impedes clinical application, and potentially undermines the development of effective autonomy-supporting interventions. Consistent operationalization of personal autonomy is necessary to advance research and improve care for persons living with dementia. Dementia Alzheimer’s disease cognitive impairment autonomy agency scoping review qualitative Figures Figure 1 1.0 Introduction Personal autonomy is fundamental to well-being for people living with dementia, who consistently identify its maintenance as crucial to their quality of life (Serbser-Koal et al. 2024 ). Supporting personal autonomy is central to person-centered care for older adults experiencing declining functionality, and particularly for persons living with dementia. Numerous empirical studies published in recent years that purport to consider the experience of autonomy in persons living with dementia lack consistent and theoretically grounded definitions of the term ‘autonomy.’ This conceptual ambiguity is problematic given that autonomy is a complex and contested concept with multiple dimensions (Collopy 1988 ). Many empirical studies implicitly assume a common understanding of autonomy without making their conception explicit, or substitute related but non-equivalent terms such as ‘independence,’ ‘competence,’ or ‘agency.’ This undermines the comparability of findings of individual studies of autonomy in persons with dementia and synthesized review studies. Furthermore, incomplete or inconsistent definitions of autonomy in research can result in interventions that fail to effectively address all aspects of personal autonomy that are important to people with dementia, potentially impacting their quality of life. A carefully articulated, common understanding of the meaning of autonomy for persons living with dementia could help synthesize and contextualize new and previous studies to better inform autonomy-promoting and quality-of-life-enhancing interventions. This scoping review begins to address this gap by systematically examining how autonomy is defined and operationalized in qualitative research involving persons living with dementia. By analyzing existing definitions against a comprehensive theoretical framework that encompasses decisional autonomy, executional autonomy, and authenticity (Stumpf, McKenzie and Beavers, under review), we aim to clarify the current state of conceptualization and highlight implications for research, policy, and clinical practice. 1.1 Background Dementia is a clinical syndrome characterized by progressive cognitive decline that interferes with daily functioning (Duong et al. 2017 ). While traditionally associated with memory impairment, current diagnostic criteria recognize that dementia can manifest with deficits in various cognitive domains, including executive function, language, and visuospatial abilities (Duong et al. 2017 ). Mild cognitive impairment, although condition distinct from dementia, may be a precursor to further cognitive deterioration in some cases and impacts cognitive domains in a similar, though less pronounced, manner (Knopman and Petersen 2014 ). Individuals experiencing cognitive dysfunction often experience difficulties with decision-making, judgment, and reasoning, which can impact their ability to exercise personal autonomy (Duong et al. 2017 ). Personal autonomy has been conceptualized in various ways, but a comprehensive understanding requires recognizing its multidimensional nature. Our framework, based on both philosophical literature and empirical research (Stumpf, McKenzie and Beavers, under review), identifies three essential dimensions of personal autonomy for persons with dementia: decisional autonomy, executional autonomy, and authenticity. Decisional autonomy refers to the capacity to set goals and make choices, encompassing the cognitive functions involved in deliberation and judgment (Cardol et al. 2002 ). This dimension is often emphasized in healthcare contexts, particularly around informed consent and medical decision-making. Executional autonomy, on the other hand, involves the ability to translate decisions into actions, including communication skills, motor control, and practical reasoning abilities invoked to implement one’s choices (Cardol et al. 2002 ). Existing dementia care research recognizes, to a greater or lesser extent, decisional and executional elements. The relevant philosophical literature, however, suggests a more nuanced understanding that incorporates an important third dimension, namely authenticity (Marceta 2018 ). Authenticity relates to a person’s ability to recognize their choices and actions as truly their own, aligning with their stable preferences, deeply held values, and sense of self (Jaworska 1999 ; Dworkin 1994 ). This dimension distinguishes between choices that have been critically reflected on and endorsed by a person versus those resulting from undue influence or coercion. For persons living with dementia, all three dimensions can be affected, but not necessarily simultaneously or to the same degree. Memory loss and cognitive changes may challenge decisional capacity, physical symptoms may hinder executional abilities, and personality changes may complicate authenticity. Yet research suggests that many individuals with dementia can continue to exercise meaningful autonomy with appropriate support (Fetherstonhaugh et al., 2013 ). Therefore, our study utilizes a three-dimensional framework of decisional, executional, and authentic autonomy proposed by our research group (Anonymized for Review) with consideration to the relational context in which personal autonomy is exercised. This approach provides a comprehensive framework of personal autonomy and is particularly relevant to the complex challenges faced by persons living with dementia in maintaining self-governance. Previous scoping reviews have focused on specific aspects of autonomy, such as shared decision-making or relational autonomy (Le et al. 2023 ; Mattos et al. 2023 ). In contrast, this study aims to address a critical gap in the literature by comprehensively examining how the phenomenon of personal autonomy is operationalized and measured in qualitative research that specifically focuses on persons living with dementia. Unlike previous reviews, our study emphasizes the importance of theoretical grounding in defining autonomy and considers a more complete conceptualization of the phenomenon. Studies of autonomy in persons living with dementia commonly operationalize autonomy by using seemingly synonymous terms, often left undefined. This approach is problematic for several reasons. For instance, ‘independence’ is sometimes used interchangeably with autonomy, but this term ignores the relational aspect of autonomy, which is crucial when considering persons with dementia who often rely on others for support. Relational approaches to autonomy demonstrate that autonomy is compatible with various levels of dependence, and may even necessitate interdependence, as we are all fundamentally dependent beings (Mackenzie 2000 ). ‘Agency’ is perhaps the term most closely linked in meaning with ‘autonomy,’ often described as the capacity to act or exert power. However, conceptions of agency tend to neglect the dimension of authenticity, which must be recognized to fully appreciate the complexity of autonomy in persons with dementia. The mere fact that an individual has acted on a decision does not render that action autonomous; the decision must also cohere with the individual’s character and core values and occur without undue coercion (Schlosser 2019 ; Ryan and Ryan 2019 ). While ‘competence’ and ‘capacity’ are importantly related to autonomy, they are often associated with high-stakes medico-legal decision-making. Using these terms as substitutes for personal autonomy risks overlooking the more mundane decisions and everyday experiences relevant to autonomy for persons with dementia (Hawkins and Charland 2020 ). Moreover, these terms may only refer to a subset of the capacities that constitute personal autonomy. For example, ‘decision-making’ focuses solely on the decisional dimension of autonomy, neglecting other important dimensions, such as executional autonomy (Naik et al. 2009 ). The uncritical substitution of terms like ‘self-determination’ and ‘self-governance’ for personal autonomy tends to frame the issue in terms of defending a person’s moral or legal rights rather than supporting their capacity to decide and act authentically. There is significant need for a shared theoretical understanding of personal autonomy that goes beyond the substitution of terms that do not fully capture the phenomenon and are often as ambiguous as ‘autonomy’ itself. Conversely, studies may use one or another of these synonyms while considering all the relevant dimensions of personal autonomy but refraining from using the exact expression ‘personal autonomy’ (Christman 2018), making it uncertain whether different researchers in this field are investigating the same phenomenon. A consensus on the use of these terms and the relationships between them is necessary to ensure the comparability and usefulness of the body of research being produced. Our review focused primarily on qualitative or mixed-methods research offering rich descriptions of the lived experience of persons with dementia to investigate whether ‘personal autonomy’ was clearly defined and understood among researchers and participants. Furthermore, in our review, we paid particular attention to how philosophical foundations influenced the conceptualization and operationalization of autonomy in persons with dementia, as these theoretical bases crucially affect understandings of complex concepts like personal autonomy in social sciences research. 2.0 Methods The scoping review was conducted by two researchers under the guidance of the Principal Investigator on the (Anonymized for Review) Project at (Anonymized for Review). We developed this scoping review following the methodological framework described by Arksey and O'Malley (2005) and refined by Levac et al. ( 2010 ). Scoping reviews are particularly appropriate for mapping key concepts and identifying gaps in research areas where existing literature has not been comprehensively reviewed (Peters et al. 2020 ). Once the researchers agreed on the keywords and specific terms, one of the researchers (Anonymized for Review) performed the search in PubMed, APA PsychNet, Embase (Ovid), and Scopus in June 2024. Eligible studies included peer-reviewed articles published within the last 20 years (2004–2024). The PubMed search used the following terms: (dementia OR “dementia” [mesh] OR Alzheimer OR “Alzheimer disease” [mesh] OR “mild cognitive impairment” OR “cognitive dysfunction” [mesh]) AND (autonom* OR “personal autonomy” [mesh] OR agency) AND (qualitative OR mixed?method*). After the initial search across the four databases, all results were exported into the citation manager, Zotero (version 6.0.37), where duplicates were removed. The remaining unique citations were then screened, first considering both title and abstract, and then full text, within the citation manager. Studies that only used terms such as ‘decision-making,’ ‘capacity,’ ‘competence,’ and ‘independence’ without explicit mention of ‘autonomy’ were excluded from our database search criteria. While these concepts are often closely related to autonomy in the context of dementia care, our primary focus was on how autonomy itself is operationalized in the literature. We assumed that studies specifically investigating autonomy, with the explicit aim of informing further research or interventions to promote autonomy and well-being in persons living with dementia, would likely include at least one instance of the term ‘autonomy,’ particularly considering the growing popularity of autonomy-supportive care interventions in research and policy (Li 2023 ; van der Weide et al. 2023 ). The deliberate exclusion of these related terms in the database search served a dual purpose. Firstly, it allowed us to maintain a focused examination of how researchers conceptualize and define autonomy when it is the primary subject of investigation. Secondly, it helped to ensure that researchers are distinguishing autonomy from related but non-synonymous concepts, as papers that do not include the term autonomy anywhere within the text may not be explicitly studying autonomy. This approach aligns with our overarching goal of understanding how autonomy is conceptualized and measured in qualitative research involving persons living with dementia. We hope to shed light on the implications of these conceptualizations for understanding the needs of persons living with dementia and the subsequent development of person-centered and autonomy-supportive care interventions. 2.1 Title/Abstract Screening Two researchers performed the title and abstract screening, ensuring a comprehensive and rigorous review. Two researchers (Anonymized for Review) independently screened all articles using predetermined inclusion criteria. The inclusion criteria were designed to capture studies that focused on autonomy and related concepts in the context of cognitive impairment, while employing qualitative social scientific methodologies. The search terms included variations of “autonom*,” “agency,” “self-determination,” “capacity,” “competence,” “decision-making,” “dependence,” and “independence.” Additionally, studies needed to focus on conditions such as dementia, Alzheimer’s disease, or mild cognitive impairment (MCI). Finally, to ensure the inclusion of social science methodologies, we looked for mentions of qualitative research techniques such as interviews, focus groups, observation, or narrative analysis. All articles were jointly assessed by the two researchers, with any disagreements resolved through discussion and consensus. This approach aligns with recommended practices for scoping reviews, ensuring a thorough and unbiased screening (Peters et al. 2020 ). 2.2 Full-Text Screening After the title and abstract screening, the two authors (Anonymized for Review) jointly assessed the full text of each article that had passed the initial stage, applying a stricter set of inclusion criteria to ensure the studies aligned with the focus of the review. This phase involved verifying that the articles included direct responses from persons with cognitive impairment or their informal caregivers. Additionally, only studies that utilized qualitative research methodologies, such as interviews or narrative approaches, were considered. The review required that papers be either original research articles or synthetic reviews. During this stage, articles were excluded for various reasons. If only the abstract was available, we judged that this did not provide enough detail for further consideration. Articles were excluded if their participant population did not include persons with cognitive impairment or their informal caregivers. Studies were also dismissed if they lacked a focus on autonomy or related concepts, as determined by whether ‘autonomy’ or any related terms were included within both the introduction and the findings of the study. The requirement for a robust focus on autonomy ensured that the studies we examined interpreted qualitative data in order to draw conclusions about autonomy based on an expressed (or unexpressed) conceptualization of autonomy, which constituted the subject of our review. Therefore, papers that simply offered a cursory mention of autonomy in the introduction or conclusion but did not engage in deliberate interpretation of ‘autonomy’ based on participant responses, were excluded. Articles not published in English were excluded to maintain consistency in the review. The careful application of these criteria ensured that only the most relevant studies were included in the final analysis. 2.3 Data Extraction and Analysis The team compiled a final list of articles and then created a table summarizing key findings from the studies included. Data were organized and visualized using Excel. The autonomy components were categorized into three key areas: decisional, authenticity and executional, based on a conceptual review of central components of autonomy conducted by our research group (Anonymized for Review). No predefined hierarchy was applied to these categories; to illustrate, we did not interpret a definition that included ‘decisional’ and ‘executional’ dimensions as superior to one which included ‘decisional’ and ‘authenticity’ dimensions. Rather, definitions were considered to be more or less comprehensive depending simply on the number of important dimensions covered. 3.0 Results 3.1 Search Results The initial search retrieved 2077 articles (PubMed (n = 432), Scopus (n = 787), Embase (n = 477), and APA PsycNet (n = 381). Figure I displays a modified PRISMA Flow Diagram. Before title and abstract screening, 518 duplicates and 7 records were removed for other reasons. Following the abstract screening, 1172 articles were excluded. Full-text screening was applied to 373 articles, after which 308 were excluded based on the following reasons: an absence of autonomy as a central topic (n = 207), incorrect participant population (n = 88), incorrect paper type (n = 8), not in English (n = 4), and incorrect methodology (n = 1), The total number of articles included was 65. 3.2 General Findings Our scoping review included 65 studies that examined various dimensions of personal autonomy in persons living with cognitive impairment through qualitative and mixed-methods approaches. Only two studies included participants with MCI in addition to those with dementia; therefore, moving forward, we will discuss the patient population as ‘persons living with dementia’ as this describes the vast majority of the review sample. Table I indicates, for each study included, whether a definition was provided and, if so, which of the three dimensions of autonomy were included. In Table I, “Definition” referred to whether the article contained a definition of autonomy. “Decisional”, “Authenticity”, and “Executional” referred to the dimensions of autonomy that we looked for when assessing the comprehensiveness of definitions, if one was given. A summary of findings, including the number of studies providing no definition, one-dimensional definitions, two-dimensional definitions, and three-dimensional definitions, is provided in Table II. More than three quarters of the studies included (77%) offered no definition or explanation of ‘autonomy’ of any kind. Among studies that provided a definition, only 5 (8% of total studies) provided definitions addressing all three core aspects of autonomy (decisional, authenticity, and executional). Six studies (9%) defined autonomy using two dimensions, while 4 studies (6%) used just one dimension. 3.3 Studies with No Definition of Autonomy Among studies without a clear definition (n = 50), several patterns emerged. Many of the studies that did not provide a clear definition of autonomy used ‘autonomy’ interchangeably with related terms which, while potentially relevant, do not appropriately operationalize autonomy. Some studies, such as Bollig et al. ( 2016 ) and Burgon et al. ( 2023 ), mentioned autonomy in their results but did not provide a working definition in their methodology or introduction. Others, such as Boyle ( 2017 ) and Chung et al. ( 2017 ), used terms like ‘independence’ or ‘agency’ interchangeably with autonomy, without distinguishing between these concepts. A few studies, including Davison et al. ( 2019 ) and Eriksen et al. ( 2022 ), discussed autonomy in relation to decision-making processes but did not explicitly define what they meant by autonomy in the context of their research. Similarly, studies like Genoe et al. ( 2010 ) and Phinney et al. ( 2007 ) discussed autonomy in relation to identity, meaningful activities, and independence but did not provide a clear definition of the concept itself. Rapaport et al. ( 2020 ) provided a circular description of autonomy as independence and “independence as an expression of autonomy” (p. 2). This definition used undefined terms to describe each other, which resulted in this paper being evaluated as having no definition of autonomy. 3.4 Studies with One-Dimensional Definitions of Autonomy A small portion of the studies (6%, 4 out of 65) operationalized autonomy using a single dimension, each of which focused solely on decisional autonomy, with none focused on executional autonomy or authenticity alone. Fetherstonhaugh et al. ( 2019 ) discussed autonomy in the context of “the importance of decision-making to exercising one’s autonomy, independence, and a sense of self for people with dementia” (p. 1220). This definition emphasizes the role of the decisional dimension in autonomy but does not address the executional or authenticity dimensions. Similarly, Samsi and Manthorpe ( 2013 ) related autonomy to “the ability to exercise choice,” which “contributes to autonomy and quality of life” (p. 949). They noted that while people with dementia and their carers rarely used the term ‘autonomy,’ they described the importance of maintaining control over decisions. Stevenson et al. ( 2019 ) also emphasized the decisional aspect, stating that “involving individuals with dementia in decisions about their everyday life and care is central to preserving autonomy, quality of life and personhood” (p. 1109). 3.5 Studies with Two-Dimensional Definitions of Autonomy Six of the studies (9%, 6 out of 65) defined autonomy using two dimensions. The majority of two-dimensional definitions (4 out of 6) focused on both decisional and executional aspects of autonomy. For example, Boyle ( 2013 ) described autonomy as involving both “support with decision-making” and “executing their decisions” (p. 555). Similarly, Caradec and Chamahian ( 2017 ) referenced Collopy’s ( 1988 ) distinction between ‘decisional autonomy’ and ‘autonomy of execution’ as the basis for their definition of autonomy, which was the “power to decide for oneself” (p. 939). This approach was also seen in Rommerskirch-Manietta et al. ( 2023 ), who defined autonomy as “having control over one’s own behaviors and goals” (p. 211), encompassing both decisional (goals) and executional (behaviors) aspects. The final paper within this group was Thorsen et al. ( 2020 ), which refers to Fox et al. (2005)’s version of autonomy as “liberty, self-government, self-determination, immunity from arbitrary exercise of authority, choice and freedom” (p. 888). The other two studies combined decisional autonomy with authenticity. Sampson and Clark ( 2016 ) defined autonomy as “individuals entitled to make fundamental choices about what constitutes the good life (for them)” (p. 1607), incorporating both decision-making and alignment with personal values. Similarly, Alsaeed et al. ( 2021 ) conceptualized autonomy as “a person’s ability and opportunity to make decisions relating to his/her own wishes” (p. 2), also addressing aspects of both decisional autonomy and authenticity. 3.6 Studies with Three-Dimensional Definitions of Autonomy Only 8% of the studies (5 out of 65) addressed all three dimensions of autonomy. By our assessment, these studies provided the most comprehensive conceptualization of autonomy, recognizing its complex and multifaceted nature in the context of dementia. Bentwich et al. ( 2018 b) defined autonomy as “patients exercising control over their choices and life, being informed and understanding their situations, encouraging and preserving their independence, and emphasizing privacy. Additionally... exercising religious beliefs and rituals are understood as reflecting part of the patient’s life and choices” (p. 124). This definition incorporates decisional aspects (making choices), executional aspects (preserving capacity to act independently), and authenticity (beliefs and rituals). Hoek et al. ( 2020 ) provided another comprehensive definition, describing autonomy as “one’s ability to live the life one wants to live” (p. 1600). The authors also stated that “experiencing control and having freedom of choice are seen as expressions of autonomy” (p. 1600). This definition encompasses decisional autonomy (freedom of choice), executional autonomy (ability to live), and authenticity (the life one wants to live). Kaplan and Bentwich ( 2023 ) used the Leino-Kilpi model of autonomy, which includes three components: “Enabling older adults suffering from physical or cognitive deterioration to control their lives and make independent choices in a way that embodies their individuality” (decisional and authenticity), “receiving information about their condition and ensuring that they understand it correctly” (decisional), and “maintaining their de facto independence by taking an active initiative on the part of caregivers to ensure the preservation of existing capabilities” (executional) (p. 941). Another study, Smebye et al. ( 2016 ), explored several theoretical constructs of autonomy, referencing notable works of philosophers such as Dworkin ( 1986 ), Jaworska ( 1999 ), and Agich ( 2003 ). These constructs highlighted varying philosophical underpinnings of autonomy, from Dworkin’s focus on dignity and respect to Jaworska’s work on value-centred decision-making in persons with dementia. 4.0 Discussion 4.1 Discussion of Key Findings Our scoping review reveals a concerning lack of conceptual clarity regarding autonomy in qualitative research on persons living with dementia. A major finding of our study was the lack of careful operationalization of the term ‘autonomy.’ More than three quarters of the studies (77%) offered no definition or explanation of ‘autonomy’ of any kind, even when autonomy was a central topic of discussion in the research. Among studies that provided a definition, there was substantial inconsistency in how autonomy was defined and conceptualized. Only 5 studies (8%) provided definitions addressing all three core aspects of autonomy (decisional, authenticity, and executional), with the others attending only to one or two dimensions. Additionally, the descriptions of autonomy within each of these dimensions varied significantly. For example, the executional component of autonomy could be described as preserving the capability to act independently (Kaplan and Bentwich 2023 ; Bentwich et al. 2018 ), while others emphasized liberty and freedom to act (Thorsen et al. 2020 ; Fox et al. 2005). Furthermore, many studies used terms such as ‘independence,’ ‘agency,’ ‘decision-making,’ or ‘competence’ interchangeably with ‘autonomy.’ The resulting conceptual unclarity presents substantial challenges for both research and practice in dementia care as it limits the generalizability of findings. The general paucity of operationalization seriously undermines the ability to effectively compare study outcomes and use this body of research to develop person-centered care interventions aimed at promoting autonomy in this population (Colquhoun et al. 2014 ). Articles that gave a definition of autonomy addressing just one or two dimensions of autonomy always included decisional autonomy. This shows a greater focus on decisional autonomy relative to executional autonomy or authenticity in the literature. However, it is important to note that the possession of personal autonomy requires not only the ability to make decisions (decisional autonomy), but also the ability to carry them out (executional autonomy). Furthermore, although a decision is made by a person, that decision may not be autonomous if it is rendered inauthentic by oppressive conditioning or manipulation. In the literature, the focus on decisional autonomy in the literature could be related to the goal of applicability to healthcare decision-making. Everyday dilemmas related to cognitive capacity, ability to give informed consent, and degree of family involvement are central to the practice of dementia care within hospital and institutional care settings. Given that these settings are where most research studies are conducted, there has been a greater relative focus on decision-making and its implications related to one of the core tenets of medical practice, ‘respect for autonomy.’ Maintaining involvement in decision-making is of high importance for people with dementia (Dening et al. 2017). Therefore, many of the included studies investigated the way in which decision-making activities are supported, often with the help of informal care partners. For example, Smebye et al. ( 2012 ) stated that shared decision-making, which involved carers and persons with dementia negotiating decisions within collaborative partnerships, was the most commonly observed decision-making approach among participants. Nearly every study involved the participation of informal care partners in some form, demonstrating the importance of others to continued autonomy expression in persons with dementia. Although we did not include relational embeddedness within the three dimensions of autonomy considered for assessment of definitions, the literature revealed that this is an essential part of the context in which people with dementia exercise autonomy. As such, we decided to include several studies in this review that noted the particular importance of relational embeddedness when describing autonomy for persons with dementia. Caradec and Chamahian ( 2017 ) distinguished between proclaimed (individual) autonomy and delegated autonomy, referring to instances where persons with dementia may delegate decision-making authority to a trusted other when they are deemed incapable of such decisions on their own. Sinclair et al. ( 2019 ) suggest that “human capacity for autonomy is developed, expressed, and always dependent on, supportive relationships of mutual recognition” (p. 588). Furthermore, Niemeijer et al. ( 2015 ) critiqued the “standard views of autonomy emphasizing non-interference and independence” as not being sensitive enough to the complex conditions that actually support the unique identity of persons (p. 308). The frequent conceptualization of autonomy as related to ‘independence’ and ‘the ability to perform activities independently’ in the literature (Rapaport et al. 2020 ; Thorsen et al. 2020 ) is problematic because the maintenance of autonomy in persons with dementia involves varying degrees of interdependence, rather than independence. Once again, greater conceptual clarity would be helpful in this instance. Notably, none of the studies in our review provided a definition that focused solely on the authenticity dimension of autonomy. This finding is reasonable given that authenticity is often examined in its application to decision-making or action-oriented scenarios (i.e., examining whether a decision aligns with one’s personal beliefs). However, the lack of attention to authenticity in the two-dimensional (authenticity in 2 out of 6) definitions in this review may reflect a more general lack of attention to authenticity compared with decisional and executional components in published research on autonomy in persons living with dementia. This is problematic because the memory loss and potential personality and behavioral changes associated with dementia greatly impact one’s sense of personal identity. When one’s sense of self is undermined, the ability to make authentic decisions is likewise diminished. A few studies included in our review identified a notable connection between autonomy and personal identity. For example, Genoe et al. ( 2010 ) connected considerations of autonomy to the “process of honouring identity… [which] involved protecting dignity while struggling for autonomy, having meaningful roles, and reaffirming sense of self in the world (p. 185). The lack of attention to authenticity identified in this scoping review indicates an insufficient consideration of this dimension of autonomy in research and practice. 4.2 Implications for Care Practices and Policy Development Significant variability in understanding and operationalization of autonomy can lead to divergent approaches in care practices. While this is not inherently problematic, different aspects of autonomy may require different support strategies. For instance, practices that focus predominantly on decisional autonomy may prioritize interventions that enhance the cognitive capabilities of persons living with dementia, such as decision aids that explicitly state the decision, provide relevant information, and summarize the benefits and harms of each option (Davies et al. 2019 ). Conversely, an expanded understanding of autonomy as relational promotes a collective approach to decision-making, closely involving caregivers and social networks (Groen-van de Ven et al. 2018; Smebye et al. 2012 ). The real difficulty arises from the fragmentation of these approaches. When research, policy and practice recommendations are developed in isolation, without awareness of how they fit into a comprehensive framework of autonomy-promoting care, the result can be an incomplete or imbalanced approach to supporting autonomy. For example, there is a notable lack of discussion in the literature related to exploring authentic expression of autonomy in practice settings, likely linked to the lack of consideration of authenticity in institutional policies. Although a systematic determination of authenticity is certainly challenging to formalize into policy given its subjective and individual nature, certain considerations outlined in policy could help improve the implementation of person-centred care in practice. Standardizing advance care planning practices that promote early discussion of the beliefs and values of the person with dementia before crisis occurs, and procedures that give time and space for deliberation about important decisions between persons with dementia, their care partners, and health professionals could potentially increase the authenticity of decisions made in institutional settings. Furthermore, a common understanding of all that autonomy entails for persons living with dementia is necessary for policymakers to create guidelines that are both comprehensive and applicable across different care settings. By incorporating all three dimensions, researchers and practitioners can develop a more nuanced understanding of autonomy that reflects the lived experiences of persons living with dementia. This comprehensive approach would allow for the development of interventions that support autonomy in its fullest sense, rather than focusing on isolated aspects. We do not wish to suggest that research focused on particular aspects of personal autonomy is problematic. But researchers and health practitioners should not be misled to think that one or another aspect is equivalent to personal autonomy as a whole. There is more to supporting autonomy than supporting decision-making, or execution of choices, or authenticity, on their own. A comprehensive autonomy framework is needed to meaningfully relate, combine and situate research on the same or different aspects of personal autonomy, and to ensure understanding of what is involved in promoting personal autonomy as a whole. 4.3 Future Directions Moving forward, there is a need for a more consistent and theoretically grounded definition of autonomy in research involving persons living with dementia to ensure a more cohesive body of knowledge and allow for greater comparability between studies. Future studies should explicitly define autonomy, ideally incorporating all three dimensions. Additionally, future research should explore how these three dimensions of autonomy interact and potentially change over the course of dementia progression. The degree of concern related to the various dimensions of autonomy depends on the type of dementia one has and where degenerative changes are occurring in the brain. For example, individuals with Lewy body dementia may experience physical symptoms of loss of coordination, muscle rigidity, or tremors sooner than other types (Alzheimer Society of Canada 2024), potentially necessitating a greater focus on executional autonomy. Additionally, there are few studies conducted with participants with moderate to advanced dementia, due to the difficulty of obtaining consent and the unproven assumption that one’s ability to express autonomy at these stages is absent. Even fewer of these studies attend to the lived experience of persons living with advanced dementia. Longitudinal studies investigating a variety of dementia diagnoses could provide valuable insights into how autonomy can be supported at different stages of the condition. 5.0 Limitations This scoping review has several limitations that should be considered when interpreting its findings. While we conducted a systematic search of the literature to address our research question, the purpose of this review was primarily to describe the current state of autonomy operationalization in qualitative studies involving persons living with dementia. As such, our findings are highly focused and are mainly descriptive in nature, not providing a comprehensive critical appraisal of the quality of the studies included. We suggest that a complete definition should include, at a minimum, the three core aspects (decisional autonomy, executional autonomy, and authenticity) evident from a review of the philosophical literature theorizing about personal autonomy, and we indicate how the studies included measure up against this three-dimensional standard, but beyond this we do not evaluate the caliber of the studies. A second limitation of our study lies in our search strategy, which focused specifically on the term ‘autonomy’ and its direct variants. While this approach allowed for a focused examination of how autonomy is explicitly conceptualized, it also presents challenges. As discussed earlier in our review, the concept of personal autonomy is often conflated with related but distinct terms such as ‘independence,’ ‘agency,’ ‘decision-making,’ ‘self-determination,’ ‘self-governance,’ ‘capacity,’ and ‘competence.’ As we excluded studies that did not directly relate the term ‘autonomy’ to other terms, we may have inadvertently omitted relevant research that explores autonomy-related concepts under these alternative terminologies. This limitation potentially narrows the scope of our findings and may not fully capture the way the phenomenon of personal autonomy is represented in current research. It is possible that studies using these related terms might offer valuable insights into aspects of autonomy for persons living with dementia even if they do not explicitly use the term ‘autonomy’ or incorrectly use a related term in the place of ‘autonomy.’ Future reviews might consider broadening the search criteria to include these related terms, while carefully distinguishing between true examinations of autonomy and studies that focus on related but distinct concepts. Additionally, our focus on qualitative studies, which provide rich, in-depth data on the lived experiences of persons living with dementia, excludes quantitative research that might offer complementary insights into the operationalization of autonomy. Biomedical research in particular often measures autonomy using proxy measurements such as instrumental activities of daily living scales (König et al. 2015 ) or includes autonomy subscales within investigations of well-being (Stoner et al. 2019 ). Future work could benefit from integrating exclusively quantitative approaches to provide a more comprehensive understanding of how autonomy is conceptualized and measured in research involving persons living with dementia. Such an analysis could potentially identify scales that incorporate a more encompassing definition of autonomy, addressing all three dimensions (decisional, executional, and authenticity). This would not only broaden our understanding of how autonomy is operationalized across different research methodologies but could also highlight areas where quantitative measures could be improved to better capture the multidimensional nature of autonomy in persons living with dementia. 6.0 Conclusion This scoping review demonstrates the need for more rigorous and consistent operationalization of autonomy in qualitative studies involving persons living with dementia. Future research should prioritize the use of clear, theoretically grounded definitions of autonomy that acknowledge its multifaceted nature, including its decisional, executional, and authenticity dimensions. This is particularly important in the context of cognitive impairment, where the concept of autonomy must be understood in ways that are adaptable to the changing capacities of individuals while maintaining conceptual precision. Such an approach ensures that interventions are appropriately designed to meet the specific and evolving needs of persons living with dementia. By enhancing conceptual clarity, we can improve the quality of research in this field in several ways. First, it will enable more accurate measurement and assessment of autonomy in persons living with dementia, leading to more reliable data. Second, it will facilitate more meaningful comparisons across studies, allowing for more robust meta-analyses and synthesis of findings. Third, it will help researchers to more precisely identify the specific aspects of autonomy that are impacted by various interventions or care approaches. There are also important implications for policy and practice related to autonomy supportive care. Healthcare professionals who want to base autonomy-promoting care policy or strategies on empirical evidence will turn to the relevant literature to learn about the lived experience of persons living with dementia. If these studies are unclear about what the phenomenon they have sought to study consists in, it will be difficult for health professionals to determine the relevance of their results, and the effect may be a correspondingly misleading and/or partial strategy for supporting personal autonomy within health care. Improved conceptual clarity and research quality will ultimately lead to more effective person-centered approaches to promoting autonomy in dementia care. Declarations Competing Interests : The authors have no competing interests to declare that are relevant to the content of this article. Ethical Approval : This article does not contain any studies with human participants performed by any of the authors. Informed Consent : This article does not contain any studies with human participants performed by any of the authors. Funding and Acknowledgements : This work was supported by ( Anonymized for Review). The authors would also like to acknowledge the team at (Anonymized for Review) for their support and collaboration. Author Contribution Conceptualization: AB, EM, AS; Methodology: AB, EM; Formal analysis and investigation: AB, EM; Writing - original draft preparation: AB, EM; Writing - review and editing: AB, EM, AS; Funding acquisition: AS; Resources: AS; Supervision: AS. Acknowledgement This work was supported by the Social Sciences and Humanities Research Council of Canada, Insight Grant awarded to Dr. Andrew Stumpf (435-2022-0530). The authors would also like to acknowledge the team at the Kernel Network Waterloo for their support and collaboration. Data Availability The data that support the findings of this study are openly available in the Open Science Framework Data Repository at (Anonymized for Review) [.](https:/doi.org/10.17605/OSF.IO/6FBMW.) References Agich G (2003) Dependence and Autonomy in Old Age: An Ethical Framework for Long-term Care. Cambridge University Press, Cambridge Alsaeed D, Orlu M, Smith F (2021) Optimising Medication Use along Dementia Progression: Recommendations from a Qualitative Study. Healthc (Basel) 9. https://doi.org/10.3390/healthcare9080982 Arksey H, O’Malley L (2005) Scoping studies: towards a methodological framework. Int J Soc Res Methodol 8:19–32. https://doi.org/10.1080/1364557032000119616 Bentwich ME, Dickman N, Oberman A (2018) Human dignity and autonomy in the care for patients with dementia: differences among formal caretakers from various cultural backgrounds. Ethn Health 23:121–141. https://doi.org/10.1080/13557858.2016.1246519 Bollig G, Gjengedal E, Rosland JH (2016) Nothing to complain about? Residents’ and relatives’ views on a ‘good life’ and ethical challenges in nursing homes. Nurs Ethics 23:142–153. https://doi.org/10.1177/0969733014557719 Boyle G (2013) She’s usually quicker than the calculator’: Financial management and decision-making in couples living with dementia. Health Soc Care Community 21:554–562. https://doi.org/10.1111/hsc.12044 Boyle G (2017) Revealing gendered identity and agency in dementia. Health Soc Care Community 25:1787–1793. https://doi.org/10.1111/hsc.12452 Burgon C, Goldberg S, Van Der Harwood WV R.H (2023) Experiences and understanding of apathy in people with neurocognitive disorders and their carers: a qualitative interview study. Age Ageing 52:afad031. https://doi.org/10.1093/ageing/afad031 Caradec V, Chamahian A (2017) The épreuve of ageing with Alzheimer’s disease. Ageing Soc 37:935–960. https://doi.org/10.1017/S0144686X16000167 Cardol M, Jong BAD, Ward CD (2002) On autonomy and participation in rehabilitation. Disabil Rehabil 24:970–974. https://doi.org/10.1080/09638280210151996 Christman J (2009) The Politics of Persons: Individual Autonomy and Socio-historical Selves. Cambridge University Press, Cambridge Chung PYF, Ellis-Hill C, Coleman P (2017) Supporting activity engagement by family carers at home: maintenance of agency and personhood in dementia. Int J Qual Stud Health Well-being 12:1267316. https://doi.org/10.1080/17482631.2016.1267316 Collopy BJ (1988) Autonomy in long term care: some crucial distinctions. Gerontologist 28:10–17 Colquhoun H, Leeman J, Michie S et al (2014) Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies. Implement Sci 9:781. https://doi.org/10.1186/1748-5908-9-51 Davies N, Schiowitz B, Rait G et al (2019) Decision aids to support decision-making in dementia care: a systematic review. Int Psychogeriatr 31:1403–1419. https://doi.org/10.1017/S1041610219000826 Davison TE, Camoes-Costa V, Clark A (2019) Adjusting to life in a residential aged care facility: Perspectives of people with dementia, family members and facility care staff. J Clin Nurs 28:3901–3913. https://doi.org/10.1111/jocn.14978 Dening KH, King M, Jones L et al (2016) Advance Care Planning in Dementia: Do Family Carers Know the Treatment Preferences of People with Early Dementia? PLoS ONE 11:e0159056. https://doi.org/10.1371/journal.pone.0159056 Donnelly S, Begley E, O’Brien M (2019) How are people with dementia involved in care-planning and decision-making? An Irish social work perspective. Dementia 18:2985–3003. https://doi.org/10.1177/1471301218763180 Duong S, Patel T, Chang F (2017) Dementia. Can Pharm J (Ott) 150:118–129. https://doi.org/10.1177/1715163517690745 Dworkin R (1994) Life’s Dominion. Random House, Inc, New York Dworkin R (1986) Autonomy and the Demented Self. Milbank Q 64:4–16. https://doi.org/10.2307/3349959 Eriksen S, Engedal K, Grov EK (2022) Lifeworld perspectives of people with dementia: a meta-aggregation of qualitative studies. BMC Geriatr 22:970. https://doi.org/10.1186/s12877-022-03660-w Fetherstonhaugh D, Rayner J-A, Tarzia L (2019) Hanging on to some autonomy in decision-making: How do spouse carers support this? Dementia: Int J Social Res Pract 18:1219–1236. https://doi.org/10.1177/1471301216678104 Fetherstonhaugh D, Tarzia L, Nay R (2013) Being central to decision making means I am still here! The essence of decision making for people with dementia. J Aging Stud 27:143–150. https://doi.org/10.1016/j.jaging.2012.12.007 Genoe R, Dupuis SL, Keller HH et al (2010) Honouring identity through mealtimes in families living with dementia. J Aging Stud 24:181–193. https://doi.org/10.1016/j.jaging.2010.02.001 De Groen-Van L, Smits C, Span M et al (2018) The challenges of shared decision making in dementia care networks. Int Psychogeriatr 30:843–857. https://doi.org/10.1017/S1041610216001381 Hawkins J, Charland LC (2020) Decision-Making Capacity. In: Zalta EN (ed) The Stanford Encyclopedia of Philosophy, Fall 2020. Metaphysics Research Lab, Stanford University Hoek LJM, Verbeek H, de Vries E et al (2020) Autonomy Support of Nursing Home Residents With Dementia in Staff-Resident Interactions: Observations of Care. J Am Med Dir Assoc 21:1600–1608e2. https://doi.org/10.1016/j.jamda.2020.04.013 Jaworska A (1999) Respecting the margins of agency: Alzheimer’s patients and the capacity to value. Philos Public Aff 28:105–138. https://doi.org/10.1111/j.1088-4963.1999.00105.x Kaplan F, Bentwich ME (2023) Do differences exist in cross-cultural caregivers’ respect for the autonomy/dignity of people with dementia? Real-time field observations in nursing homes. Dement (London) 22:935–963. https://doi.org/10.1177/14713012231158410 Knopman DS, Petersen RC (2014) Mild Cognitive Impairment and Mild Dementia: A Clinical Perspective. Mayo Clinic proceedings 89:1452. https://doi.org/10.1016/j.mayocp.2014.06.019 König A, Crispim-Junior CF, Covella AGU et al (2015) Ecological Assessment of Autonomy in Instrumental Activities of Daily Living in Dementia Patients by the Means of an Automatic Video Monitoring System. Front Aging Neurosci 7:98. https://doi.org/10.3389/fnagi.2015.00098 Le TD, Lin S-C, Huang M-C et al (2023) Factors impacting the demonstration of relational autonomy in medical decision-making: A meta-synthesis. Nurs Ethics 09697330231200570. https://doi.org/10.1177/09697330231200570 Levac D, Colquhoun H, O’Brien KK (2010) Scoping studies: advancing the methodology. Implement Sci 5:69. https://doi.org/10.1186/1748-5908-5-69 Li J (2023) Autonomy-supportive environments for people with dementia: an evidence-based review. Interdisciplinary Nurs Res 2:188. https://doi.org/10.1097/NR9.0000000000000036 Mackenzie C (2000) Imagining Oneself Otherwise. In: Mackenzie C, Stoljar N (eds) Relational Autonomy. Oxford University Press, New York, USA, pp 124–150 Marceta JA (2018) A non-ideal authenticity-based conceptualization of personal autonomy. Med Healthc Philos 22:387. https://doi.org/10.1007/s11019-018-9879-1 Mattos MK, Gibson JS, Wilson D et al (2023) Shared decision-making in persons living with dementia: A scoping review. Dement (London) 22:875–909. https://doi.org/10.1177/14713012231156976 Mccormack B (2001) Autonomy and the relationship between nurses and older people. Ageing Soc 21:417–446. https://doi.org/10.1017/S0144686X01008303 Naik AD, Dyer CB, Kunik ME, McCullough LB (2009) Patient Autonomy for the Management of Chronic Conditions: A Two-Component Re-conceptualization. Am J Bioeth 9:23–30. https://doi.org/10.1080/15265160802654111 Niemeijer AR, Depla MFIA, Frederiks BJM, Hertogh CMPM (2015) The experiences of people with dementia and intellectual disabilities with surveillance technologies in residential care. Nurs Ethics 22:307–320. https://doi.org/10.1177/0969733014533237 Peters MDJ, Marnie C, Tricco AC et al (2020) Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth 18:2119–2126. https://doi.org/10.11124/JBIES-20-00167 Phinney A, Chaudhury H, O’Connor DL (2007) Doing as much as I can do: The meaning of activity for people with dementia. Aging Ment Health 11:384–393. https://doi.org/10.1080/13607860601086470 Rapaport P, Burton A, Leverton M et al (2020) I just keep thinking that I don’t want to rely on people.’ a qualitative study of how people living with dementia achieve and maintain independence at home: stakeholder perspectives. BMC Geriatr 20:5. https://doi.org/10.1186/s12877-019-1406-6 Rommerskirch-Manietta M, Manietta C, Purwins D et al (2023) This is Slowly Becoming my Interest… The Understanding of Leisure and Preferences for Leisure Activities of People Receiving Adult Day Services. Res Aging 46:210. https://doi.org/10.1177/01640275231221162 Ryan WS, Ryan RM (2019) Toward a Social Psychology of Authenticity: Exploring Within-Person Variation in Autonomy, Congruence, and Genuineness Using Self-Determination Theory. Rev Gen Psychol 23:99–112. https://doi.org/10.1037/gpr0000162 Sampson MS, Clark A (2016) Deferred or chickened out?’ Decision making among male carers of people with dementia. Dementia: Int J Social Res Pract 15:1605–1621. https://doi.org/10.1177/1471301214566663 Samsi K, Manthorpe J (2013) Everyday decision-making in dementia: Findings from a longitudinal interview study of people with dementia and family carers. Int Psychogeriatr 25:949–961. https://doi.org/10.1017/S1041610213000306 Schlosser M (2019) Agency. In: Zalta EN (ed) The Stanford Encyclopedia of Philosophy, Winter 2019. Metaphysics Research Lab, Stanford University Serbser-Koal J, Dreyer J, Roes M (2024) Autonomy and its relevance for the construction of personhood in dementia– a thematic synthesis. BMC Geriatr 24:255. https://doi.org/10.1186/s12877-024-04808-6 Sinclair C, Gersbach K, Hogan M et al (2019) A Real Bucket of Worms’: Views of People Living with Dementia and Family Members on Supported Decision-Making. J Bioeth Inq 16:587–608. https://doi.org/10.1007/s11673-019-09945-x Smebye KL, Kirkevold M, Engedal K (2012) How do persons with dementia participate in decision making related to health and daily care? a multi-case study. BMC Health Serv Res 12:241. https://doi.org/10.1186/1472-6963-12-241 Smebye KL, Kirkevold M, Engedal K (2016) Ethical dilemmas concerning autonomy when persons with dementia wish to live at home: a qualitative, hermeneutic study. BMC Health Serv Res 16:21. https://doi.org/10.1186/s12913-015-1217-1 Stevenson M, Savage B, Taylor BJ (2019) Perception and communication of risk in decision making by persons with dementia. Dementia: Int J Social Res Pract 18:1108–1127. https://doi.org/10.1177/1471301217704119 Stoner CR, Orrell M, Spector A (2019) The psychometric properties of the control, autonomy, self-realisation and pleasure scale (CASP-19) for older adults with dementia. Aging Ment Health 23:643–649. https://doi.org/10.1080/13607863.2018.1428940 Thorsen K, Dourado MCN, Johannessen A (2020) Developing dementia: The existential experience of the quality of life with young-onset dementia—A longitudinal case study. Dementia: Int J Social Res Pract 19:878–893. https://doi.org/10.1177/1471301218789990 van der Weide H, Lovink MH, Luijkx KG, Gerritsen DL (2023) Supporting autonomy for people with dementia living in nursing homes: A rapid realist review. Int J Nurs Stud 137:104382. https://doi.org/10.1016/j.ijnurstu.2022.104382 Tables Table I: Autonomy operationalization within included studies Citation Definition Decisional Authenticity Executional Alsaeed et al. 2021 x x x - Bentwich et al. 2018 a x x x x Bentwich et al. 2018 b x x x x Boddington & Featherstone, 2018 - - - - Bollig et al. 2016 - - - - Boyle, 2013 x x - x Boyle, 2017 - - - - Bronner et al. 2016 - - - - Burgon et al. 2023 - - - - Caradec & Chamahian, 2017 x x - x Chung et al. 2017 - - - - Davison et al. 2019 - - - - Dimech et al. 2021 - - - - Elliott et al. 2009 - - - - Eriksen et al. 2022 - - - - Farrington et al. 2023 - - - - Fetherstonhaugh et al. 2019 x x - - Forsund et al. 2018 - - - - Gamm et al. 2024 - - - - Genoe et al. 2010 - - - - Groen-Van De Ven et al. 2018 - - - - Groenvynck et al. 2023 - - - - Heggestad et al. 2013 - - - - Hoek et al. 2020 x x x x Horton-Deutsch et al. 2007 - - - - Kaplan. & Bentwich, 2023 x x x x Kaufmann & Engel, 2016 - - - - Kiwi, 2023 - - - - Landau et al. 2010 - - - - Liou & Jarrott, 2013 - - - - Lord et al. 2016 - - - - MacQuarrie, 2005 - - - - Mesbah et al. 2023 - - - - Motta-Ochoa et al. 2022 - - - - Niemeijer et al. 2015 - - - - Noone & Jenkins, 2018 - - - - Nygard et al. 2023 - - - - Ohman & Nygard, 2005 - - - - Phinney et al. 2007 - - - - Pyer & Ward, 2024 - - - - Rapaport et al. 2020 - - - - Rees et al. 2020 - - - - Rimkeit & McIntosh, 2017 - - - - Rommerskirch-Manietta et al. 2023 x x - x Ross et al. 2024 - - - - Sagbakken et al. 2017 - - - - Sampson & Clark, 2016 x x x - Samsi & Manthorpe, 2013 x x - - Sinclair et al. 2019 - - - - Smebye et al. 2012 - - - - Smebye et al. 2016 x x x x Stevenson et al. 2019 x x - - Stewart-Archer et al. 2016 - - - - Stockwell-Smith et al. 2019 - - - - Taylor et al. 2023 x x - - Thorsen et al. 2020 x x - x Tortosa-Martínez et al. 2020 - - - - Tranvag et al. 2015 - - - - Van Gennip et al. 2014 - - - - van Oppen et al. 2022 - - - - Wang et al. 2011 - - - - Xanthopoulou & McCabe, 2019 - - - - Yeh et al. 2021 - - - - Zeilig et al. 2019 - - - - Ziebuhr et al. 2023 - - - - Table II: Totals and Percentages of included studies for each Autonomy Operationalization Category Overall Three Dimensions Two Dimensions One Dimension No Definition Total (n = 65) n = 5 n = 6 n = 4 n = 50 Percentage (100%) (8%) (9%) (6%) (77%) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 03 Feb, 2026 Reviews received at journal 29 Sep, 2025 Reviews received at journal 27 Sep, 2025 Reviews received at journal 26 Sep, 2025 Reviews received at journal 25 Sep, 2025 Reviews received at journal 23 Sep, 2025 Reviews received at journal 23 Sep, 2025 Reviews received at journal 22 Sep, 2025 Reviews received at journal 16 Sep, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers invited by journal 06 Sep, 2025 Editor assigned by journal 06 Sep, 2025 Editor invited by journal 29 Aug, 2025 Submission checks completed at journal 11 Aug, 2025 First submitted to journal 11 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7190181","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":571077809,"identity":"f9cd87d0-8d0a-407a-a388-84d9cefd1676","order_by":0,"name":"Avery Jesse Beavers","email":"","orcid":"","institution":"University of Waterloo","correspondingAuthor":false,"prefix":"","firstName":"Avery","middleName":"Jesse","lastName":"Beavers","suffix":""},{"id":571077810,"identity":"f58f089a-d491-4ac2-9e7b-f6c9007ee635","order_by":1,"name":"Erin Leigh McKenzie","email":"","orcid":"","institution":"University of Waterloo","correspondingAuthor":false,"prefix":"","firstName":"Erin","middleName":"Leigh","lastName":"McKenzie","suffix":""},{"id":571077811,"identity":"bb8449af-c2fd-4c28-b9b2-72bfd9b948a8","order_by":2,"name":"Andrew Douglas Heslop Stumpf","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYFCCHAjF3t4AYfARpeUAkOI5AyITGBjYiNdyI4FILfztuYc/f2zblscj+cZM4ucPm3w29uYDDD9qcGuROPMuTeJg2+1iHukcM8mehDTLNp5jCYw9x/BYcyPHjAGoJXE/UMsNnoTDBmwSOQbM+JwnfyPH+ANIS4/kGbObfxL+Q7X8w63F4EaOgQRYiwSP2W2ehAMQLYxtuLUYngH6+sw5oF940sp/y6QlG7AB/XKwtw+3FrnjQIdVlN3O42E/vNnwjY2dAT9788EHP77h8T4UJKDwDhDWgK5lFIyCUTAKRgEyAABmX1O2muCx2QAAAABJRU5ErkJggg==","orcid":"","institution":"University of Waterloo","correspondingAuthor":true,"prefix":"","firstName":"Andrew","middleName":"Douglas Heslop","lastName":"Stumpf","suffix":""}],"badges":[],"createdAt":"2025-07-22 20:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7190181/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7190181/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100361583,"identity":"8db488dc-9b9a-47d2-bedf-296ffccb470d","added_by":"auto","created_at":"2026-01-16 07:45:20","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63395,"visible":true,"origin":"","legend":"","description":"","filename":"Fig1PRISMA1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/72186d33163fb67b11096d09.docx"},{"id":100361695,"identity":"bf145428-fcc8-483f-99bd-cec8a488cb5c","added_by":"auto","created_at":"2026-01-16 07:45:31","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2648664,"visible":true,"origin":"","legend":"","description":"","filename":"AutonomyOperationlizationHSSC3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/8c748abdf3e0616afe7a8eae.docx"},{"id":100014582,"identity":"8f5dbc70-8667-48b3-939c-5a60f263b8dc","added_by":"auto","created_at":"2026-01-12 06:24:50","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":37090,"visible":true,"origin":"","legend":"","description":"","filename":"Table1IncludedStudies1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/ff8305f9bf2c35a9978ce027.docx"},{"id":100014564,"identity":"f5888b27-4b83-48d6-a99d-88833e2f06b2","added_by":"auto","created_at":"2026-01-12 06:24:49","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":19075,"visible":true,"origin":"","legend":"","description":"","filename":"Table2Totals1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/a1eb703f402ee931ac461635.docx"},{"id":100014590,"identity":"4bc6f7c5-9ed5-4a1e-a334-25fdb5877a13","added_by":"auto","created_at":"2026-01-12 06:24:50","extension":"json","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5811,"visible":true,"origin":"","legend":"","description":"","filename":"36cf2fdbcc894b748cce82e786e3ba11.json","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/a51c917d4fbfc2a5551cfcab.json"},{"id":100014555,"identity":"dbdc13de-df57-4378-9d5f-04e0b1be2d6d","added_by":"auto","created_at":"2026-01-12 06:24:48","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":158380,"visible":true,"origin":"","legend":"","description":"","filename":"36cf2fdbcc894b748cce82e786e3ba111enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/33cf4a993be0d225b63fea32.xml"},{"id":100014583,"identity":"eea29cda-b643-4513-a339-3d6fab085544","added_by":"auto","created_at":"2026-01-12 06:24:50","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":411631,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/cb67bc0e631c31666a84cdb5.jpeg"},{"id":100014625,"identity":"938891f8-b20a-49a9-9ed3-256f0b686a88","added_by":"auto","created_at":"2026-01-12 06:24:51","extension":"jpeg","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":38053,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/4af0097ba265be1520544305.jpeg"},{"id":100014572,"identity":"6917012a-1377-49a0-8288-ecd6b6916b39","added_by":"auto","created_at":"2026-01-12 06:24:49","extension":"jpeg","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":53715,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/d0c2c081a482041959fd556d.jpeg"},{"id":100014587,"identity":"567678ca-50b4-4e71-9768-03b9e8f49128","added_by":"auto","created_at":"2026-01-12 06:24:50","extension":"jpeg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":36803,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/4a55e25c5609af70503e2ed5.jpeg"},{"id":100361857,"identity":"b7540304-31e0-484e-b1bc-680c802152e9","added_by":"auto","created_at":"2026-01-16 07:45:51","extension":"jpeg","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23668,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/15e84decb441c7ef796aad2c.jpeg"},{"id":100362149,"identity":"9801e639-b1e4-4489-b9fd-e71ec2b5fb23","added_by":"auto","created_at":"2026-01-16 07:46:13","extension":"jpeg","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1074,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/9c62adc2be5022208c8a7c5a.jpeg"},{"id":100014577,"identity":"5216a7d3-9a39-4cf6-a3f2-9f935b1aae27","added_by":"auto","created_at":"2026-01-12 06:24:50","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91850,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/6bc46921d0f6dd438ef574f1.png"},{"id":100014584,"identity":"dd48bcf9-b56c-4d84-99a9-b3228769d2e7","added_by":"auto","created_at":"2026-01-12 06:24:50","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7016,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/ba13c9c775ce03522e828a62.png"},{"id":100014574,"identity":"8e466b9e-08b8-4050-925d-17db042b1aea","added_by":"auto","created_at":"2026-01-12 06:24:49","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8996,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/73ee1e9cf199286b037884dd.png"},{"id":100361592,"identity":"e00a0664-271d-4f06-82b5-35a11b021d17","added_by":"auto","created_at":"2026-01-16 07:45:21","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7834,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/72e9df2c55fedf4c6097b976.png"},{"id":100014569,"identity":"551a9360-49e2-42de-a299-7c455799fe52","added_by":"auto","created_at":"2026-01-12 06:24:49","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4590,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/8ce5c3db54a90ece4ebee19b.png"},{"id":100014630,"identity":"7af732d9-6d3d-46a1-a90d-4e6dc49cb24e","added_by":"auto","created_at":"2026-01-12 06:24:51","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":935,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/9ebe6b50831201158254a9e5.png"},{"id":100014632,"identity":"f2a1d8fc-1e3c-4719-95d8-f58a6e68f715","added_by":"auto","created_at":"2026-01-12 06:24:51","extension":"xml","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":156254,"visible":true,"origin":"","legend":"","description":"","filename":"36cf2fdbcc894b748cce82e786e3ba111structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/a80ca74f11c659b53ad2e670.xml"},{"id":100014579,"identity":"16e442a4-0912-4883-9ced-09e37cc76b98","added_by":"auto","created_at":"2026-01-12 06:24:50","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":165522,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/8d0227189d6c9e4ff6381a40.html"},{"id":100362625,"identity":"8ae5923e-1b8b-4649-a765-4618607d5063","added_by":"auto","created_at":"2026-01-16 07:47:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":53364,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003eModified PRISMA Flow Diagram\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdapted From: \u003c/em\u003e\u0026nbsp;Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/37daefc0a5d106179a0e489c.png"},{"id":100381060,"identity":"a708e2d8-3448-4756-9036-04a10ca8ddd3","added_by":"auto","created_at":"2026-01-16 10:37:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":977154,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7190181/v1/016f9fbb-a08b-46a8-be3d-9663842bf248.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The operationalization of autonomy in qualitative studies of persons living with dementia: A scoping review","fulltext":[{"header":"1.0 Introduction","content":"\u003cp\u003ePersonal autonomy is fundamental to well-being for people living with dementia, who consistently identify its maintenance as crucial to their quality of life (Serbser-Koal et al. \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Supporting personal autonomy is central to person-centered care for older adults experiencing declining functionality, and particularly for persons living with dementia. Numerous empirical studies published in recent years that purport to consider the experience of autonomy in persons living with dementia lack consistent and theoretically grounded definitions of the term \u0026lsquo;autonomy.\u0026rsquo; This conceptual ambiguity is problematic given that autonomy is a complex and contested concept with multiple dimensions (Collopy \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1988\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMany empirical studies implicitly assume a common understanding of autonomy without making their conception explicit, or substitute related but non-equivalent terms such as \u0026lsquo;independence,\u0026rsquo; \u0026lsquo;competence,\u0026rsquo; or \u0026lsquo;agency.\u0026rsquo; This undermines the comparability of findings of individual studies of autonomy in persons with dementia and synthesized review studies. Furthermore, incomplete or inconsistent definitions of autonomy in research can result in interventions that fail to effectively address all aspects of personal autonomy that are important to people with dementia, potentially impacting their quality of life.\u003c/p\u003e \u003cp\u003eA carefully articulated, common understanding of the meaning of autonomy for persons living with dementia could help synthesize and contextualize new and previous studies to better inform autonomy-promoting and quality-of-life-enhancing interventions. This scoping review begins to address this gap by systematically examining how autonomy is defined and operationalized in qualitative research involving persons living with dementia. By analyzing existing definitions against a comprehensive theoretical framework that encompasses decisional autonomy, executional autonomy, and authenticity (Stumpf, McKenzie and Beavers, under review), we aim to clarify the current state of conceptualization and highlight implications for research, policy, and clinical practice.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Background\u003c/h2\u003e \u003cp\u003eDementia is a clinical syndrome characterized by progressive cognitive decline that interferes with daily functioning (Duong et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). While traditionally associated with memory impairment, current diagnostic criteria recognize that dementia can manifest with deficits in various cognitive domains, including executive function, language, and visuospatial abilities (Duong et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Mild cognitive impairment, although condition distinct from dementia, may be a precursor to further cognitive deterioration in some cases and impacts cognitive domains in a similar, though less pronounced, manner (Knopman and Petersen \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Individuals experiencing cognitive dysfunction often experience difficulties with decision-making, judgment, and reasoning, which can impact their ability to exercise personal autonomy (Duong et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePersonal autonomy has been conceptualized in various ways, but a comprehensive understanding requires recognizing its multidimensional nature. Our framework, based on both philosophical literature and empirical research (Stumpf, McKenzie and Beavers, under review), identifies three essential dimensions of personal autonomy for persons with dementia: decisional autonomy, executional autonomy, and authenticity. Decisional autonomy refers to the capacity to set goals and make choices, encompassing the cognitive functions involved in deliberation and judgment (Cardol et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). This dimension is often emphasized in healthcare contexts, particularly around informed consent and medical decision-making. Executional autonomy, on the other hand, involves the ability to translate decisions into actions, including communication skills, motor control, and practical reasoning abilities invoked to implement one\u0026rsquo;s choices (Cardol et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Existing dementia care research recognizes, to a greater or lesser extent, decisional and executional elements. The relevant philosophical literature, however, suggests a more nuanced understanding that incorporates an important third dimension, namely authenticity (Marceta \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Authenticity relates to a person\u0026rsquo;s ability to recognize their choices and actions as truly their own, aligning with their stable preferences, deeply held values, and sense of self (Jaworska \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Dworkin \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). This dimension distinguishes between choices that have been critically reflected on and endorsed by a person versus those resulting from undue influence or coercion.\u003c/p\u003e \u003cp\u003eFor persons living with dementia, all three dimensions can be affected, but not necessarily simultaneously or to the same degree. Memory loss and cognitive changes may challenge decisional capacity, physical symptoms may hinder executional abilities, and personality changes may complicate authenticity. Yet research suggests that many individuals with dementia can continue to exercise meaningful autonomy with appropriate support (Fetherstonhaugh et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Therefore, our study utilizes a three-dimensional framework of decisional, executional, and authentic autonomy proposed by our research group (Anonymized for Review) with consideration to the relational context in which personal autonomy is exercised. This approach provides a comprehensive framework of personal autonomy and is particularly relevant to the complex challenges faced by persons living with dementia in maintaining self-governance.\u003c/p\u003e \u003cp\u003ePrevious scoping reviews have focused on specific aspects of autonomy, such as shared decision-making or relational autonomy (Le et al. \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Mattos et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In contrast, this study aims to address a critical gap in the literature by comprehensively examining how the phenomenon of personal autonomy is operationalized and measured in qualitative research that specifically focuses on persons living with dementia. Unlike previous reviews, our study emphasizes the importance of theoretical grounding in defining autonomy and considers a more complete conceptualization of the phenomenon.\u003c/p\u003e \u003cp\u003eStudies of autonomy in persons living with dementia commonly operationalize autonomy by using seemingly synonymous terms, often left undefined. This approach is problematic for several reasons. For instance, \u0026lsquo;independence\u0026rsquo; is sometimes used interchangeably with autonomy, but this term ignores the relational aspect of autonomy, which is crucial when considering persons with dementia who often rely on others for support. Relational approaches to autonomy demonstrate that autonomy is compatible with various levels of dependence, and may even necessitate interdependence, as we are all fundamentally dependent beings (Mackenzie \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). \u0026lsquo;Agency\u0026rsquo; is perhaps the term most closely linked in meaning with \u0026lsquo;autonomy,\u0026rsquo; often described as the capacity to act or exert power. However, conceptions of agency tend to neglect the dimension of authenticity, which must be recognized to fully appreciate the complexity of autonomy in persons with dementia. The mere fact that an individual has acted on a decision does not render that action autonomous; the decision must also cohere with the individual\u0026rsquo;s character and core values and occur without undue coercion (Schlosser \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Ryan and Ryan \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). While \u0026lsquo;competence\u0026rsquo; and \u0026lsquo;capacity\u0026rsquo; are importantly related to autonomy, they are often associated with high-stakes medico-legal decision-making. Using these terms as substitutes for personal autonomy risks overlooking the more mundane decisions and everyday experiences relevant to autonomy for persons with dementia (Hawkins and Charland \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Moreover, these terms may only refer to a subset of the capacities that constitute personal autonomy. For example, \u0026lsquo;decision-making\u0026rsquo; focuses solely on the decisional dimension of autonomy, neglecting other important dimensions, such as executional autonomy (Naik et al. \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). The uncritical substitution of terms like \u0026lsquo;self-determination\u0026rsquo; and \u0026lsquo;self-governance\u0026rsquo; for personal autonomy tends to frame the issue in terms of defending a person\u0026rsquo;s moral or legal rights rather than supporting their capacity to decide and act authentically. There is significant need for a shared theoretical understanding of personal autonomy that goes beyond the substitution of terms that do not fully capture the phenomenon and are often as ambiguous as \u0026lsquo;autonomy\u0026rsquo; itself. Conversely, studies may use one or another of these synonyms while considering all the relevant dimensions of personal autonomy but refraining from using the exact expression \u0026lsquo;personal autonomy\u0026rsquo; (Christman 2018), making it uncertain whether different researchers in this field are investigating the same phenomenon. A consensus on the use of these terms and the relationships between them is necessary to ensure the comparability and usefulness of the body of research being produced. Our review focused primarily on qualitative or mixed-methods research offering rich descriptions of the lived experience of persons with dementia to investigate whether \u0026lsquo;personal autonomy\u0026rsquo; was clearly defined and understood among researchers and participants. Furthermore, in our review, we paid particular attention to how philosophical foundations influenced the conceptualization and operationalization of autonomy in persons with dementia, as these theoretical bases crucially affect understandings of complex concepts like personal autonomy in social sciences research.\u003c/p\u003e \u003c/div\u003e"},{"header":"2.0 Methods","content":"\u003cp\u003eThe scoping review was conducted by two researchers under the guidance of the Principal Investigator on the (Anonymized for Review) Project at (Anonymized for Review). We developed this scoping review following the methodological framework described by Arksey and O'Malley (2005) and refined by Levac et al. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Scoping reviews are particularly appropriate for mapping key concepts and identifying gaps in research areas where existing literature has not been comprehensively reviewed (Peters et al. \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOnce the researchers agreed on the keywords and specific terms, one of the researchers (Anonymized for Review) performed the search in PubMed, APA PsychNet, Embase (Ovid), and Scopus in June 2024. Eligible studies included peer-reviewed articles published within the last 20 years (2004\u0026ndash;2024). The PubMed search used the following terms: (dementia OR \u0026ldquo;dementia\u0026rdquo; [mesh] OR Alzheimer OR \u0026ldquo;Alzheimer disease\u0026rdquo; [mesh] OR \u0026ldquo;mild cognitive impairment\u0026rdquo; OR \u0026ldquo;cognitive dysfunction\u0026rdquo; [mesh]) AND (autonom* OR \u0026ldquo;personal autonomy\u0026rdquo; [mesh] OR agency) AND (qualitative OR mixed?method*). After the initial search across the four databases, all results were exported into the citation manager, Zotero (version 6.0.37), where duplicates were removed. The remaining unique citations were then screened, first considering both title and abstract, and then full text, within the citation manager. Studies that only used terms such as \u0026lsquo;decision-making,\u0026rsquo; \u0026lsquo;capacity,\u0026rsquo; \u0026lsquo;competence,\u0026rsquo; and \u0026lsquo;independence\u0026rsquo; without explicit mention of \u0026lsquo;autonomy\u0026rsquo; were excluded from our database search criteria. While these concepts are often closely related to autonomy in the context of dementia care, our primary focus was on how autonomy itself is operationalized in the literature. We assumed that studies specifically investigating autonomy, with the explicit aim of informing further research or interventions to promote autonomy and well-being in persons living with dementia, would likely include at least one instance of the term \u0026lsquo;autonomy,\u0026rsquo; particularly considering the growing popularity of autonomy-supportive care interventions in research and policy (Li \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; van der Weide et al. \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe deliberate exclusion of these related terms in the database search served a dual purpose. Firstly, it allowed us to maintain a focused examination of how researchers conceptualize and define autonomy when it is the primary subject of investigation. Secondly, it helped to ensure that researchers are distinguishing autonomy from related but non-synonymous concepts, as papers that do not include the term autonomy anywhere within the text may not be explicitly studying autonomy.\u003c/p\u003e \u003cp\u003eThis approach aligns with our overarching goal of understanding how autonomy is conceptualized and measured in qualitative research involving persons living with dementia. We hope to shed light on the implications of these conceptualizations for understanding the needs of persons living with dementia and the subsequent development of person-centered and autonomy-supportive care interventions.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Title/Abstract Screening\u003c/h2\u003e \u003cp\u003eTwo researchers performed the title and abstract screening, ensuring a comprehensive and rigorous review. Two researchers (Anonymized for Review) independently screened all articles using predetermined inclusion criteria. The inclusion criteria were designed to capture studies that focused on autonomy and related concepts in the context of cognitive impairment, while employing qualitative social scientific methodologies.\u003c/p\u003e \u003cp\u003eThe search terms included variations of \u0026ldquo;autonom*,\u0026rdquo; \u0026ldquo;agency,\u0026rdquo; \u0026ldquo;self-determination,\u0026rdquo; \u0026ldquo;capacity,\u0026rdquo; \u0026ldquo;competence,\u0026rdquo; \u0026ldquo;decision-making,\u0026rdquo; \u0026ldquo;dependence,\u0026rdquo; and \u0026ldquo;independence.\u0026rdquo; Additionally, studies needed to focus on conditions such as dementia, Alzheimer\u0026rsquo;s disease, or mild cognitive impairment (MCI). Finally, to ensure the inclusion of social science methodologies, we looked for mentions of qualitative research techniques such as interviews, focus groups, observation, or narrative analysis.\u003c/p\u003e \u003cp\u003eAll articles were jointly assessed by the two researchers, with any disagreements resolved through discussion and consensus. This approach aligns with recommended practices for scoping reviews, ensuring a thorough and unbiased screening (Peters et al. \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Full-Text Screening\u003c/h2\u003e \u003cp\u003eAfter the title and abstract screening, the two authors (Anonymized for Review) jointly assessed the full text of each article that had passed the initial stage, applying a stricter set of inclusion criteria to ensure the studies aligned with the focus of the review. This phase involved verifying that the articles included direct responses from persons with cognitive impairment or their informal caregivers. Additionally, only studies that utilized qualitative research methodologies, such as interviews or narrative approaches, were considered. The review required that papers be either original research articles or synthetic reviews. During this stage, articles were excluded for various reasons. If only the abstract was available, we judged that this did not provide enough detail for further consideration. Articles were excluded if their participant population did not include persons with cognitive impairment or their informal caregivers. Studies were also dismissed if they lacked a focus on autonomy or related concepts, as determined by whether \u0026lsquo;autonomy\u0026rsquo; or any related terms were included within both the introduction and the findings of the study. The requirement for a robust focus on autonomy ensured that the studies we examined interpreted qualitative data in order to draw conclusions about autonomy based on an expressed (or unexpressed) conceptualization of autonomy, which constituted the subject of our review. Therefore, papers that simply offered a cursory mention of autonomy in the introduction or conclusion but did not engage in deliberate interpretation of \u0026lsquo;autonomy\u0026rsquo; based on participant responses, were excluded. Articles not published in English were excluded to maintain consistency in the review. The careful application of these criteria ensured that only the most relevant studies were included in the final analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Extraction and Analysis\u003c/h2\u003e \u003cp\u003eThe team compiled a final list of articles and then created a table summarizing key findings from the studies included. Data were organized and visualized using Excel. The autonomy components were categorized into three key areas: decisional, authenticity and executional, based on a conceptual review of central components of autonomy conducted by our research group (Anonymized for Review). No predefined hierarchy was applied to these categories; to illustrate, we did not interpret a definition that included \u0026lsquo;decisional\u0026rsquo; and \u0026lsquo;executional\u0026rsquo; dimensions as superior to one which included \u0026lsquo;decisional\u0026rsquo; and \u0026lsquo;authenticity\u0026rsquo; dimensions. Rather, definitions were considered to be more or less comprehensive depending simply on the number of important dimensions covered.\u003c/p\u003e \u003c/div\u003e"},{"header":"3.0 Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Search Results\u003c/h2\u003e \u003cp\u003eThe initial search retrieved 2077 articles (PubMed (n\u0026thinsp;=\u0026thinsp;432), Scopus (n\u0026thinsp;=\u0026thinsp;787), Embase (n\u0026thinsp;=\u0026thinsp;477), and APA PsycNet (n\u0026thinsp;=\u0026thinsp;381). Figure I displays a modified PRISMA Flow Diagram. Before title and abstract screening, 518 duplicates and 7 records were removed for other reasons. Following the abstract screening, 1172 articles were excluded. Full-text screening was applied to 373 articles, after which 308 were excluded based on the following reasons: an absence of autonomy as a central topic (n\u0026thinsp;=\u0026thinsp;207), incorrect participant population (n\u0026thinsp;=\u0026thinsp;88), incorrect paper type (n\u0026thinsp;=\u0026thinsp;8), not in English (n\u0026thinsp;=\u0026thinsp;4), and incorrect methodology (n\u0026thinsp;=\u0026thinsp;1), The total number of articles included was 65.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 General Findings\u003c/h2\u003e \u003cp\u003eOur scoping review included 65 studies that examined various dimensions of personal autonomy in persons living with cognitive impairment through qualitative and mixed-methods approaches. Only two studies included participants with MCI in addition to those with dementia; therefore, moving forward, we will discuss the patient population as \u0026lsquo;persons living with dementia\u0026rsquo; as this describes the vast majority of the review sample. Table I indicates, for each study included, whether a definition was provided and, if so, which of the three dimensions of autonomy were included. In Table I, \u0026ldquo;Definition\u0026rdquo; referred to whether the article contained a definition of autonomy. \u0026ldquo;Decisional\u0026rdquo;, \u0026ldquo;Authenticity\u0026rdquo;, and \u0026ldquo;Executional\u0026rdquo; referred to the dimensions of autonomy that we looked for when assessing the comprehensiveness of definitions, if one was given. A summary of findings, including the number of studies providing no definition, one-dimensional definitions, two-dimensional definitions, and three-dimensional definitions, is provided in Table II. More than three quarters of the studies included (77%) offered no definition or explanation of \u0026lsquo;autonomy\u0026rsquo; of any kind. Among studies that provided a definition, only 5 (8% of total studies) provided definitions addressing all three core aspects of autonomy (decisional, authenticity, and executional). Six studies (9%) defined autonomy using two dimensions, while 4 studies (6%) used just one dimension.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Studies with No Definition of Autonomy\u003c/h2\u003e \u003cp\u003eAmong studies without a clear definition (n\u0026thinsp;=\u0026thinsp;50), several patterns emerged. Many of the studies that did not provide a clear definition of autonomy used \u0026lsquo;autonomy\u0026rsquo; interchangeably with related terms which, while potentially relevant, do not appropriately operationalize autonomy. Some studies, such as Bollig et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and Burgon et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), mentioned autonomy in their results but did not provide a working definition in their methodology or introduction. Others, such as Boyle (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and Chung et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), used terms like \u0026lsquo;independence\u0026rsquo; or \u0026lsquo;agency\u0026rsquo; interchangeably with autonomy, without distinguishing between these concepts. A few studies, including Davison et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and Eriksen et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), discussed autonomy in relation to decision-making processes but did not explicitly define what they meant by autonomy in the context of their research. Similarly, studies like Genoe et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) and Phinney et al. (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) discussed autonomy in relation to identity, meaningful activities, and independence but did not provide a clear definition of the concept itself. Rapaport et al. (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) provided a circular description of autonomy as independence and \u0026ldquo;independence as an expression of autonomy\u0026rdquo; (p. 2). This definition used undefined terms to describe each other, which resulted in this paper being evaluated as having no definition of autonomy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Studies with One-Dimensional Definitions of Autonomy\u003c/h2\u003e \u003cp\u003eA small portion of the studies (6%, 4 out of 65) operationalized autonomy using a single dimension, each of which focused solely on decisional autonomy, with none focused on executional autonomy or authenticity alone. Fetherstonhaugh et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) discussed autonomy in the context of \u0026ldquo;the importance of decision-making to exercising one\u0026rsquo;s autonomy, independence, and a sense of self for people with dementia\u0026rdquo; (p. 1220). This definition emphasizes the role of the decisional dimension in autonomy but does not address the executional or authenticity dimensions. Similarly, Samsi and Manthorpe (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) related autonomy to \u0026ldquo;the ability to exercise choice,\u0026rdquo; which \u0026ldquo;contributes to autonomy and quality of life\u0026rdquo; (p. 949). They noted that while people with dementia and their carers rarely used the term \u0026lsquo;autonomy,\u0026rsquo; they described the importance of maintaining control over decisions. Stevenson et al. (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) also emphasized the decisional aspect, stating that \u0026ldquo;involving individuals with dementia in decisions about their everyday life and care is central to preserving autonomy, quality of life and personhood\u0026rdquo; (p. 1109).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Studies with Two-Dimensional Definitions of Autonomy\u003c/h2\u003e \u003cp\u003eSix of the studies (9%, 6 out of 65) defined autonomy using two dimensions. The majority of two-dimensional definitions (4 out of 6) focused on both decisional and executional aspects of autonomy. For example, Boyle (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) described autonomy as involving both \u0026ldquo;support with decision-making\u0026rdquo; and \u0026ldquo;executing their decisions\u0026rdquo; (p. 555). Similarly, Caradec and Chamahian (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) referenced Collopy\u0026rsquo;s (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1988\u003c/span\u003e) distinction between \u0026lsquo;decisional autonomy\u0026rsquo; and \u0026lsquo;autonomy of execution\u0026rsquo; as the basis for their definition of autonomy, which was the \u0026ldquo;power to decide for oneself\u0026rdquo; (p. 939). This approach was also seen in Rommerskirch-Manietta et al. (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), who defined autonomy as \u0026ldquo;having control over one\u0026rsquo;s own behaviors and goals\u0026rdquo; (p. 211), encompassing both decisional (goals) and executional (behaviors) aspects. The final paper within this group was Thorsen et al. (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), which refers to Fox et al. (2005)\u0026rsquo;s version of autonomy as \u0026ldquo;liberty, self-government, self-determination, immunity from arbitrary exercise of authority, choice and freedom\u0026rdquo; (p. 888).\u003c/p\u003e \u003cp\u003eThe other two studies combined decisional autonomy with authenticity. Sampson and Clark (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) defined autonomy as \u0026ldquo;individuals entitled to make fundamental choices about what constitutes the good life (for them)\u0026rdquo; (p. 1607), incorporating both decision-making and alignment with personal values. Similarly, Alsaeed et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) conceptualized autonomy as \u0026ldquo;a person\u0026rsquo;s ability and opportunity to make decisions relating to his/her own wishes\u0026rdquo; (p. 2), also addressing aspects of both decisional autonomy and authenticity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Studies with Three-Dimensional Definitions of Autonomy\u003c/h2\u003e \u003cp\u003eOnly 8% of the studies (5 out of 65) addressed all three dimensions of autonomy. By our assessment, these studies provided the most comprehensive conceptualization of autonomy, recognizing its complex and multifaceted nature in the context of dementia. Bentwich et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003eb) defined autonomy as \u0026ldquo;patients exercising control over their choices and life, being informed and understanding their situations, encouraging and preserving their independence, and emphasizing privacy. Additionally... exercising religious beliefs and rituals are understood as reflecting part of the patient\u0026rsquo;s life and choices\u0026rdquo; (p. 124). This definition incorporates decisional aspects (making choices), executional aspects (preserving capacity to act independently), and authenticity (beliefs and rituals). Hoek et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) provided another comprehensive definition, describing autonomy as \u0026ldquo;one\u0026rsquo;s ability to live the life one wants to live\u0026rdquo; (p. 1600). The authors also stated that \u0026ldquo;experiencing control and having freedom of choice are seen as expressions of autonomy\u0026rdquo; (p. 1600). This definition encompasses decisional autonomy (freedom of choice), executional autonomy (ability to live), and authenticity (the life one wants to live). Kaplan and Bentwich (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) used the Leino-Kilpi model of autonomy, which includes three components: \u0026ldquo;Enabling older adults suffering from physical or cognitive deterioration to control their lives and make independent choices in a way that embodies their individuality\u0026rdquo; (decisional and authenticity), \u0026ldquo;receiving information about their condition and ensuring that they understand it correctly\u0026rdquo; (decisional), and \u0026ldquo;maintaining their \u003cem\u003ede facto\u003c/em\u003e independence by taking an active initiative on the part of caregivers to ensure the preservation of existing capabilities\u0026rdquo; (executional) (p. 941). Another study, Smebye et al. (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), explored several theoretical constructs of autonomy, referencing notable works of philosophers such as Dworkin (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1986\u003c/span\u003e), Jaworska (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1999\u003c/span\u003e), and Agich (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). These constructs highlighted varying philosophical underpinnings of autonomy, from Dworkin\u0026rsquo;s focus on dignity and respect to Jaworska\u0026rsquo;s work on value-centred decision-making in persons with dementia.\u003c/p\u003e \u003c/div\u003e"},{"header":"4.0 Discussion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Discussion of Key Findings\u003c/h2\u003e \u003cp\u003eOur scoping review reveals a concerning lack of conceptual clarity regarding autonomy in qualitative research on persons living with dementia. A major finding of our study was the lack of careful operationalization of the term \u0026lsquo;autonomy.\u0026rsquo; More than three quarters of the studies (77%) offered no definition or explanation of \u0026lsquo;autonomy\u0026rsquo; of any kind, even when autonomy was a central topic of discussion in the research. Among studies that provided a definition, there was substantial inconsistency in how autonomy was defined and conceptualized. Only 5 studies (8%) provided definitions addressing all three core aspects of autonomy (decisional, authenticity, and executional), with the others attending only to one or two dimensions. Additionally, the descriptions of autonomy within each of these dimensions varied significantly. For example, the executional component of autonomy could be described as preserving the capability to act independently (Kaplan and Bentwich \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Bentwich et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), while others emphasized liberty and freedom to act (Thorsen et al. \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Fox et al. 2005). Furthermore, many studies used terms such as \u0026lsquo;independence,\u0026rsquo; \u0026lsquo;agency,\u0026rsquo; \u0026lsquo;decision-making,\u0026rsquo; or \u0026lsquo;competence\u0026rsquo; interchangeably with \u0026lsquo;autonomy.\u0026rsquo; The resulting conceptual unclarity presents substantial challenges for both research and practice in dementia care as it limits the generalizability of findings. The general paucity of operationalization seriously undermines the ability to effectively compare study outcomes and use this body of research to develop person-centered care interventions aimed at promoting autonomy in this population (Colquhoun et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eArticles that gave a definition of autonomy addressing just one or two dimensions of autonomy always included decisional autonomy. This shows a greater focus on decisional autonomy relative to executional autonomy or authenticity in the literature. However, it is important to note that the possession of personal autonomy requires not only the ability to make decisions (decisional autonomy), but also the ability to carry them out (executional autonomy). Furthermore, although a decision is made by a person, that decision may not be autonomous if it is rendered inauthentic by oppressive conditioning or manipulation. In the literature, the focus on decisional autonomy in the literature could be related to the goal of applicability to healthcare decision-making. Everyday dilemmas related to cognitive capacity, ability to give informed consent, and degree of family involvement are central to the practice of dementia care within hospital and institutional care settings. Given that these settings are where most research studies are conducted, there has been a greater relative focus on decision-making and its implications related to one of the core tenets of medical practice, \u0026lsquo;respect for autonomy.\u0026rsquo; Maintaining involvement in decision-making is of high importance for people with dementia (Dening et al. 2017). Therefore, many of the included studies investigated the way in which decision-making activities are supported, often with the help of informal care partners. For example, Smebye et al. (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) stated that shared decision-making, which involved carers and persons with dementia negotiating decisions within collaborative partnerships, was the most commonly observed decision-making approach among participants. Nearly every study involved the participation of informal care partners in some form, demonstrating the importance of others to continued autonomy expression in persons with dementia.\u003c/p\u003e \u003cp\u003eAlthough we did not include relational embeddedness within the three dimensions of autonomy considered for assessment of definitions, the literature revealed that this is an essential part of the context in which people with dementia exercise autonomy. As such, we decided to include several studies in this review that noted the particular importance of relational embeddedness when describing autonomy for persons with dementia. Caradec and Chamahian (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) distinguished between proclaimed (individual) autonomy and delegated autonomy, referring to instances where persons with dementia may delegate decision-making authority to a trusted other when they are deemed incapable of such decisions on their own. Sinclair et al. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) suggest that \u0026ldquo;human capacity for autonomy is developed, expressed, and always dependent on, supportive relationships of mutual recognition\u0026rdquo; (p. 588). Furthermore, Niemeijer et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) critiqued the \u0026ldquo;standard views of autonomy emphasizing non-interference and independence\u0026rdquo; as not being sensitive enough to the complex conditions that actually support the unique identity of persons (p. 308). The frequent conceptualization of autonomy as related to \u0026lsquo;independence\u0026rsquo; and \u0026lsquo;the ability to perform activities independently\u0026rsquo; in the literature (Rapaport et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Thorsen et al. \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) is problematic because the maintenance of autonomy in persons with dementia involves varying degrees of interdependence, rather than independence. Once again, greater conceptual clarity would be helpful in this instance.\u003c/p\u003e \u003cp\u003eNotably, none of the studies in our review provided a definition that focused solely on the authenticity dimension of autonomy. This finding is reasonable given that authenticity is often examined in its application to decision-making or action-oriented scenarios (i.e., examining whether a decision aligns with one\u0026rsquo;s personal beliefs). However, the lack of attention to authenticity in the two-dimensional (authenticity in 2 out of 6) definitions in this review may reflect a more general lack of attention to authenticity compared with decisional and executional components in published research on autonomy in persons living with dementia. This is problematic because the memory loss and potential personality and behavioral changes associated with dementia greatly impact one\u0026rsquo;s sense of personal identity. When one\u0026rsquo;s sense of self is undermined, the ability to make authentic decisions is likewise diminished. A few studies included in our review identified a notable connection between autonomy and personal identity. For example, Genoe et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) connected considerations of autonomy to the \u0026ldquo;process of honouring identity\u0026hellip; [which] involved protecting dignity while struggling for autonomy, having meaningful roles, and reaffirming sense of self in the world (p. 185). The lack of attention to authenticity identified in this scoping review indicates an insufficient consideration of this dimension of autonomy in research and practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Implications for Care Practices and Policy Development\u003c/h2\u003e \u003cp\u003eSignificant variability in understanding and operationalization of autonomy can lead to divergent approaches in care practices. While this is not inherently problematic, different aspects of autonomy may require different support strategies. For instance, practices that focus predominantly on decisional autonomy may prioritize interventions that enhance the cognitive capabilities of persons living with dementia, such as decision aids that explicitly state the decision, provide relevant information, and summarize the benefits and harms of each option (Davies et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Conversely, an expanded understanding of autonomy as relational promotes a collective approach to decision-making, closely involving caregivers and social networks (Groen-van de Ven et al. 2018; Smebye et al. \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). The real difficulty arises from the fragmentation of these approaches. When research, policy and practice recommendations are developed in isolation, without awareness of how they fit into a comprehensive framework of autonomy-promoting care, the result can be an incomplete or imbalanced approach to supporting autonomy. For example, there is a notable lack of discussion in the literature related to exploring authentic expression of autonomy in practice settings, likely linked to the lack of consideration of authenticity in institutional policies. Although a systematic determination of authenticity is certainly challenging to formalize into policy given its subjective and individual nature, certain considerations outlined in policy could help improve the implementation of person-centred care in practice. Standardizing advance care planning practices that promote early discussion of the beliefs and values of the person with dementia before crisis occurs, and procedures that give time and space for deliberation about important decisions between persons with dementia, their care partners, and health professionals could potentially increase the authenticity of decisions made in institutional settings. Furthermore, a common understanding of all that autonomy entails for persons living with dementia is necessary for policymakers to create guidelines that are both comprehensive and applicable across different care settings. By incorporating all three dimensions, researchers and practitioners can develop a more nuanced understanding of autonomy that reflects the lived experiences of persons living with dementia. This comprehensive approach would allow for the development of interventions that support autonomy in its fullest sense, rather than focusing on isolated aspects. We do not wish to suggest that research focused on particular aspects of personal autonomy is problematic. But researchers and health practitioners should not be misled to think that one or another aspect is equivalent to personal autonomy as a whole. There is more to supporting autonomy than supporting decision-making, or execution of choices, or authenticity, on their own. A comprehensive autonomy framework is needed to meaningfully relate, combine and situate research on the same or different aspects of personal autonomy, and to ensure understanding of what is involved in promoting personal autonomy as a whole.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Future Directions\u003c/h2\u003e \u003cp\u003eMoving forward, there is a need for a more consistent and theoretically grounded definition of autonomy in research involving persons living with dementia to ensure a more cohesive body of knowledge and allow for greater comparability between studies. Future studies should explicitly define autonomy, ideally incorporating all three dimensions. Additionally, future research should explore how these three dimensions of autonomy interact and potentially change over the course of dementia progression. The degree of concern related to the various dimensions of autonomy depends on the type of dementia one has and where degenerative changes are occurring in the brain. For example, individuals with Lewy body dementia may experience physical symptoms of loss of coordination, muscle rigidity, or tremors sooner than other types (Alzheimer Society of Canada 2024), potentially necessitating a greater focus on executional autonomy. Additionally, there are few studies conducted with participants with moderate to advanced dementia, due to the difficulty of obtaining consent and the unproven assumption that one\u0026rsquo;s ability to express autonomy at these stages is absent. Even fewer of these studies attend to the lived experience of persons living with advanced dementia. Longitudinal studies investigating a variety of dementia diagnoses could provide valuable insights into how autonomy can be supported at different stages of the condition.\u003c/p\u003e \u003c/div\u003e"},{"header":"5.0 Limitations","content":"\u003cp\u003eThis scoping review has several limitations that should be considered when interpreting its findings. While we conducted a systematic search of the literature to address our research question, the purpose of this review was primarily to describe the current state of autonomy operationalization in qualitative studies involving persons living with dementia. As such, our findings are highly focused and are mainly descriptive in nature, not providing a comprehensive critical appraisal of the quality of the studies included. We suggest that a complete definition should include, at a minimum, the three core aspects (decisional autonomy, executional autonomy, and authenticity) evident from a review of the philosophical literature theorizing about personal autonomy, and we indicate how the studies included measure up against this three-dimensional standard, but beyond this we do not evaluate the caliber of the studies.\u003c/p\u003e \u003cp\u003eA second limitation of our study lies in our search strategy, which focused specifically on the term \u0026lsquo;autonomy\u0026rsquo; and its direct variants. While this approach allowed for a focused examination of how autonomy is explicitly conceptualized, it also presents challenges. As discussed earlier in our review, the concept of personal autonomy is often conflated with related but distinct terms such as \u0026lsquo;independence,\u0026rsquo; \u0026lsquo;agency,\u0026rsquo; \u0026lsquo;decision-making,\u0026rsquo; \u0026lsquo;self-determination,\u0026rsquo; \u0026lsquo;self-governance,\u0026rsquo; \u0026lsquo;capacity,\u0026rsquo; and \u0026lsquo;competence.\u0026rsquo; As we excluded studies that did not directly relate the term \u0026lsquo;autonomy\u0026rsquo; to other terms, we may have inadvertently omitted relevant research that explores autonomy-related concepts under these alternative terminologies. This limitation potentially narrows the scope of our findings and may not fully capture the way the phenomenon of personal autonomy is represented in current research. It is possible that studies using these related terms might offer valuable insights into aspects of autonomy for persons living with dementia even if they do not explicitly use the term \u0026lsquo;autonomy\u0026rsquo; or incorrectly use a related term in the place of \u0026lsquo;autonomy.\u0026rsquo; Future reviews might consider broadening the search criteria to include these related terms, while carefully distinguishing between true examinations of autonomy and studies that focus on related but distinct concepts.\u003c/p\u003e \u003cp\u003eAdditionally, our focus on qualitative studies, which provide rich, in-depth data on the lived experiences of persons living with dementia, excludes quantitative research that might offer complementary insights into the operationalization of autonomy. Biomedical research in particular often measures autonomy using proxy measurements such as instrumental activities of daily living scales (K\u0026ouml;nig et al. \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) or includes autonomy subscales within investigations of well-being (Stoner et al. \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Future work could benefit from integrating exclusively quantitative approaches to provide a more comprehensive understanding of how autonomy is conceptualized and measured in research involving persons living with dementia. Such an analysis could potentially identify scales that incorporate a more encompassing definition of autonomy, addressing all three dimensions (decisional, executional, and authenticity). This would not only broaden our understanding of how autonomy is operationalized across different research methodologies but could also highlight areas where quantitative measures could be improved to better capture the multidimensional nature of autonomy in persons living with dementia.\u003c/p\u003e"},{"header":"6.0 Conclusion","content":"\u003cp\u003eThis scoping review demonstrates the need for more rigorous and consistent operationalization of autonomy in qualitative studies involving persons living with dementia. Future research should prioritize the use of clear, theoretically grounded definitions of autonomy that acknowledge its multifaceted nature, including its decisional, executional, and authenticity dimensions. This is particularly important in the context of cognitive impairment, where the concept of autonomy must be understood in ways that are adaptable to the changing capacities of individuals while maintaining conceptual precision. Such an approach ensures that interventions are appropriately designed to meet the specific and evolving needs of persons living with dementia. By enhancing conceptual clarity, we can improve the quality of research in this field in several ways. First, it will enable more accurate measurement and assessment of autonomy in persons living with dementia, leading to more reliable data. Second, it will facilitate more meaningful comparisons across studies, allowing for more robust meta-analyses and synthesis of findings. Third, it will help researchers to more precisely identify the specific aspects of autonomy that are impacted by various interventions or care approaches. There are also important implications for policy and practice related to autonomy supportive care. Healthcare professionals who want to base autonomy-promoting care policy or strategies on empirical evidence will turn to the relevant literature to learn about the lived experience of persons living with dementia. If these studies are unclear about what the phenomenon they have sought to study consists in, it will be difficult for health professionals to determine the relevance of their results, and the effect may be a correspondingly misleading and/or partial strategy for supporting personal autonomy within health care. Improved conceptual clarity and research quality will ultimately lead to more effective person-centered approaches to promoting autonomy in dementia care.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCompeting Interests\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/span\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEthical Approval\u003c/span\u003e:\u003c/strong\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis article does not contain any studies with human participants performed by any of the authors.\u003c/span\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eInformed Consent\u003c/span\u003e:\u003c/strong\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis article does not contain any studies with human participants performed by any of the authors.\u003c/span\u003e \u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003eand Acknowledgements\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis work was supported by (\u003c/span\u003eAnonymized for Review). \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe authors would also like to acknowledge the team at\u003c/span\u003e (Anonymized for Review) \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003efor their support and collaboration.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: AB, EM, AS; Methodology: AB, EM; Formal analysis and investigation: AB, EM; Writing - original draft preparation: AB, EM; Writing - review and editing: AB, EM, AS; Funding acquisition: AS; Resources: AS; Supervision: AS.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis work was supported by the Social Sciences and Humanities Research Council of Canada, Insight Grant awarded to Dr. Andrew Stumpf (435-2022-0530). The authors would also like to acknowledge the team at the Kernel Network Waterloo for their support and collaboration.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are openly available in the Open Science Framework Data Repository at (Anonymized for Review) [.](https:/doi.org/10.17605/OSF.IO/6FBMW.)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAgich G (2003) Dependence and Autonomy in Old Age: An Ethical Framework for Long-term Care. Cambridge University Press, Cambridge\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsaeed D, Orlu M, Smith F (2021) Optimising Medication Use along Dementia Progression: Recommendations from a Qualitative Study. Healthc (Basel) 9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/healthcare9080982\u003c/span\u003e\u003cspan address=\"10.3390/healthcare9080982\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArksey H, O\u0026rsquo;Malley L (2005) Scoping studies: towards a methodological framework. Int J Soc Res Methodol 8:19\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/1364557032000119616\u003c/span\u003e\u003cspan address=\"10.1080/1364557032000119616\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBentwich ME, Dickman N, Oberman A (2018) Human dignity and autonomy in the care for patients with dementia: differences among formal caretakers from various cultural backgrounds. Ethn Health 23:121\u0026ndash;141. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13557858.2016.1246519\u003c/span\u003e\u003cspan address=\"10.1080/13557858.2016.1246519\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBollig G, Gjengedal E, Rosland JH (2016) Nothing to complain about? Residents\u0026rsquo; and relatives\u0026rsquo; views on a \u0026lsquo;good life\u0026rsquo; and ethical challenges in nursing homes. Nurs Ethics 23:142\u0026ndash;153. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0969733014557719\u003c/span\u003e\u003cspan address=\"10.1177/0969733014557719\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoyle G (2013) She\u0026rsquo;s usually quicker than the calculator\u0026rsquo;: Financial management and decision-making in couples living with dementia. Health Soc Care Community 21:554\u0026ndash;562. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/hsc.12044\u003c/span\u003e\u003cspan address=\"10.1111/hsc.12044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoyle G (2017) Revealing gendered identity and agency in dementia. Health Soc Care Community 25:1787\u0026ndash;1793. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/hsc.12452\u003c/span\u003e\u003cspan address=\"10.1111/hsc.12452\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurgon C, Goldberg S, Van Der Harwood WV R.H (2023) Experiences and understanding of apathy in people with neurocognitive disorders and their carers: a qualitative interview study. Age Ageing 52:afad031. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ageing/afad031\u003c/span\u003e\u003cspan address=\"10.1093/ageing/afad031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaradec V, Chamahian A (2017) The \u0026eacute;preuve of ageing with Alzheimer\u0026rsquo;s disease. Ageing Soc 37:935\u0026ndash;960. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0144686X16000167\u003c/span\u003e\u003cspan address=\"10.1017/S0144686X16000167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardol M, Jong BAD, Ward CD (2002) On autonomy and participation in rehabilitation. Disabil Rehabil 24:970\u0026ndash;974. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09638280210151996\u003c/span\u003e\u003cspan address=\"10.1080/09638280210151996\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristman J (2009) The Politics of Persons: Individual Autonomy and Socio-historical Selves. Cambridge University Press, Cambridge\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung PYF, Ellis-Hill C, Coleman P (2017) Supporting activity engagement by family carers at home: maintenance of agency and personhood in dementia. Int J Qual Stud Health Well-being 12:1267316. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/17482631.2016.1267316\u003c/span\u003e\u003cspan address=\"10.1080/17482631.2016.1267316\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollopy BJ (1988) Autonomy in long term care: some crucial distinctions. Gerontologist 28:10\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColquhoun H, Leeman J, Michie S et al (2014) Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies. Implement Sci 9:781. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1748-5908-9-51\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-9-51\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavies N, Schiowitz B, Rait G et al (2019) Decision aids to support decision-making in dementia care: a systematic review. Int Psychogeriatr 31:1403\u0026ndash;1419. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S1041610219000826\u003c/span\u003e\u003cspan address=\"10.1017/S1041610219000826\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavison TE, Camoes-Costa V, Clark A (2019) Adjusting to life in a residential aged care facility: Perspectives of people with dementia, family members and facility care staff. J Clin Nurs 28:3901\u0026ndash;3913. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jocn.14978\u003c/span\u003e\u003cspan address=\"10.1111/jocn.14978\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDening KH, King M, Jones L et al (2016) Advance Care Planning in Dementia: Do Family Carers Know the Treatment Preferences of People with Early Dementia? PLoS ONE 11:e0159056. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0159056\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0159056\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonnelly S, Begley E, O\u0026rsquo;Brien M (2019) How are people with dementia involved in care-planning and decision-making? An Irish social work perspective. Dementia 18:2985\u0026ndash;3003. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1471301218763180\u003c/span\u003e\u003cspan address=\"10.1177/1471301218763180\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuong S, Patel T, Chang F (2017) Dementia. Can Pharm J (Ott) 150:118\u0026ndash;129. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1715163517690745\u003c/span\u003e\u003cspan address=\"10.1177/1715163517690745\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDworkin R (1994) Life\u0026rsquo;s Dominion. Random House, Inc, New York\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDworkin R (1986) Autonomy and the Demented Self. Milbank Q 64:4\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2307/3349959\u003c/span\u003e\u003cspan address=\"10.2307/3349959\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEriksen S, Engedal K, Grov EK (2022) Lifeworld perspectives of people with dementia: a meta-aggregation of qualitative studies. BMC Geriatr 22:970. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-022-03660-w\u003c/span\u003e\u003cspan address=\"10.1186/s12877-022-03660-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFetherstonhaugh D, Rayner J-A, Tarzia L (2019) Hanging on to some autonomy in decision-making: How do spouse carers support this? Dementia: Int J Social Res Pract 18:1219\u0026ndash;1236. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1471301216678104\u003c/span\u003e\u003cspan address=\"10.1177/1471301216678104\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFetherstonhaugh D, Tarzia L, Nay R (2013) Being central to decision making means I am still here! The essence of decision making for people with dementia. J Aging Stud 27:143\u0026ndash;150. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaging.2012.12.007\u003c/span\u003e\u003cspan address=\"10.1016/j.jaging.2012.12.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGenoe R, Dupuis SL, Keller HH et al (2010) Honouring identity through mealtimes in families living with dementia. J Aging Stud 24:181\u0026ndash;193. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaging.2010.02.001\u003c/span\u003e\u003cspan address=\"10.1016/j.jaging.2010.02.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Groen-Van L, Smits C, Span M et al (2018) The challenges of shared decision making in dementia care networks. Int Psychogeriatr 30:843\u0026ndash;857. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S1041610216001381\u003c/span\u003e\u003cspan address=\"10.1017/S1041610216001381\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawkins J, Charland LC (2020) Decision-Making Capacity. In: Zalta EN (ed) The Stanford Encyclopedia of Philosophy, Fall 2020. Metaphysics Research Lab, Stanford University\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoek LJM, Verbeek H, de Vries E et al (2020) Autonomy Support of Nursing Home Residents With Dementia in Staff-Resident Interactions: Observations of Care. J Am Med Dir Assoc 21:1600\u0026ndash;1608e2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jamda.2020.04.013\u003c/span\u003e\u003cspan address=\"10.1016/j.jamda.2020.04.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaworska A (1999) Respecting the margins of agency: Alzheimer\u0026rsquo;s patients and the capacity to value. Philos Public Aff 28:105\u0026ndash;138. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1088-4963.1999.00105.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1088-4963.1999.00105.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplan F, Bentwich ME (2023) Do differences exist in cross-cultural caregivers\u0026rsquo; respect for the autonomy/dignity of people with dementia? Real-time field observations in nursing homes. Dement (London) 22:935\u0026ndash;963. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/14713012231158410\u003c/span\u003e\u003cspan address=\"10.1177/14713012231158410\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnopman DS, Petersen RC (2014) Mild Cognitive Impairment and Mild Dementia: A Clinical Perspective. Mayo Clinic proceedings 89:1452. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.mayocp.2014.06.019\u003c/span\u003e\u003cspan address=\"10.1016/j.mayocp.2014.06.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026ouml;nig A, Crispim-Junior CF, Covella AGU et al (2015) Ecological Assessment of Autonomy in Instrumental Activities of Daily Living in Dementia Patients by the Means of an Automatic Video Monitoring System. Front Aging Neurosci 7:98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fnagi.2015.00098\u003c/span\u003e\u003cspan address=\"10.3389/fnagi.2015.00098\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLe TD, Lin S-C, Huang M-C et al (2023) Factors impacting the demonstration of relational autonomy in medical decision-making: A meta-synthesis. Nurs Ethics 09697330231200570. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/09697330231200570\u003c/span\u003e\u003cspan address=\"10.1177/09697330231200570\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevac D, Colquhoun H, O\u0026rsquo;Brien KK (2010) Scoping studies: advancing the methodology. Implement Sci 5:69. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1748-5908-5-69\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-5-69\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi J (2023) Autonomy-supportive environments for people with dementia: an evidence-based review. Interdisciplinary Nurs Res 2:188. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/NR9.0000000000000036\u003c/span\u003e\u003cspan address=\"10.1097/NR9.0000000000000036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMackenzie C (2000) Imagining Oneself Otherwise. In: Mackenzie C, Stoljar N (eds) Relational Autonomy. Oxford University Press, New York, USA, pp 124\u0026ndash;150\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarceta JA (2018) A non-ideal authenticity-based conceptualization of personal autonomy. Med Healthc Philos 22:387. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11019-018-9879-1\u003c/span\u003e\u003cspan address=\"10.1007/s11019-018-9879-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMattos MK, Gibson JS, Wilson D et al (2023) Shared decision-making in persons living with dementia: A scoping review. Dement (London) 22:875\u0026ndash;909. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/14713012231156976\u003c/span\u003e\u003cspan address=\"10.1177/14713012231156976\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMccormack B (2001) Autonomy and the relationship between nurses and older people. Ageing Soc 21:417\u0026ndash;446. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0144686X01008303\u003c/span\u003e\u003cspan address=\"10.1017/S0144686X01008303\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaik AD, Dyer CB, Kunik ME, McCullough LB (2009) Patient Autonomy for the Management of Chronic Conditions: A Two-Component Re-conceptualization. Am J Bioeth 9:23\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15265160802654111\u003c/span\u003e\u003cspan address=\"10.1080/15265160802654111\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiemeijer AR, Depla MFIA, Frederiks BJM, Hertogh CMPM (2015) The experiences of people with dementia and intellectual disabilities with surveillance technologies in residential care. Nurs Ethics 22:307\u0026ndash;320. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0969733014533237\u003c/span\u003e\u003cspan address=\"10.1177/0969733014533237\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeters MDJ, Marnie C, Tricco AC et al (2020) Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth 18:2119\u0026ndash;2126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.11124/JBIES-20-00167\u003c/span\u003e\u003cspan address=\"10.11124/JBIES-20-00167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhinney A, Chaudhury H, O\u0026rsquo;Connor DL (2007) Doing as much as I can do: The meaning of activity for people with dementia. Aging Ment Health 11:384\u0026ndash;393. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13607860601086470\u003c/span\u003e\u003cspan address=\"10.1080/13607860601086470\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRapaport P, Burton A, Leverton M et al (2020) I just keep thinking that I don\u0026rsquo;t want to rely on people.\u0026rsquo; a qualitative study of how people living with dementia achieve and maintain independence at home: stakeholder perspectives. BMC Geriatr 20:5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-019-1406-6\u003c/span\u003e\u003cspan address=\"10.1186/s12877-019-1406-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRommerskirch-Manietta M, Manietta C, Purwins D et al (2023) This is Slowly Becoming my Interest\u0026hellip; The Understanding of Leisure and Preferences for Leisure Activities of People Receiving Adult Day Services. Res Aging 46:210. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/01640275231221162\u003c/span\u003e\u003cspan address=\"10.1177/01640275231221162\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyan WS, Ryan RM (2019) Toward a Social Psychology of Authenticity: Exploring Within-Person Variation in Autonomy, Congruence, and Genuineness Using Self-Determination Theory. Rev Gen Psychol 23:99\u0026ndash;112. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/gpr0000162\u003c/span\u003e\u003cspan address=\"10.1037/gpr0000162\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSampson MS, Clark A (2016) Deferred or chickened out?\u0026rsquo; Decision making among male carers of people with dementia. Dementia: Int J Social Res Pract 15:1605\u0026ndash;1621. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1471301214566663\u003c/span\u003e\u003cspan address=\"10.1177/1471301214566663\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamsi K, Manthorpe J (2013) Everyday decision-making in dementia: Findings from a longitudinal interview study of people with dementia and family carers. Int Psychogeriatr 25:949\u0026ndash;961. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S1041610213000306\u003c/span\u003e\u003cspan address=\"10.1017/S1041610213000306\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchlosser M (2019) Agency. In: Zalta EN (ed) The Stanford Encyclopedia of Philosophy, Winter 2019. Metaphysics Research Lab, Stanford University\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSerbser-Koal J, Dreyer J, Roes M (2024) Autonomy and its relevance for the construction of personhood in dementia\u0026ndash; a thematic synthesis. BMC Geriatr 24:255. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-024-04808-6\u003c/span\u003e\u003cspan address=\"10.1186/s12877-024-04808-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinclair C, Gersbach K, Hogan M et al (2019) A Real Bucket of Worms\u0026rsquo;: Views of People Living with Dementia and Family Members on Supported Decision-Making. J Bioeth Inq 16:587\u0026ndash;608. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11673-019-09945-x\u003c/span\u003e\u003cspan address=\"10.1007/s11673-019-09945-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmebye KL, Kirkevold M, Engedal K (2012) How do persons with dementia participate in decision making related to health and daily care? a multi-case study. BMC Health Serv Res 12:241. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1472-6963-12-241\u003c/span\u003e\u003cspan address=\"10.1186/1472-6963-12-241\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmebye KL, Kirkevold M, Engedal K (2016) Ethical dilemmas concerning autonomy when persons with dementia wish to live at home: a qualitative, hermeneutic study. BMC Health Serv Res 16:21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-015-1217-1\u003c/span\u003e\u003cspan address=\"10.1186/s12913-015-1217-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevenson M, Savage B, Taylor BJ (2019) Perception and communication of risk in decision making by persons with dementia. Dementia: Int J Social Res Pract 18:1108\u0026ndash;1127. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1471301217704119\u003c/span\u003e\u003cspan address=\"10.1177/1471301217704119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStoner CR, Orrell M, Spector A (2019) The psychometric properties of the control, autonomy, self-realisation and pleasure scale (CASP-19) for older adults with dementia. Aging Ment Health 23:643\u0026ndash;649. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13607863.2018.1428940\u003c/span\u003e\u003cspan address=\"10.1080/13607863.2018.1428940\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThorsen K, Dourado MCN, Johannessen A (2020) Developing dementia: The existential experience of the quality of life with young-onset dementia\u0026mdash;A longitudinal case study. Dementia: Int J Social Res Pract 19:878\u0026ndash;893. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1471301218789990\u003c/span\u003e\u003cspan address=\"10.1177/1471301218789990\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan der Weide H, Lovink MH, Luijkx KG, Gerritsen DL (2023) Supporting autonomy for people with dementia living in nursing homes: A rapid realist review. Int J Nurs Stud 137:104382. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijnurstu.2022.104382\u003c/span\u003e\u003cspan address=\"10.1016/j.ijnurstu.2022.104382\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cu\u003eTable I: Autonomy operationalization within included studies\u003c/u\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"616\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCitation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecisional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthenticity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExecutional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eAlsaeed et al. 2021\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eBentwich et al. 2018\u003c/em\u003e\u003cem\u003ea\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eBentwich et al. 2018\u003c/em\u003e\u003cem\u003eb\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eBoddington \u0026amp; Featherstone, 2018\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eBollig et al. 2016\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eBoyle, 2013\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eBoyle, 2017\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eBronner et al. 2016\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eBurgon et al. 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eCaradec \u0026amp; Chamahian, 2017\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eChung et al. 2017\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eDavison et al. 2019\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eDimech et al. 2021\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eElliott et al. 2009\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eEriksen et al. 2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eFarrington et al. 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eFetherstonhaugh et al. 2019\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eForsund et al. 2018\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eGamm et al. 2024\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eGenoe et al. 2010\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eGroen-Van De Ven et al. 2018\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eGroenvynck et al. 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eHeggestad et al. 2013\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eHoek et al. 2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eHorton-Deutsch et al. 2007\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eKaplan. \u0026amp; Bentwich, 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eKaufmann \u0026amp; Engel, 2016\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eKiwi, 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eLandau et al. 2010\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eLiou \u0026amp; Jarrott, 2013\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eLord et al. 2016\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eMacQuarrie, 2005\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eMesbah et al. 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eMotta-Ochoa et al. 2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eNiemeijer et al. 2015\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eNoone \u0026amp; Jenkins, 2018\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eNygard et al. 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eOhman \u0026amp; Nygard, 2005\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003ePhinney et al. 2007\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003ePyer \u0026amp; Ward, 2024\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eRapaport et al. 2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eRees et al. 2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eRimkeit \u0026amp; McIntosh, 2017\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eRommerskirch-Manietta et al. 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eRoss et al. 2024\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eSagbakken et al. 2017\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eSampson \u0026amp; Clark, 2016\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eSamsi \u0026amp; Manthorpe, 2013\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eSinclair et al. 2019\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eSmebye et al. 2012\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eSmebye et al. 2016\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eStevenson et al. 2019\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eStewart-Archer et al. 2016\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eStockwell-Smith et al. 2019\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eTaylor et al. 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eThorsen et al. 2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eTortosa-Mart\u0026iacute;nez et al. 2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eTranvag et al. 2015\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eVan Gennip et al. 2014\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003evan Oppen et al. 2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eWang et al. 2011\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eXanthopoulou \u0026amp; McCabe, 2019\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eYeh et al. 2021\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eZeilig et al. 2019\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cem\u003eZiebuhr et al. 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable II:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eTotals and Percentages of included studies for each Autonomy Operationalization Category\u003c/u\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"619\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThree Dimensions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTwo\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDimensions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOne\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo Definition\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTotal (n = 65)\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003en = \u0026nbsp;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003en = \u0026nbsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003en = 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003en = 50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePercentage (100%)\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e(8%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e(9%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e(6%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e(77%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Dementia, Alzheimer’s disease, cognitive impairment, autonomy, agency, scoping review, qualitative","lastPublishedDoi":"10.21203/rs.3.rs-7190181/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7190181/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe concept of personal autonomy is fundamental to person-centred care, particularly for persons living with cognitive impairments due to conditions such as dementia. Many empirical studies investigating autonomy in persons with dementia do not provide consistent and theoretically grounded definitions of the term \u0026ldquo;autonomy,\u0026rdquo; leading to a problematic lack of conceptual clarity.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThe aim of this study is to identify and assess definitions of autonomy in qualitative research that considers the phenomenon of autonomy in persons living with dementia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA scoping review was completed in PubMed, Embase (Ovid), Scopus and APA PsycNet. Keywords included terms within the content areas of dementia and autonomy. Inclusion criteria were as follows: mentions of autonomy, participant population with cognitive impairment, adult participants, and qualitative methodology. Included studies were assessed according to whether descriptions of autonomy (if provided) addressed important dimensions of autonomy, namely decisional autonomy, executional autonomy, and authenticity.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 65 eligible articles, the majority (77%, n\u0026thinsp;=\u0026thinsp;50) provided no definition of autonomy. Of those that did define autonomy, only 5 (8%) addressed all three dimensions of decisional autonomy, executional autonomy, and authenticity, while 6 (9%) addressed two dimensions, and 4 (6%) addressed only one dimension.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAutonomy is inconsistently and incompletely defined in empirical literature on dementia, with most studies lacking careful theoretical grounding. This conceptual ambiguity hampers research synthesis, impedes clinical application, and potentially undermines the development of effective autonomy-supporting interventions. Consistent operationalization of personal autonomy is necessary to advance research and improve care for persons living with dementia.\u003c/p\u003e","manuscriptTitle":"The operationalization of autonomy in qualitative studies of persons living with dementia: A scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 06:24:07","doi":"10.21203/rs.3.rs-7190181/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-03T11:51:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-29T09:29:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-27T12:09:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-26T06:47:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-25T04:16:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-24T02:02:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-23T11:31:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-22T21:37:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-16T21:30:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53429787005691099402445482575990022707","date":"2025-09-12T01:42:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12709692139634948487744199539118255340","date":"2025-09-10T14:55:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"41343961555700351761777590674807748873","date":"2025-09-10T08:56:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120623418570904982168462545625930154815","date":"2025-09-08T15:26:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"148015068888476651142379242661949191390","date":"2025-09-08T11:10:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61619121765829486505942944217295743372","date":"2025-09-08T05:10:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280373048300615617990593499308912100176","date":"2025-09-06T15:16:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256150888251091683254862272292776658126","date":"2025-09-06T14:41:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-06T14:35:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-06T14:23:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-29T09:44:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-11T15:46:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Humanities and Social Sciences Communications","date":"2025-08-11T15:43:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b5058159-2bb5-4f86-9b5f-e56406efa6ed","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T00:23:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 06:24:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7190181","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7190181","identity":"rs-7190181","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}