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. Author manuscript; available in PMC: 2026 May 13.
Published in final edited form as: J Gerontol Nurs. 2026 May 1;52(5):6–13. doi: 10.3928/00989134-20260414-02

Ethical considerations in promoting physical activity for nursing home residents with cognitive impairment: implications for policy and practice

Jieun Lim 1,2, Adriana Perez 1,2
PMCID: PMC13167142  NIHMSID: NIHMS2164767  PMID: 42054240

Abstract

PURPOSE:

Promoting physical activity (PA) among nursing home (NH) residents, particularly those with cognitive impairment, often generates ethical tensions that may be rooted in paternalism, risk-averse cultures, and institutional routines. Therefore, it is necessary to address ethical considerations that can inform policy and practice aimed at promoting safe and effective PA intervention strategies.

METHOD:

PA promotion was examined through the bioethical principles of autonomy, beneficence, nonmaleficence, and justice. The analysis was extended by introducing a relational autonomy framework suited to contexts of cognitive vulnerability.

RESULTS:

By situating agency within relational, cultural, and organizational structures, the relational autonomy framework clarifies how ethically grounded and cognitively responsive PA can be enabled or constrained in long-term care settings. The analysis further demonstrated that principlist approaches alone are insufficient to address the relational dependencies and fluctuating capacities that shape NH residents’ participation.

CONCLUSION:

Meaningful PA requires communication strategies attuned to cognitive fluctuation, identity-aligned activity design, and institutional flexibility that reduces structural barriers. Integrating relational autonomy into PA policy, staff training, and everyday care practices is ethically necessary to not only promote overall health, but to uphold agency, equity, and personhood for cognitively impaired NH residents.

Keywords: physical activity, cognitive impairment, relational autonomy, nursing homes, dignity

Introduction

Cognitive impairment, including mild cognitive impairment (MCI) and dementia, is highly prevalent among nursing home (NH) residents (Mukamel et al., 2023) and constitutes a major source of disability, dependence, and diminished quality of life (Livingston et al., 2020; World Health Organization, 2017). As populations age, cognitive decline increasingly co-occurs with frailty and multimorbidity, further intensifying residents’ vulnerability and constraining their capacity to participate in everyday activities (Clegg et al., 2013; Yuan et al., 2021). Taken together, these intersecting challenges underscore the urgent need for integrated and sustained approaches that support cognitive, physical, and emotional well-being.

Physical activity (PA) in this paper refers to a broad range of structured and unstructured movement-based activities, including exercise classes, walking routines, mobility-oriented practices, and adapted one-on-one activities—intended to support residents’ physical, cognitive, or emotional well-being. As such, PA is widely recognized as a promising non-pharmacological strategy for enhancing activities of daily living (ADLs), cognition, and emotional well-being among older adults with cognitive impairment (Biazus-Sehn et al., 2020; Demurtas et al., 2020). Yet within NHS, PA is frequently operationalized through rigid routines and risk-averse institutional cultures that can convert a potentially autonomy-enhancing practice into a locus of ethical concern (Benjamin et al., 2009; Hallam & Lewis, 2022). Documented resident preferences may not be readily accessible or consistently communicated to NH staff at the point of care, limiting their integration into care delivery and potentially undermining residents’ autonomy (Heid et al., 2024). Such structural and relational dynamics may paradoxically restrict residents’ agency, reinforce dependency, or inadvertently exclude cognitively impaired residents from opportunities for authentic, person-centered engagement.

These tensions are fundamentally ethical in nature rather than merely operational. Organizational constraints, paternalistic assumptions, and restrictive safety policies can undermine residents’ autonomy by curtailing choice and can compromise dignity by obscuring identity, personhood, and the meaningful dimensions of lived experience (Kunyk & Austin, 2021; van der Geugten & Goossensen, 2020). While the principlist framework—autonomy, beneficence, nonmaleficence, and justice—offers a foundational analytic lens, it remains insufficient without a relational conception of autonomy that acknowledges residents’ agency as socially, relationally, and institutionally co-constructed, particularly within contexts of cognitive vulnerability (Beauchamp & Childress, 2019; Gómez-Vírseda et al., 2019).

To address these gaps, this paper (1) analyzes PA promotion through the four core bioethical principles; (2) demonstrates why a principle-only approach fails to account for cognitive fluctuation, relational dependence, and institutional constraint; and (3) introduces a relational-autonomy framework that offers concrete ethical guidance for redesigning PA practices, organizational routines, and policy structures. The sections that follow systematically examine these tensions and articulate how relational autonomy can inform ethically grounded, cognitively responsive, and dignity-affirming PA in long-term care settings.

Bioethical Principles

Ethical analysis of PA promotion in NHs requires attention to the four core bioethical principles—autonomy, beneficence, nonmaleficence, and justice. Each principle is implicated in distinct yet interconnected ways: autonomy is shaped by institutional routines, beneficence by the design and relevance of activities, nonmaleficence by safety practices and risk cultures, and justice by systemic inequities that limit access to cognitively responsive and identity-aligned PA.

Autonomy

The principle of autonomy requires that residents retain meaningful opportunities for choice and self-determination, even in the presence of cognitive impairment. However, traditional conceptions of autonomy assume stable decisional capacity and independent choice-making—assumptions that do not reflect the lived realities of NH residents with cognitive impairment. For these residents, decisional capacity fluctuates with fatigue, environmental cues, and interpersonal context (Trachsel et al., 2015).

Such variability demonstrates the limits of an individualistic model of autonomy in NH settings, where opportunities for choice are shaped not only by cognitive ability but also by how staff interpret residents’ expressions and provide communicative or procedural support (Duan et al., 2020; Groenvynck et al., 2023). Research consistently shows that individuals with mild-to-moderate dementia can reliably express preferences when instructions are simplified and supportive communication is provided (Smebye et al., 2012).

Thus, autonomy is not eliminated by cognitive impairment; rather, it is contingent on environmental and relational conditions that can either enable or constrain choice. This underscores the need for approaches—developed further in later sections—that support autonomy through context-sensitive, relationally attuned practices in PA delivery.

Beneficence

Beneficence obligates caregivers to promote resident well-being across physical, cognitive, emotional, and social domains (Cheraghi et al., 2023; Varkey, 2021). PA aligns strongly with beneficence by improving function, reducing frailty progression, enhancing mood, and supporting cognitive resilience (Biazus-Sehn et al., 2020; Demurtas et al., 2020). Maintaining mobility remains central to preserving independence and participation.

Beneficence, however, is often compromised unintentionally. A cognitively impaired resident may be encouraged to join a fast-paced exercise class that overwhelms rather than supports engagement. Standardized sessions that overlook cultural identity or past roles can feel alienating, undermining beneficence despite therapeutic intent. Such disconnects reveal how “beneficial” programmes can undermine personal resonance or emotional safety when not aligned with residents’ abilities or life histories.

By contrast, beneficence is strengthened when PA is identity-aligned—integrating familiar music, culturally meaningful movements, past hobbies, or one-to-one pacing (Juntunen & Sutela, 2023; Young et al., 2024). Beneficence is achieved not through activity minutes but through activities that affirm identity and support the resident’s lived experience by enabling emotionally and culturally resonant engagement.

Nonmaleficence

Nonmaleficence—the obligation to avoid harm—is central in NHs where fall prevention heavily influences decision-making (Gray-Miceli, 2017). Overly risk-averse cultures may excessively restrict PA, unintentionally accelerating deconditioning, reducing cognitive stimulation, and increasing apathy (Bowes et al., 2022). These restrictive practices are also reflected in NH settings, where nursing staff report worry about risk outcomes for residents or themselves (71.6%) and lack of policy and procedural support (48.1%) in these situations (Behrens et al., 2023). Such constraints may limit residents’ mobility, and research further shows that mobility limitation directly contributes to functional decline among frail older adults (Gill et al., 2006)

Harm arises not only from poorly supervised or cognitively mismatched activities but also from institutional policies that default to excessive restriction (Smit et al., 2017). For example, a resident with moderate dementia who ambulated with minimal assistance prior to admission may be placed in a wheelchair for all unit-based activities because the facility’s fall-prevention protocol discourages assisted walking during busy shifts. Such policies aim to reduce immediate physical risk yet inadvertently produce long-term harm—accelerated deconditioning, loss of balance, increased agitation, and diminished confidence (Atee et al., 2024). From a nonmaleficence perspective, restricting movement to avoid potential falls can constitute a form of structural harm when risk-avoidance systematically outweighs residents’ need for mobility, stimulation, and dignity-affirming engagement.

Justice

Justice requires equitable access to PA that is adapted, culturally attuned, cognitively responsive, and delivered at a level of quality that genuinely supports residents’ well-being (Harrington et al., 2020; National Academies of Sciences, Engineering, and Medicine, 2022).Yet systemic inequities in staffing, funding, case-mix severity, and facility resources create substantial disparities in both access to—and the quality of—PA across NHs.

Well-resourced facilities typically offer diverse, engaging, professionally designed PA programs, whereas rural or financially constrained NHs often rely on repetitive, low-cost activities that provide limited stimulation. These discrepancies reduce participation among residents in under-resourced settings and diminish the cognitive, physical, and emotional benefits PA can offer (Andrews et al., 2024; Feenstra et al., 2023; Telenius et al., 2022). Structural inequities in PA access are well documented: the National Academies report that residents in low-resource NHs receive fewer and less diverse activity opportunities due to chronic staffing shortages and limited programming (Harrington et al., 2020). Survey evidence likewise shows that inadequate staffing, insufficient activity-specialist training, and underinvestment in activity programs systematically reduce opportunities for meaningful engagement8, indicating that these disparities are patterned rather than incidental (Benjamin et al., 2009).

Justice also concerns whose preferences are recognized, whose needs are prioritized, and whose identities are supported within existing PA structures. Facilities with limited staffing, equipment, or culturally relevant programming effectively restrict opportunities for meaningful movement, creating capability gaps among residents. Drawing on a capability-oriented conception of justice, ethically adequate PA provision requires institutions to guarantee not only access but equitable conditions for participation, particularly for residents with cognitive impairment who rely more heavily on relational and environmental support.

Justice therefore demands organizational and policy commitments to adequate staffing, interpreter services, and resource-allocation models that ensure consistent access to safe, culturally grounded, and cognitively responsive PA opportunities across all units.

How PA Promotion Produces Ethical Tensions

PA promotion occurs within environments shaped by structural constraints, relational dependence, and cognitive vulnerability. Structural pressures, such as understaffing, inflexible routines, and limited resources—profoundly shape how PA can be implemented in residential care (Johnson et al., 2005). Relational dependence further influences PA, as residents’ autonomy and participation are embedded within care relationships and institutional routines (Perkins et al., 2012). Cognitive vulnerability, including memory decline, attentional limitations, and fluctuating capacity—also affects how residents interpret and tolerate activity demands (Chen et al., 2025).

Institutional routines

Rigid schedules often produce “default participation,” such as escorting a hesitant resident simply because “it is time,” reflecting institutional efficiency over individualized preference (Moilanen et al., 2021; Xue et al., 2025). Fixed schedules rarely align with residents’ fluctuating cognitive readiness, diminishing autonomy, relational support, and personhood (van Loon et al., 2024).

Overprotective and risk-averse cultures

Fear of falls frequently leads to movement restrictions, contributing to deconditioning, reduced stimulation, and worsening functional decline (Albasha et al., 2023). Poorly supervised or cognitively mismatched activities can also produce harm, revealing that nonmaleficence is threatened by both insufficient activity and inappropriate activity demands (Gebhard & Mir, 2021).

Paternalistic framing of PA

PA is frequently framed as something residents “should do,” privileging institutional expectations over resident meaning (Hallam & Lewis, 2022). Staff often assume that cognitive impairment eliminates meaningful choice, despite strong evidence that residents can reliably articulate preferences when communication is adapted and relational support is provided (Visser et al., 2022). These assumptions reinforce relational inequality and erode autonomy.

Lack of authentic autonomy-supportive choice

Many PA programs offer limited options in type, intensity, or cultural relevance, weakening motivation and undermining dignity. Activities that lack cultural or personal resonance risk infantilization, whereas identity-aligned PA supports sustained engagement and emotional well-being (Telenius et al., 2022). Taken together, these structural, relational, and cultural dynamics show that ethical tensions in PA arise not from individual choices but from organizational conditions that determine whether autonomy, dignity, and equitable participation are meaningfully supported—or systematically constrained.

Summary

Across these domains, PA promotion exposes ethical tensions shaped by relational, structural, and cultural conditions. The ethical significance of PA depends on how it is structured, supported, and experienced; it can either reinforce or erode autonomy, beneficence, nonmaleficence, and dignity depending on whether activities are delivered in ways that recognize cognitive vulnerability, relational dependence, and personhood.

Relational Autonomy Framework for Ethical PA Promotion

Relational-autonomy discussions have largely centered on decision-making, consent processes, and major care transitions, as reflected in prior conceptual reviews and empirical work (Beauchamp & Childress, 2019; Gómez-Vírseda et al., 2019). Although these areas illustrate how autonomy emerges within relationships, they give limited attention to the embodied, routine, and activity-based aspects of daily life that shape well-being for cognitively impaired NH residents.

Extending relational-autonomy thinking to PA highlights that autonomy unfolds through everyday rhythms, staff interactions, cultural identity, and institutional routines—not merely through discrete choices (Sherwin & Winsby, 2011; van Loon et al., 2023). Such a perspective clarifies why principlism alone cannot adequately guide ethical PA promotion and underscores the need to understand PA as a relational and environmental achievement. The four dimensions below illustrate how this approach can be applied in cognitively responsive PA practice.

1. Supporting Everyday Choice-Making

Ethically grounded PA begins with everyday choice-making. Small, concrete options—when to start, which movements to use—form the foundation of autonomy in cognitively vulnerable contexts. Everyday autonomy emerges when residents can express preferences in ways that match their cognitive and sensory abilities (Moilanen et al., 2022). Simplified options, predictable routines, and reduced task load help transform PA from a task imposed on residents into a context where they can exercise agency.

Example 1: A resident who hesitates to join a group session may re-engage when staff offer a simple choice (“Shall we start with stretching or with music?”).

Example 2: Another resident participates more fully when given extra time to process instructions rather than being rushed “because it’s activity time.”

2. Cognitive-Responsive Communication and Relational Support

Cognitive fluctuations shape how residents understand instructions, initiate activity, and sustain engagement. Communication adapted to cognitive capacity—slowed pacing, familiar cues, stepwise sequencing, modeling, and relational continuity—prevents cognitive overload and emotional distress, allowing residents to participate without becoming disoriented (Chen et al., 2022; Trachsel et al., 2015). Autonomy becomes possible only when relational scaffolding reduces anxiety and builds trust and provides residents with a sense of safety and predictability.

Example 1: A resident who becomes confused by multi-step directions is able to follow along when movements are modeled one at a time.

Example 2: Residents often initiate activity more confidently when working with familiar staff whose faces and voices reduce anxiety.

3. Embedding Identity, Culture, and Meaning into PA

PA supports dignity and personhood when activities reflect residents’ histories, cultural identity, spiritual practices, sensory preferences, and embodied expressions. PA becomes meaningful when movements align with familiar music, past hobbies, occupational roles, or culturally rooted traditions (Li et al., 2022). Identity-aligned PA strengthens motivation, emotional well-being, and continuity of self (Jin & Roumell, 2021).

Example 1: A resident who rarely participates becomes animated when exercises are paired with traditional music from her home culture.

Example 2: A former gardener engages meaningfully when PA incorporates planting or digging motions rather than generic arm lifts.

4. Flexibility Over Routine: Redesigning Institutional Structures

Rigid schedules, standardized group formats, and task-driven routines often limit the space for relational autonomy. Ethically grounded PA requires institutional flexibility—smaller groups, one-on-one formats, spontaneous engagement opportunities, and adaptable schedules aligned with residents’ energy levels and cognitive rhythms (van der Wardt et al., 2020). When PA is fully integrated into relational care rather than treated as an add-on task, residents are more able to engage authentically and safely (Trollebø et al., 2024)

Example 1: A resident who is too drowsy for morning PA participates actively when the session is offered later in the afternoon.

Example 2: Residents with sensory overload or attention limitations benefit more from one-on-one or small-group formats than from large, overstimulating activity groups.

Summary of the Framework

Together, these dimensions show that autonomy is co-constructed through the NH environment, communication, relationship, and organizational culture. Relational autonomy reframes PA as an ethical, identity-affirming practice rather than a routine task that supports dignity, agency, and meaningful participation—even amid cognitive vulnerability.

Discussion

The ethical tensions identified in the analysis show that PA promotion in NHs is shaped as much by institutional and relational conditions as by clinical benefit. Although PA supports cognitive, emotional, and physical well-being, its delivery often occurs within environments marked by limited staffing, rigid routines, and risk-averse cultures that restrict individualized engagement. These dynamics can unintentionally constrain autonomy and beneficence, increase the risk of harm, and diminish dignity—particularly for residents with cognitive impairment who remain vulnerable to depersonalization (Roos et al., 2022; Wachholz & Giacomin, 2023).

This paper makes a distinctive contribution to nursing ethics by reframing PA not as a routine clinical task but as a relational and identity-embedded practice that requires ethical scrutiny. It advances the concept of cognitive-responsive autonomy and identifies organizational and policy-level obligations that shape residents’ opportunities for autonomy, dignity, justice, and equitable participation. Through this lens, the paper demonstrates why relational autonomy provides an ethically robust foundation for PA promotion in cognitively vulnerable populations.

Positioning PA as an ethically significant domain—rather than as a secondary recreational task—broadens ongoing conversations in nursing ethics. The ethical analysis shows that autonomy, beneficence, nonmaleficence, and justice are continually negotiated through everyday routines, staff interactions, cultural meanings, and institutional structures in NHs. Integrating relational autonomy with principlism offers a more comprehensive ethical lens that clarifies how dignity-affirming engagement can be supported for residents living with cognitive vulnerability and fluctuating agency. This broadened perspective also generates concrete directions for empirical inquiry. Relational-autonomy markers, such as identity-aligned activities, staff–resident interaction quality, cognitive-responsive communication, and institutional flexibility, can be operationalized and evaluated within PA interventions (Chen et al., 2022; Gray-Miceli, 2017; Mattos et al., 2023). Understanding how organizational policies and routines enable or constrain autonomy and well-being further informs program design, staff training, and policy development. In this sense, relational autonomy functions not as a theoretical ideal but as a practical, measurable, and implementable standard for ethical PA practice in long-term care.

Nonmaleficence is frequently threatened when safety concerns dominate PA decision-making. Overly restrictive fall-prevention policies may inadvertently promote deconditioning and cognitive under-stimulation—forms of harm that contradict their protective intent. Conversely, poorly supervised, or cognitively mismatched activities may introduce distress or injury, underscoring the need to balance safety with forms of engagement that are cognitively responsive and emotionally tolerable.

Beneficence and dignity depend heavily on whether PA aligns with residents’ histories, cultural identities, and embodied preferences. Identity-aligned activities, such as familiar music, movements linked to past roles, or culturally meaningful practices—support motivation and personhood, while standardized or repetitive programmes may feel infantilizing or irrelevant. Meaningful-engagement research further shows that culturally attuned PA fosters emotional well-being and sustained participation more effectively than task-oriented models (Gidgup et al., 2022; Marquez et al., 2015).

These findings demonstrate that ethical responsibility for PA promotion cannot rest solely on individual caregivers. It must be recognized as an institutional and policy-level commitment requiring organizational accountability, dementia-informed communication training, and relationally supportive environments that enable autonomy, dignity, and equitable participation of NH residents with cognitive impairment. Direct-care staff play a central role in operationalizing relational autonomy through simplified choices, stepwise cues, and relational continuity that reduce anxiety and support engagement. Staff training policies and procedures should emphasize dementia-informed communication, relational ethics, and approaches that balance safety with autonomy. At the organizational level, flexible scheduling policies, small-group or one-to-one formats, and environments designed to support safe movement are essential for equitable PA access (U.S. Department of Health and Human Services, 2023; Webster et al., 2023). Treating PA as core to person-centered care—not an optional add-on—is critical to supporting autonomy, dignity, and well-being among residents with cognitive impairment. Overall, ethical considerations for PA promotion require shifting from compliance-driven policies, routine-based programming toward relational, identity-aligned, and dignity-affirming practices that meaningfully support autonomy, beneficence, nonmaleficence, and justice.

Conclusion

PA holds significant ethical potential to support the agency, identity, and well-being of NH residents with cognitive impairment, yet this potential is often diminished by institutional policies and safety-driven practices that restrict autonomy and suppress opportunities for cognitively responsive and identity-aligned engagement. A relational understanding of autonomy makes clear that ethically grounded PA requires environments that enable everyday choice-making, adaptive communication, and activities that resonate with residents’ histories and cultural identities. Direct-care staff share an ethical responsibility to balance safety with relationally supported autonomy, while institutions must redesign policies related to staffing structures and schedules, as well as activity formats to ensure equitable access to high-quality, dignity-affirming PA. Ultimately, relational autonomy should guide PA policy, staff training, and daily care so that residents experience PA not as a task imposed upon them, but as an expression of personhood, relational agency, and ethical care.

Acknowledgements

The authors are grateful to Penn Nursing’s NewCourtland Center for Transitions and Health for their support in completing this initiative.

Funding

Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number T32NR009356. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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