Part 1: Ethical Safeguards
The ethical safeguards planned for clinical research, may not always be viable for evidence-based practice or evidence-based practice application plans ( Grady, 2018) . The reason is that they might have the impact of limiting the scope for evidence collection, making a decision, and subject treatment. The safeguard tends to limit the use and collection of data based on human subjects. Researchers are expected to work with the proper safeguards intended for clinical research. Such investigators should entirely follow the safeguards in clinical search.
On the contrary, the evidence-based practice search ensures that the most elegant proof is obtainable for healthcare practice and clinical decisions. The statement means that the procedure of discovering the best evidence must not be intermittent by the formulated ethical safeguards for clinical research. Evidence-based practice entails incorporating case studies, subjects of the humans, and investigations on-site to compile more information on diseases.
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Moreover, it also includes data seeking from the patient's past to safeguard that the preeminent investigation proof is accessible. The moral protections for clinical research places confines on the subject participation and restrictions on the type of data must be gathered. In proof-based practice, evidence production is the role of the research employees ( Grady, 2018) . The ethical safeguards formulated for clinical research are stern on who ought to access data for the patient and the quintessence of seeking approval. Due to this, the ethical guarantees may interfere with the workforce of the investigating employees. It also hampers the five stages of evidence-based practice. Those stages comprise of; question inquiring, investigating, judgmentally appraising the data, executing, and lastly, evaluating. Alternatively, the phases should gather the data essential for deciding clinics. This progression, certain ethical safeguards, tend to be dishonored in the practice of clinics. Hence, ethical protections intended for clinical research might not be possible for evidence-based preparation application of plans due to goals that conflict.
Part 2: The Three Major Ethical Controversies
The two ethical exemplar studies revealed some significant controversies. In the case of infection to the bloodstream caused by catheters, John Hopkins University examiners investigated the effects of introducing evidence-based strategies to reduce these rates of infections ( Melnyk & Fineout-Overholt, 2015) . The research involved educational involvements aimed at ICU employees to improve the safety of the patients. In this first exemplar, the controversies stemmed up between the Office for Human Research Protections OHRP and IRB as to whether the project was EBQI or a clinical study. The IRB held that it was a quality intervention while the OHRP maintained that it was clinical research. The other ethical regulation violated was the prior informed consent was waived. The IRB argued that the review could have determined that informed consent was not required ethically since the five infections guiding principle were based on evidence.
The second exemplar involved an educational program in Spain about whether the project was in agreement with evidence-based guidelines for patients with severe sepsis who were assessed for its effect on the mortality rate ( Melnyk & Fineout-Overholt, 2015) . The project's major controversy as to whether it was evidence or research-based. Also, another ethical issue is informed consent, as human subjects were not consulted before the project. The third ethical controversy in bloodstream infection exemplars arises from the attempt to enhance quality care, which may result in potential harm in some patients or benefit others in the process. Though the response of OHRP on the employment of quality enhancement checklist is disputable, there is some justification for it. Using experimental drugs on human subjects with no federal regulation and formal written consent from the participants is unethical.
The principle of beneficence relates to these controversies in that both projects aim at the ultimate good and best outcome desired to improve the quality of life from the patient suffering from bloodstream infection and severe sepsis. The nonmaleficence principle is a cause of concern as in the bloodstream infection case; the project coordinators were in a way negligent as they used experimental drugs on their human subjects, which could bring harm to them. Also, the ethical deliberations in both cases were in violation of the principle of autonomy as the human subjects' informed consent was ignored, limiting their ability to make healthcare decisions ( Melnyk & Fineout-Overholt, 2015) . Justice principle target equitable distribution of healthcare resources as well as medical choices amongst the group of patients, in the catheter-related infections exemplar, the human subject was selected proportionally in that each Intensive Care Units comprised of one nurse and a physician as team leaders.
Part 3: Patients' Responsibilities
Among the core ethical principle, autonomy conflicts with the idea of the patients having a moral obligation in improving healthcare. This principle gives the patient the full control on how they want care administered to them ( Chaiyachati & Kangovi, 2019) . Under this moral code, the medical practitioner loses the power to exercise their full mandate over the patient, which may implore legal consequences. Doctors may sometimes not be able to protect their patients from the medical decision they make, which may, either way, deteriorate the patient's health. The principle of autonomy is mostly designed toward the patients participating in the medical decision, not necessarily the consequences that ensue after such decisions are made.
Patients having such powers without limitation may hinder dispensation of proper care, causing conflict on the ideas of patients having moral duties to improving healthcare. Enhancement of care should not be paternalistic, imposing too much on the medical practitioners as they are required to keep the balance in the healthcare system, which is almost impossible ( Chaiyachati & Kangovi, 2019) . The ethical responsibility affects mostly on doctors and rarely on patients, which makes the quest for improving healthcare difficult.
In solving such conflicts, patient autonomy should be somehow limited so that the medical practitioners can perform their duties of enhancement of care. Patients alongside healthcare practitioners should have a unified objective of improving care. By this patient should not withhold useful information, refuse advice/opinion from medical experts or deny to receive care because of the underlying personal reasons which are not scientifically viable so that they improve care. Patients who knowingly interfere with care dispensation should be further held accountable for such actions.
References
Chaiyachati, K., & Kangovi, S. (2019). Inappropriate ED visits: patient responsibility or an attribution bias?
Grady, C. (2018). Ethical principles in clinical research. In Principles and practice of clinical research (pp. 19-31). Academic Press.
Melnyk, B. M., & Fineout-Overholt, E. (2015). Box 1.3: Rating system for the hierarchy of evidence for intervention/treatment questions. Evidence-based practice in nursing & healthcare: A guide to best practice , 11.
