DNP/705 Week 6: Ethical Foundations of Practice and Inquiry, sample paper

Residents Who Cannot Consent and an Alarm That Might Help Them: The Ethics of a DNP Project Changing Bed-Exit Alarms on a Memory Care Unit, Judged by Four Principles, Seven Requirements and the QI Line

[Student Name]

University of Phoenix

DNP/705: Philosophy, Theory, and Science for Nursing Practice

Week 6 Assignment

[Instructor Name]

[Date]

The facility and scenario are composites written for a model paper.

I am a nurse practitioner at a 120-bed long-term care facility with a 30-bed memory care unit. Our unit uses bed-exit and chair alarms for residents at risk of falling. Staff report that the alarms sound dozens of times a night, startle residents and often do not prevent falls. I plan a DNP project to remove alarms for selected residents and replace them with hourly purposeful rounding and personalized toileting schedules, then compare fall rates. Most residents have moderate to severe dementia and cannot consent. This paper examines the ethical foundations of the project.

Four Principles Plus Scope

Gillon (1994) argued that the four familiar principles, honoring self-determination, doing good, avoiding harm and acting fairly, provide a common framework for medical ethics across cultures, and that attention to their scope, to whom each obligation is owed, resolves many apparent conflicts.

Autonomy

Residents cannot give informed consent, but they can express preferences through behavior, such as distress when an alarm sounds. Respect for autonomy extends to honoring these expressions and involving their surrogates. Each resident's health care agent will be told about the change and may decline it.

Beneficence

The project aims to benefit residents: less startle, better sleep and possibly fewer falls. The rationale is plausible, since alarms have not been shown to reduce falls reliably and rounding addresses the reasons residents get up, such as toileting needs and pain.

Nonmaleficence

Removing alarms could increase falls if rounding is inconsistent. This is the central risk. Protections include selecting residents with lower fall risk first, monitoring falls weekly, and a stopping rule: if any resident has an injurious fall, the project pauses for review.

Justice

Justice asks whether burdens and benefits are fairly distributed. Selecting only the easiest residents would give unfair benefits to some, while exposing the highest-risk residents first would concentrate risk. A staged approach, starting with moderate-risk residents and extending as safety is shown, balances these concerns.

The residents could not say yes, so every protection had to be built as though they could still say no.

Seven Requirements

Emanuel et al. (2000) argued that informed consent is neither necessary nor sufficient for ethical research and proposed seven conditions that together make a study ethical: it must be worth doing, designed well enough to answer its question, fair in whom it enrolls, weighted toward benefit over risk, reviewed by people with no stake in it, consented to where possible and respectful of participants throughout, including their privacy, their freedom to leave and ongoing attention to their welfare.

Applying the Requirements

Value: reducing unnecessary alarms and falls in dementia care matters to residents, families and staff. Validity: I will compare fall rates, sleep disruptions and alarm events before and after, with enough months to see a real change. Fair selection: residents are chosen by clinical criteria, not convenience. Risk-benefit: risks are minimized by monitoring and a stopping rule. Independent review: addressed below. Consent: surrogates will be informed and may decline for their resident. Respect: residents' privacy will be protected in data collection, their comfort monitored and any resident showing increased distress or risk returned to prior care.

Quality Improvement or Research?

Lynn et al. (2007), writing for a Hastings Center group, described quality improvement as organized, data-driven work aimed at making care better right away in a particular place, treated it as part of ordinary health care operations and judged that the majority of such projects are not research on human subjects and are better supervised through the normal oversight of clinical practice than through formal review boards. They proposed that the characteristics of a project and its context be used to categorize it and noted that both clinicians and patients have an ethical responsibility to participate in quality improvement that meets ethical requirements.

Categorizing This Project

The project aims to improve care on our unit, uses standard approaches, involves a change within normal practice and does not assign residents randomly. These features point toward quality improvement. However, it involves a vulnerable population, removes a safety measure and I intend to publish the results. Given those features, I will submit the project to our affiliated university's institutional review board for a determination rather than decide myself.

Monitoring During the Project

A weekly review by the director of nursing and me will examine falls, near falls, sleep observations and any signs of distress for each included resident. Results will be shared with the interdisciplinary team at its monthly meeting, and any resident whose risk rises will return to alarm use immediately.

Additional Protections for Vulnerable Residents

Beyond the requirements, I will ensure that a physician and the director of nursing review each resident's inclusion, that night staff receive rounding training before any alarm is removed and that families receive a phone call, not only a letter.

The Ethics of the Status Quo

Continuing to use alarms is also an ethical choice. Alarms that sound dozens of times a night disturb sleep, provoke agitation and may lead staff to tune them out, so the current practice carries its own risks. Nonmaleficence applies to the status quo as much as to the change, and doing nothing is not ethically neutral.

Data Privacy

Fall reports, alarm logs and sleep observations will be recorded without names in the project database, stored on the facility's secure server and accessible only to the project team. Results will be reported in aggregate. Residents' dignity extends to how their information is handled.

Families' Perspectives

Some families may believe alarms keep their relative safe and feel anxious about removing them. Explaining the evidence, the rounding schedule and the stopping rule, and inviting questions, respects their role as surrogates and may reveal concerns that improve the plan.

Staff as Stakeholders

Staff also bear burdens. Rounding requires more frequent checks. I will involve staff in designing the schedule, and if workload proves unsustainable, the project will be modified.

Staff Burden and Resident Safety

Asking aides to add hourly rounds without adjusting other duties would shift risk onto staff and, through fatigue, back onto residents. The rounding schedule will be built with night staff, tested for two weeks on one hallway and adjusted before it is extended.

Publishing Responsibly

If results are published, the facility will not be named without permission, and residents will never be identifiable. Negative or mixed results will be reported as fully as positive ones, since other facilities deserve to know if the change did not work.

Conclusion

A project removing bed-exit alarms for residents with dementia raises tensions among autonomy, beneficence, nonmaleficence and justice, addressed by surrogate involvement, a staged approach, monitoring and a stopping rule. The seven requirements for ethical research identify additional safeguards, and the Hastings Center framework suggests the project is likely quality improvement, but its vulnerable population and planned publication justify an independent determination.

References

Emanuel, E. J., Wendler, D., & Grady, C. (2000). What makes clinical research ethical? JAMA, 283(20), 2701-2711. https://doi.org/10.1001/jama.283.20.2701

Gillon, R. (1994). Medical ethics: Four principles plus attention to scope. BMJ, 309(6948), 184-188. https://doi.org/10.1136/bmj.309.6948.184

Lynn, J., Baily, M. A., Bottrell, M., Jennings, B., Levine, R. J., Davidoff, F., Casarett, D., Corrigan, J., Fox, E., Wynia, M. K., Agich, G. J., O'Kane, M., Speroff, T., Schyve, P., Batalden, P., Tunis, S., Berlinger, N., Cronenwett, L., Fitzmaurice, J. M., . . . James, B. (2007). The ethics of using quality improvement methods in health care. Annals of Internal Medicine, 146(9), 666-673. https://doi.org/10.7326/0003-4819-146-9-200705010-00155