Coursework Sample: Applying Care Ethics to a Clinical Scenario

Model Answer

Introduction

This assignment critically applies an ethics-of-care framework to a single anonymised clinical scenario encountered during a community hospital placement. In line with Nursing and Midwifery Council (NMC, 2018) confidentiality guidance, all identifying details have been changed and the patient is referred to as Mrs A. The discussion first outlines the scenario, then introduces Tronto’s (1993) ethics-of-care framework as the primary analytical lens, applies it to the nursing response observed, and compares this with the four-principles approach associated with Beauchamp and Childress (2019). The assignment concludes by evaluating the practical and professional implications of adopting a care-ethics perspective in everyday nursing practice. Ethical frameworks are rarely taught as competing alternatives in isolation from real practice, and this assignment deliberately uses a single, ordinary clinical situation — rather than an extreme or unusual dilemma — because the great majority of ethical reasoning in nursing takes place in exactly this kind of everyday, low-drama interaction, where the quality of the ethical response is easy to overlook precisely because no obvious crisis forces it into view.

The Clinical Scenario

Mrs A is an 82-year-old woman living with moderate dementia, admitted to a community hospital rehabilitation ward following a fall at home. On several mornings, Mrs A became visibly distressed and physically resistant when staff attempted to assist her with washing and dressing, at times pushing carers’ hands away and raising her voice. Mrs A’s daughter, who visited daily, was concerned that her mother was not receiving adequate personal care and asked staff directly why she often appeared unwashed by mid-morning. Ward staff, working under considerable time pressure across a full bay of patients, faced a genuine tension between respecting Mrs A’s apparent refusal in the moment and their professional duty of care to maintain her hygiene, dignity and skin integrity. This tension between two legitimate concerns — autonomy in the moment versus an ongoing duty of care — is precisely the kind of situation that a purely rule-based ethical framework struggles to resolve, and for which an ethics-of-care approach offers a genuinely different, and arguably more useful, way of thinking. It is also a situation in which documentation alone could easily obscure the ethical substance of what actually happened: a note recording ‘personal care declined’ after each morning attempt would be technically accurate but would reduce a complex relational encounter to a single tick-box outcome, without capturing why Mrs A was distressed or what, if anything, staff had tried in response.

The Ethics of Care Framework

Tronto (1993) and Tronto and Fisher (1990) conceptualise care not as a discrete act but as an ongoing relational process comprising four interlocking phases: caring about (recognising that care is needed), caring for (taking responsibility for ensuring the need is met), care-giving (the direct, hands-on labour of care), and care-receiving (recognising and responding to how the care was actually experienced by the person receiving it). A later, widely cited addition, caring with, emphasises that sustainable, high-quality care depends on trust and solidarity built over repeated interactions, not a single encounter (Tronto, 2013). Gilligan’s (1982) earlier work on an “ethic of care” similarly argued that moral reasoning grounded in relationships, context and responsiveness to particular others is at least as valid as reasoning from abstract, universal principles — a challenge to the dominant Kohlbergian model of moral development that Gilligan considered insufficiently attentive to relational and contextual reasoning. Held (2006) further distinguishes care ethics from simple kindness or sentiment by stressing that it requires practical competence: caring intentions that are not translated into competently delivered care do not, on this view, constitute good care at all. Bowden (1997) develops this practical emphasis further, arguing that care is best understood as a skilled practice built through repeated, attentive engagement with particular people over time, rather than as a fixed personality trait some nurses simply possess and others do not; on this view, Mrs A’s case tests practical skill — noticing, interpreting and responding to distress correctly — as much as it tests good intentions.

Application to the Scenario

Applying Tronto’s framework to Mrs A’s case, caring about was clearly present: staff recognised, and recorded in the nursing notes, that Mrs A’s hygiene needs were not being fully met and that this required a response. Caring for was also evident at an organisational level, in that personal care was formally assigned as part of the daily care plan. The point at which the situation became ethically difficult was care-giving: the actual, hands-on attempt to deliver care in a way Mrs A experienced as safe and dignified, rather than as a source of distress. A purely task-focused approach — completing personal care because it is scheduled, regardless of the patient’s response in the moment — would satisfy caring about and caring for while failing badly at care-giving and care-receiving. This distinction matters in practice: a nurse can complete every scheduled task on a care plan and still, in Tronto’s terms, fail at care-giving if the manner of delivery causes unnecessary distress rather than meeting the underlying need with the least possible harm.

In this instance, the nursing team’s eventual response illustrated a genuinely care-ethics-informed practice: rather than persisting with washing at the scheduled time or documenting a blanket refusal, staff paused, identified through Mrs A’s daughter that she had always preferred an evening bath to a morning wash at home, and adjusted her personal care plan accordingly. This is care-receiving in Tronto’s sense — checking whether the care given actually met the need as experienced by the person receiving it, and adapting practice in response, rather than assuming staff already know best. The daughter’s knowledge of Mrs A’s lifelong routine also reflects caring with: sustainable, trusting care depended on incorporating the family’s relational knowledge of Mrs A as a person with a history and preferences that predate her dementia diagnosis, not simply on following a generic ward protocol.

This reframing had a measurable effect: over the following days, physical resistance during personal care reduced markedly, and Mrs A appeared calmer during the evening sessions than she had during the earlier morning attempts. From a care-ethics perspective, this outcome is not incidental but is exactly what the framework would predict — because attentiveness and responsiveness to the particular person, rather than to a generic protocol, are treated as central to what constitutes good care, not merely as a courteous addition to it. It is worth noting, too, that this was not a large or resource-intensive intervention: switching the timing of a single routine task cost nothing beyond a five-minute conversation with Mrs A’s daughter, which underlines that applying an ethics-of-care lens is not primarily about doing more for patients, but about attending more closely to what a specific patient is communicating, including through non-verbal resistance, before deciding how care should be delivered.

Comparison with Principle-Based Ethics

The four-principles approach associated with Beauchamp and Childress (2019) — autonomy, beneficence, non-maleficence and justice — offers a complementary but structurally different analysis of the same scenario. Respect for autonomy would initially seem to support honouring Mrs A’s in-the-moment refusal of morning personal care. However, the Mental Capacity Act 2005 requires that any apparent refusal from a person with dementia be assessed against the specific decision at hand, and that capacity is presumed unless proven otherwise; distress and physical resistance during a single task are not, by themselves, sufficient evidence of a settled, capacitous refusal of personal care as a whole. Beneficence and non-maleficence would support intervening to protect Mrs A’s hygiene and skin integrity, while justice requires that Mrs A receive care of the same standard as any other patient on the ward, regardless of the additional time her care required.

Applied mechanically, the four principles can be balanced against one another in more than one defensible way, and offer relatively little guidance on how, in practice, staff should have identified that an evening bath would resolve the apparent conflict. The ethics-of-care framework, by contrast, does not treat this as a competition between abstract principles at all, but directs attention toward the relational, practical question of what this particular patient actually needs and how that need can be competently met — which is precisely the question that led staff to the family conversation that resolved the situation. The NMC (2018) Code’s requirement to “treat people as individuals and uphold their dignity” arguably sits closer in spirit to the relational, attentive orientation of care ethics than to a principle-balancing exercise, even though the Code itself is not written in explicitly care-ethics terms. It is also worth noting that the two frameworks are not simply interchangeable labels for the same reasoning process: a principle-based analysis proceeds by identifying which abstract duties apply and weighing them against one another, whereas a care-ethics analysis proceeds by asking what this particular relationship, at this particular moment, actually requires — a difference in method, not just in vocabulary, with direct consequences for how a nurse approaches an unfamiliar patient under time pressure.

Evaluation

The ethics-of-care framework has clear strengths in a scenario of this kind: it is well suited to situations involving communication difficulty, fluctuating capacity, and family involvement, because it treats relational knowledge — in this case, the daughter’s insight into Mrs A’s established routine — as ethically significant evidence rather than as background information. It also resists a narrow, task-completion view of care that can develop under time pressure, refocusing attention on the lived experience of care-receiving rather than on whether a task was technically completed.

However, care ethics is not without limitation. Held (2006) and other commentators acknowledge that an exclusive focus on particular relationships risks under-weighting broader questions of fairness across a whole ward or caseload — the justice consideration that principle-based ethics foregrounds more explicitly. A purely relational approach could also, in principle, be used to justify inconsistent standards of care between patients depending on how well staff happen to know them, which is precisely the kind of variation the NMC Code and organisational governance structures are designed to prevent. In practice, the strongest response to Mrs A’s situation combined both frameworks: the relational attentiveness of care ethics identified what Mrs A actually needed, while principle-based reasoning, particularly around capacity and non-maleficence, provided the professional and legal justification for adjusting her care plan formally and defensibly. This combined approach also has implications beyond Mrs A’s individual case: a ward culture that consistently pairs relational attentiveness with clear, principle-based documentation is better placed to defend its decisions during incident review or complaint investigation than one relying on either approach alone, since it can demonstrate both that the patient’s perspective was genuinely sought and that recognised professional standards were followed.

Conclusion

This assignment has shown that an ethics-of-care framework, applied to Mrs A’s case, offers a more complete account of what went wrong in the initial morning care attempts, and what subsequently put it right, than a purely principle-based analysis on its own. Tronto’s four (and later five) phases of care — caring about, caring for, care-giving, care-receiving and caring with — provide a structured way of checking whether care that is well-intentioned is also competently and responsively delivered. At the same time, principle-based ethics remains important for the formal, defensible justification of care decisions, particularly around capacity and consent. For pre-registration nursing practice, the clearest implication is that attentiveness to the particular person — asking what this individual, in this context, actually needs — should sit alongside, rather than be replaced by, the profession’s established principle-based and Code-based standards. As a final reflection, Mrs A’s case illustrates that ethical competence in nursing is rarely tested by dramatic, high-stakes dilemmas; far more often, it is tested by whether a nurse notices a small, everyday sign of distress, takes it seriously as ethically significant information rather than as mere non-compliance, and is willing to adapt an otherwise routine care plan in response.

References

Beauchamp, T.L. and Childress, J.F. (2019) Principles of Biomedical Ethics. 8th edn. Oxford: Oxford University Press.

Bowden, P. (1997) Caring: Gender-Sensitive Ethics. London: Routledge.

Gilligan, C. (1982) In a Different Voice: Psychological Theory and Women’s Development. Cambridge, MA: Harvard University Press.

Held, V. (2006) The Ethics of Care: Personal, Political, and Global. Oxford: Oxford University Press.

Mental Capacity Act 2005. London: The Stationery Office.

Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.

Tronto, J.C. (1993) Moral Boundaries: A Political Argument for an Ethic of Care. New York: Routledge.

Tronto, J.C. (2013) Caring Democracy: Markets, Equality, and Justice. New York: New York University Press.

Tronto, J.C. and Fisher, B. (1990) ‘Toward a feminist theory of caring’, in Abel, E. and Nelson, M. (eds.) Circles of Care. Albany: State University of New York Press, pp. 36–54.