Successful treatment of mental health requires a patient centred and holistic approach to treatment. One way of ensuring treatment is, in fact, patient centred is with the implementation of joint care plans.  


Today we will be taking a closer look at what a care plan is and how you can implement it effectively within an inpatient setting.  


What is a Care Plan? 


Before we discuss the formation of a care plan within your service, we must first define a care plan and what it means in the healthcare sector.  


‘Care planning’ can be defined as the process whereby clinicians and patients discuss, agree, and review plans to achieve goals’, Bacon et al (2017). A care plan is the document recording these discussions.  


Care plans should outline unique needs to the service user from their perspective, if done successfully, they can serve as a gateway between service user and clinician, allowing clinicians to review needs and treatment plans based on their distinctive goals. Care plans, especially within a rehabilitation setting, should be recovery focused, empowering them to achieve goals and have successful integration into the community.  


Effective Care Planning 


Therapeutic Relationships:

Care planning requires skill and practice in order for it to be done effectively. Studies show how the care planning process can aid therapeutic relationships between service user and clinician (Coffey et al 2018, Faulkner 2017). Grundy et al (2016) detail the importance of therapeutic relationships throughout the care planning process. Meaningful relationships allows the service user to feel supported in collaborating to produce an patient centred care plan. The service user should be involved throughout the care planning process.  


Treatment Goals:

Within mental health inpatient settings, behaviour change as part of a treatment plan is common. Goal setting within care planning allows an individual to identify specific behaviours to change, alongside a plan as to how this will be achieved (Bailey 2017). NICE guidelines (2017) recommend the use of SMART goals when creating treatment goals with a service user. This is an acronym created for specific goals: 


S – Specific, the specific goal that the service user would like to achieve. 

M – Measurable, how the individual will measure the progress or outcome. 

A – Achievable, is the goal achievable? 

R – Relevant, is the goal relevant to the service users recovery and care plan 

T – Time, what time frame or stages would the service user/ clinicians/ carers like the achieve the goal in.  


The use of SMART goals allow for the service user and clinician to have clear expectations of the goal. As discussed by Bailey (2017) the main limitation to SMART goals is that it does not detail how the service user will reach the goal, it is vital that with the support of the clinicians service users are supported in creating action plans as an addition to the SMART goal.  




For care plans to be effective they must be patient centred and individualised to that service user. Research has shown that service users often felt ‘left out’ of the care planning process. Brookes et al (2015) describe service users views on care planning, service users felt care plans were to benefit the organisation and manage risk, as appose to their life and treatment goals. SCEI (2017) discuss the important of service user involvement throughout the care planning process. They express that within joint care planning, power should be shared equally between service user and clinician, respecting the service users right to take risks and that the service user is supported in expressing how they would like their care and treatment to be delivered. There should be an ongoing mutual goal of achieving the service users goals with clear actions for those involved in their care. If the service user wishes family, friends and carers views should also be taken into consideration throughout the care plan.  


Limitations and Challenges 


A key challenge of successful care planning within inpatient settings is engagement. Brooks et al (2015) discussed in interviews with service users how they struggled to engage with care plans, for several reasons such as medication and mental state. Service users also felt that care plans were lengthy documents and struggled to engage throughout. Co production with services and the service users in how engagement can be improved and/or maintained should be considered.  

Care plans being ‘too risk focused’ can also be a limitation. It can bring back distressing memories for service users when a care plan should be helping them to focus on the future and achieving goals. It is vital that care plans do capture risk however should remain goal focused.  




In summary, successful care planning in mental health inpatient settings hinges on a holistic and patient-centric approach, the development of therapeutic relationships, and the implementation of SMART goal-setting. These care plans should be tailored to the individual’s needs, prioritising the service user’s objectives rather than being excessively focused on the service users risk. Overcoming obstacles such as engagement and promoting meaningful collaboration between service users and clinicians is imperative for effective care planning. This approach fosters a more supportive and goal-oriented environment for service users, ultimately enhancing their mental health and overall well-being. 








The importance of relationships: Care planning and care coordination in mental health – Faulkner – 2017 – Journal of Psychiatric and Mental Health Nursing – Wiley Online Library 

Goal Setting and Action Planning for Health Behavior Change – Ryan R. Bailey, 2019 ( 

Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives – Grundy – 2016 – Journal of Psychiatric and Mental Health Nursing – Wiley Online Library 

Professional perspectives on service user and carer involvement in mental health care planning: A qualitative study – ScienceDirect 

Recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings: a cross national comparative mixed methods study | BMC Psychiatry | Full Text ( – care plans being achievable  

Full article: Balancing between a Person-Centred and a Common Staff Approach: Nursing Staff’s Experiences of Good Nursing Practice for Patients Who Self-Harm ( care planning routine 

MCA: Care planning, involvement and person-centred care | SCIE effective care planning  

Quality statement 6: Joint care planning | Service user experience in adult mental health services | Quality standards | NICE joint care planning  

Are we stripping the care out of care plans? | British Journal of General Practice (