Care planning process in healthcare practice

Unit 20 Care planning process in
healthcare practice
Session 7
L03 Review the challenges and benefits of planning person-centred
care in the workplace.
Focus on strategies developed to overcome any barriers to
implementing care plans
Last session a critical review on challenges to planning person centred
care and in care planning was discussed in association with the
benefits of following a person centred care.

Strategies for overcoming barriers in care
planning/ promoting person centred care
Working in partnership approaches and effective communication in
resolving challenges:
Training and workforce development
Agreed ways of working in teams, clarity of roles and responsibilities
Agreed outcomes
Input from individual and family, friends and carers
Target setting:
SMART (specific, measurable, achievable, realistic, timely) targets
Risk assessment

An interactive, collaborative process between providers and patients that is used to make
healthcare decisions in which at least 2 individuals work together as partners with mutual
expertise to exchange information and clarify values in relation to options and thereby arrive
at a discrete decision. In principle working in partnership with service users, families , and
various health care professionals can solve problems and challenges in promoting person
centered care.
Practitioner as an advocate to the patient
Identifying, supporting and addressing the
needs of the individual
Helping to provide information
To discuss options
To clarify values and preferences
To support consumer autonomy
Provide a care plan that is agreed
A person-centered, supportive
encounter which promotes the
ideal conditions for effective
decision making to occur
Patients are empowered with
information so that their autonomy
or control over healthcare decision
making is increased

Shared Decision Making (SDM) – Working in
partnership with MDT team and families

How SDM Supports Patient
Empowerment and Participation
In the shared decision-making process, practitioners are encouraged to think
about and apply:
1. Self-directed care
2. Self-determination
3. Person-centered planning
For patients to participate fully as partners in a shared decision making
process, they will need to accurate information, skills, and confidence
Steps in a Shared Decision Making Process
1. Recognition that a decision needs to be made
2. Identification of the partners in the process as equals
3. Statement of options as equal
4. Exchange of information on pros and cons of options
5. Exploration of understanding and expectations
6. Identifying preferences
7. Negotiating options and concordance
8. Sharing the decision
9. Arranging follow-up to evaluate decision making outcomes


Decide what the person
wants instead of what they
don’t want—when what the
person is doing is not
working, have him or her do
something different.
Stage of Change
In contemplation:
aware of the
problem, but
ambivalent about
making a change
“How important do you
think it is to others—
family, friends, doctor—
that you consider making
these changes for your
Identification of something
YOU (the patient) want to
accomplish or a problem
that you want to resolve

Recognition that a decision needs to be made
Matching Techniques and Approaches to the
Shared Decision Making Process


Amplify and build on strengths to
promote change in areas identified
by the person and the view he/she
holds for wanting things to be
Practitioners and patients
construct the solutions
together …sometimes
inventing them
Stage of Change
Providers respect the
particular needs of
persons in various stages
and adjust their stance
(nurturing parent, Socratic
teacher, coach,
consultant) to support
specific actions necessary
for the person to progress
to the next stage
Empowerment Persons
are allowed to direct their own
course, focusing on one or two
items that fit their interest or
This process will generate
feelings of self efficacy,
competence and build

Identification of the partners in the process as equals 7
Matching Techniques and Approaches…
Benefits of effective communication in person
centred care
First, it greatly contributes to the ability to provide patients with personalised
. Health care professionals who take the time to understand the unique
and concerns of their patients will be better prepared to advocate on
their behalf and properly address issues as they arise. This greater focus on
communication frequently leads to
better patient outcomes as well as a good
continuity of care.
Effective communication improves responsiveness of service users and they are
more likely to
disclose the true extent of their feelings and symptoms much
. Patients may also feel more satisfaction and feel valued.
Interpersonal communication can satisfy the innate needs of the patient as
outlined in Maslow’s hierarchy of needs
. Maslow (1962) Those needs include the
feelings of safety, love and confidence, all of which are important during a
patient’s treatment and recovery.

Effective partnership working and good communication between everyone
is essential. Health and social care workers must trust, value and respect
one another, having belief in everyone’s ability to work together to achieve
shared goals.
For communication to be good and effective it must be open, accurate and
Ways of communicating and language must be right for the individual so
you can be sure that they understand what is being said. Workers should
avoid using jargon which can be misunderstood.
When working with people who have communication needs, it may be
necessary to consider translators, pictures or communication boards to
support them to communicate well.
Training staff
The ultimate goal of a training program is not just to increase the skills
health care workers, but also to help health care
recognize and report problems that could impact the health,
and well-being of all individuals who require health care.
Training staff improves the quality of care of staff members
Training staff enables health care workers more capable in to provide
holistic care and person centred care.
Improve CQC rating, and organisation are meeting the requirement of the
law and regulatory bodies.
Training staff increases loyalty and employee engagement
Training staff improves competences, knowledge , skills and abilities.
Training improves Dignity and choices for resident.
Health care workers should agree on how
Providing care and support
Working in a person-centred way
Communicating well
Building relationships and promoting equality and diversity
Working as part of a team
Being a supportive team member and developing your skills to improve your work
Contributing to activities in a safe way
Keeping and filing clear records
Keeping to regulations
Following the agreed way of working
Respecting confidentiality by not discussing any personal information on individuals or
staff with unauthorised people, and storing records securely
Action planning – creating SMART goals depending on your weakness
and plan for improvement.

Goal setting: what do we want to achieve and by when?
• Action planning: what are we going to do, who is responsible, and
when will it be reviewed?
SMART is a well-known acronym for Specific, Measureable,
Attainable/Achievable, Relevant/Realistic and Timebound/Timely/Time limited (Basi and Green, 2016)
. It has been used to support systematic planning in many areas
including health, business, and education. It can help you to develop
plans that are clear, can be implemented, and can be evaluated.
Group work
Using the SMART target setting process in care planning.
Read the article and guideline and answer the scenario
Share your responses to the class.
Assess your work place setting and share if there any other solutions
or strategies used to deal with barriers in care planning or person
centred care.

Basi, J. and Green, C. (2016). Writing good care plans. [online] Available at: [Accessed 6 Nov.
Maslow, A. H. (1962). Toward a psychology of being. Princeton: D. Van
Nostrand Company