Building collaborative cultures of care

within NSW mental health services

Back to accessibility links

Systems, practices and care planning

Systems, practices and processes are the design features of care that support consistent care coordination, practice, approaches and implementation.

Collaboration enables health service staff to learn about a person’s strengths and strategies for self-management.

People with lived experience of mental health issues collaborate in assessment and care planning to inform and direct their care.


Advance mental health directives outline care preferences and decision-making when a person has been assessed as lacking the capacity to engage in shared decision-making.

An advance care directive should be completed when a person has the capacity to make these decisions.

It should be recorded as a legal document if possible.

If a person lacks the capacity to engage in shared decision-making, it may only be for a short time. It should not be assumed that the person cannot or does not want to engage in their care throughout their entire journey. The views of the person themselves should be reviewed and incorporated in the care plan as soon as engagement can occur.

Family and carers can be crucial collaborators in care planning. They may be aware of the person’s history (including trauma), needs and preferences. This can help to inform services when the person is most disabled and if he/she is unable to contribute to the discussion. This information can also be vital to avoid re-traumatisation.

Information sharing between care settings such as community or primary care (general practices and primary health network services) and specialist or LHD services, may not be well facilitated. Family and carer involvement also supports information sharing.

People who are at risk of restrictive clinical and organisational practices have the opportunity to prepare a safety or continuum plan for periods of increased mental distress, aiming to prevent the use of restrictive practices.

Proactive planning can minimise and eventually eradicate use of restrictive practices and further improve risk assessment and safety planning 692629

The safety or continuum plan is strongly encouraged to be woven into the care plan, where actions can be incorporated to support the person’s needs and priorities alongside minimising the risks to the person or others.


A range of systems and tools can reduce the use of restrictive interventions. These include:

  • local policy and practice guidelines20
  • organisational priority and responsibilities for change2122
  • collaboration with people with lived experience, their families, kinship groups, and carers to identify opportunities and collaborate for areas of improvement22123
  • person-centred, trauma-informed recovery oriented care and practice approaches that are culturally appropriate2324and
  • collaborative care planning approaches to develop individualised plans and strategies to improve experiences and outcomes of care.2224