Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Tips for Collaborating in Interdisciplinary Settings Across Sectors and Practice Settings When Providing Clinical Care in Collaboration with Youth and Family
  • Identify all stakeholders within the circle of care (interdisciplinary healthcare team in both acute and community settings, youth and family, significant others, community partners, academic and spiritual supports).
  • Identify essential stakeholders required to move the plan of care forward.
  • Identify a key worker who will facilitate communication, goal-setting, implementation and evaluation of the plan. This role is usually fulfilled by a registered nurse,
  • Invite identified stakeholders to participate in discussions about supporting and enhancing re-integration of youth back into the community.
  • Develop a plan of care and support with specific goals for each stakeholder that will enhance re-integration, reduce risk and promote health, while maintaining the collaboration of all stakeholders involved.
  • Implement the desired plan of care with ongoing evaluation and revisions as required.
  • Ensure that follow-up planning is addressed and available as required.