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Collaborative Care Plan

Collaborative Care Planning emanates from an intense multidisciplinary examination of the biopsychosocial causes of the individual's suffering. It leads to Interdisciplinary case conceptualisation and care planning (Baker et al., 2019). Ruth's recovery-based care plan will emphasise her interests and requirements in establishing care objectives and aspirations based on psychological and biological techniques. A crucial evaluation will also evaluate Ruth, a patient, her interaction with medical treatment, and the care effects from her perspective.

Ruth is presently at an inpatient facility. Consequently, an interdisciplinary care team comprised of mental healthcare practitioners, a physical therapist, an aboriginal liaison officer, a dietitian, a fitness instructor, a neurologist, and a psychologist are all part of the team. A general practitioner got informed to develop a comprehensive care plan to counter Ruth's Schizophrenia which has relapsed (Bailey, 2012). Notably, there has been a history of borderline personality disorder, antisocial personality disorder, and substance addiction disorder. She has difficulty staying away from illegal substances, and her substance abuse contributes to her sickness. Ruth was unconcerned about her treatment while in the community. She doesn't have a steady salary and lacks life and social skills. Ruth has a limited understanding of her sickness and the need to adhere to the treatment. She lacks judgment and is prone to rash behaviour. Ruth has auditory hallucinations and delusions, which are significant symptoms of Schizophrenia.

Ruth is currently willing to participate in drug and alcohol treatments and has claimed that she would continue to do so even after discharge. Ruth would prefer to live in a stable environment after being discharged from the hospital. Ruth expressed an interest in baking and stated that she might be able to use her baking abilities for a career while living in the community. She also said she was interested in participating in a course where she would receive instruction to improve her baking talents. Occupational therapists at the hospital organise workshops to help patients improve their daily skills (García-Pérez et al., 2021). They are willing to assist Ruth with enrolling in a baking and cake designing course once she is released into the community.

Ruth's goals and aims for care require focusing on the best treatment plan. According to Baker et al. (2019), a possible alternative concept is a collaborative care. The biopsychosocial is one of the collaborating models to employ as a mental nurse, and to make it user-centred, Ruth must be encouraged to participate in the entire process. Patients striving to manage chronic diseases require constant assistance in modifying and adopting self-management strategies (Chunchu et al., 2012). Practical problem-solving focuses on Ruth and avoids the provider putting objectives and plans on her. One of the most commonly debated ideas in medical practice is patient-centred care (Ishikawa et al., 2013). According to Ishikawa et al. (2018), two-way communication is a critical component of such treatment since it enables clients and physicians to share ideas and discover common interests.

Nursing care throughout the rehabilitation stage is one of the Schizophrenia treatment approaches. The social worker and occupational therapists will significantly aid Ruth's recuperation. Occupational therapy combines art and science that directs patients to specific tasks to enhance and preserve health and avoid impairment via activities and job activities for mentally and physically impaired persons (Khadijah et al., 2020). D'amico (2018) demonstrates that every impact of psychosocial therapy and rehabilitation neutralises the causes of patients' retreat from social life. Social skills training is required to teach patients how to return to conditions in which they will be able to function normally in their surroundings. Ruth can also be linked to a community pantry where she can get low-cost or free food. All of these things may be organised with the assistance of a social worker. Ruth will consequently require assistance in growing this notion, and she will obtain a job that will allow her to be financially stable.

Setting And Service That Ruth Is Accessing

Ruth is an Aboriginal woman, and by providing culturally sensitive community-based supportive therapy, the Aboriginal liaison specialist will assist and guide her throughout the collaborative care program (Mackean et al., 2020). Moreover, Mackean et al. (2020) claimed Schizophrenia is a debilitating mental condition characterised by impairments in cognition, emotion, and psychosocial and vocational functioning.

Essentially, recovery-centred and trauma-informed care. A psychiatric nurse can employ active listening, reflecting, and summarising approaches to boost Ruth's optimism and guarantee medication adherence (Kohpeima et al., 2016). Administer medicine and keep an eye out for any adverse effects. To address her behavioural concerns, she underwent a motivational interview. There are steps for dealing with borderline personality disorder, antisocial personality disorder, and substance abuse disorder to establish rapport with nurses. Care is evidence-based and oriented toward the consumer. Her mental state is being monitored and risk assessed on an ongoing basis. Nurses can lead a group or participate in other activities for her.

A social worker can arrange for housing, reconnecting with relatives, improved accessibility to a daughter in foster care, and financial assistance from Centrelink Australia, such as a Newstart allowance or disability pension. Ruth is suffering significant financial difficulties due to her lack of a consistent salary and unemployment, which must be handled. Ruth can enrol in a baking school, which will assist her in finding work once she is discharged and the previously stated Centrelink assistance. Housing in Australia might be arranged through a social worker or other support groups. Make a recommendation for Ruth to access free or reduced-cost food and other essential living necessities.

All occupational therapy techniques must have a mental health component. Ruth receives therapy and prevention from occupational therapists. Individuals obtain a wide range of abilities, develop good habits, establish therapeutic goals, and understand and manage physiological difficulties with these specialists' assistance (Lindson et al., 2019). An occupational therapist aids in the restoration of normality before disability by addressing physical and cognitive impairments. Mahajan et al. (2021) claimed that people suffering from mental illnesses, such as depression or manic depression, might benefit from occupational therapy services. Ruth's rehabilitation can be aided by the Aboriginal sobriety group using indigenous healing procedures and rituals such as healing circles (Lee, 2014). Once Ruth is released into mainstream society, the aboriginal liaison officer will ensure that she is placed in an emotionally and socially welcoming setting that allows her to maintain her social identity (Lee, 2014).

Currently, Remington et al. (2016) claimed that physicians occasionally resort to therapies deemed more "benign" and keep with standard therapeutic practice. Their start, which might occur before the first psychotic episode, also implies that therapies are delayed. As this is highly important for Ruth, trauma-informed treatment may be provided. In addition, because she has a lengthy history of substance usage, she will undergo drug and alcohol rehabilitation therapy (Remington et al., 2016). Look at the possibilities accessible in Australia. Cognitive and behavioural treatments will aid Ruth's rehabilitation. There is a history of borderline and antisocial personality disorder.

Ruth's Goals and Aims For Care

Administration of drugs such as antipsychotics, antidepressants, or other pharmaceuticals to control her schizophrenia diagnosis, borderline personality disorder, antisocial personality disorder, and substance addiction disorder are vital to Ruth's recovery. Furthermore, based on the mental state evaluation and psychometric tests, drug therapy should continue or change. Besides, Dodell-Feder et al. (2015) posited that neuroplasticity-based treatments show that focused cognitive training improves brain networks that enable fundamental cognitive functions. It is crucial to monitor harmful pharmacological side effects and emotional states. Atypical antipsychotics and guaranteeing the minimal antipsychotic dosage are among the feasible approaches employed while maintaining positive symptom management, an antidepressant trial, and non-somatic therapies (Remington et al., 2016). Modifications can be used to assess symptoms and adverse effects.

The interdisciplinary care team has aided Ruth's recuperation. Throughout the decision-making process, she recognises her value, and her preferences have been integrated into the care plan. She did, however, remark that her experience had been challenging at times. As a mental nurse, I provided Ruth with empathy, compassion, and compassion that she did not experience early (Taylor et al., 2020). She admits that her sleep has increased, that her appetite has increased slightly, that she likes her cake baking sessions with occupational therapy, and that she is looking forward to returning to her community to live with her daughter. She also stated that she has adaptive abilities for dealing with her anger and that she channels her anger via valuable activities. She still struggles to avoid smoking when provoked by pressures, but she has improved her self-management skills via social skill training.

As the consumer's nurse, I ensured that she was handled in a secure, professional, practical, and culturally aware environment. To guarantee this, Valdez (2021) encourages the examination of providers' assumptions, prejudices, and denominations about customers with a criminal history which I did. Ruth proved challenging to engage with since she was resistant to reform, aggressively dangerous, and afflicted with psychosis, which can wreak havoc on social interactions (Oades et al., 2021). By being nonjudgmental and offering unconditional consideration and experience of her concerns, I utilised tolerance, compassion, and empathy to create Ruth's safe and supportive therapy environment.

To ensure that Ruth receives excellent, I collaborated with the other individuals of the healthcare experts to provide equal care to identify and collect appropriate resources (Oades et al., 2021). I had formed a profound attachment with her during the care time, which I subsequently classified as countertransference. In the nursing profession, I saw the importance of tolerance, empathy, and clinical decision making are essential due to my encounter with Ruth. (Sorenson et al., 2016). I made sure that the ethical and legislative standards were satisfied.

As a mental health nurse, I ensured that Ruth's therapy and personal details were protected private in all coverage areas. To persuade Ruth, I had to demonstrate the delimitations of the confidentiality principle (Chiumento et al., 2015). Ruth did not initially trust me with her private information, thoughts, and sentiments, which jeopardised her chances of regaining possession of her daughter. Nevertheless, I gained her confidence with tolerance and consistent dialogue, and I emphasised that the treatment team maintained her data security. Ruth has gained some understanding of her therapy and acknowledges having a mental illness. She believes that her substance abuse and her refusal to take medications have contributed to her health deterioration. Ruth is committed to taking medicine and enrolling in drug rehabilitation sessions. She recognises that lowering the severity of her psychiatric condition will enable her to gain custody of her child. Medication is helping her with her auditory hallucinations.

Psychosocial Strategies

I stressed the necessity of her consent and engagement in the care plan choice at the start of the care since it will create a goal for her, enhance her optimism, and make her feel meaningful. Her main concern was that the information she gave to me might be used to discover a better solution in the healthcare institution. I made sure that I described a good result for her and assisted her in writing three acts of thankfulness each day to boost her self-confidence. I saw a favourable attitude regarding the thankfulness practice treatment approach (Cunha et al., 2019). I explained that this is a slow process that will improve with time. Ruth's encounter and mission were as unexpected as Ruth's. However, I recognised my value as a psychiatric nurse in making a difference in an individual's life.


The Collaborative Recovery existed as a framework for providing recovery-oriented mental health services to manage Schizophrenia. Ruth's collaborative care was therapeutic in and of itself since it empowered her to help herself rather than dictating her treatment. While teamwork is vital, it also seeks to achieve a result that benefits persons in recovery while improving care. Recovery-based programs should be part of mainstream healthcare policies.


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