Nurse Education Today 33 (2013) 262–267

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Nurse Education Today

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An exploration of the midwifery continuity of care program at one Australian

University as a symbiotic clinical education model
Linda P. Sweet a,⁎, Pauline Glover b, 1
a
Flinders University Rural Clinical School, GPO Box 2100, Adelaide, SA 5001, Australia
b
School of Nursing and Midwifery, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia

a r t i c l e i n f o s u m m a r y

Article history: Objective: This discussion paper analyses a midwifery Continuity of Care program at an Australian University
Accepted 18 November 2011 with the symbiotic clinical education model, to identify strengths and weakness, and identify ways in which
this new pedagogical approach can be improved.
Keywords: Background: In 2002 a major change in Australian midwifery curricula was the introduction of a pedagogical
Midwifery innovation known as the Continuity of Care experience. This innovation contributes a significant portion of
Continuity of care
clinical experience for midwifery students. It is intended as a way to give midwifery students the opportunity
Symbiosis
Clinical education
to provide continuity of care in partnership with women, through their pregnancy and childbirth, thus imi-
tating a model of continuity of care and continuity of carer.
Methods: A qualitative study was conducted in 2008/9 as part of an Australian Learning and Teaching Council
Associate Fellowship. Evidence and findings from this project (reported elsewhere) are used in this paper to
illustrate the evaluation of midwifery Continuity of Care experience program at an Australian university with
the symbiotic clinical education model.
Findings: Strengths of the current Continuity of Care experience are the strong focus on relationships between
midwifery students and women, and early clinical exposure to professional practice. Improved facilitation
through the development of stronger relationships with clinicians will improve learning, and result in im-
proved access to authentic supported learning and increased provision of formative feedback. This paper pre-
sents a timely review of the Continuity of Care experience for midwifery student learning and highlights the
potential of applying the symbiotic clinical education model to enhance learning.
Conclusion: Applying the symbiotic clinical education framework to evidence gathered about the Continuity
of Care experience in Australian midwifery education highlights strengths and weaknesses which may be
used to guide curricula and pedagogical improvements.
© 2011 Elsevier Ltd. All rights reserved.

Introduction With the introduction of the three year Bachelor of Midwifery pro-
gram in Australia in 2002, a pedagogical innovation called the Conti-
The midwifery profession espouse the concept of woman centred nuity of Care (CoC) experience was commenced. The CoC experience
care that includes continuity of care and carer for women, although has been designed as a way to afford students the opportunity to fol-
this is not universally practised in Australia (Pairman et al., 2010). low women through their pregnancy and childbirth working in part-
In professions such as midwifery, students need a range of experi- nership. This innovation is based on experiences where midwifery
ences in a variety of occupational settings to develop capacity for students engage with pregnant women through the period leading
their professional practice (Billett, 2002). Midwifery education pro- up to and immediately after the birth of their baby. The peak
grams have traditionally been based on models similar to nursing, Australian Midwifery regulatory authorities adopted the recommen-
whereby students undertake theoretical learning and early skill de- dation that students undertake a minimum of 30 CoC experiences in
velopment in University, and are placed in clinical environments for the 3-year Bachelor of Midwifery program (Australian College of
practice based experiences predominantly in tertiary level teaching Midwives Inc., 2006). The required number of CoC experiences was
hospitals (McKenna and Rolls, 2007). amended in 2010 to 20 over the three years.
Whilst mandating the inclusion of CoC experiences, there was a
dearth of guidance on how to embed these within the curriculum to
optimise student learning (Glover, 2003). At the study university,
⁎ Corresponding author. Tel.: + 61 8 82045017; fax: + 61 8 82045800.
E-mail addresses: linda.sweet@flinders.edu.au (L.P. Sweet),
midwifery students are required to recruit and manage their own
pauline.glover@flinders.edu.au (P. Glover). caseload of women for these 20 CoC experiences. At the completion
1
Tel.: + 61 882 013404; fax: + 61 8 8276 1602. of each CoC experience, students are required to write a brief

0260-6917/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2011.11.020
L.P. Sweet, P. Glover / Nurse Education Today 33 (2013) 262–267 263

reflection of their learning. This is documented in a reflective portfo-

lio for summative assessment. Students experience the woman's
pregnancy care, birth and post natal care in whichever clinical setting
is chosen by the woman. The longitudinal involvement of the student
in a woman's pregnancy and birth experience predicates the likeli-
hood of continuity. It is timely to evaluate the value and benefit of
the CoC to learning and to identify ways in which this pedagogical ap-
proach can be improved.
One approach to evaluate a clinical education program is to ana-
lyse it using the symbiotic clinical education model documented in
the medical education literature (Worley, 2002a,b; Prideaux et al.,
2007). The symbiotic clinical education model asserts that effective
health professional education requires integration of the many com-
ponents (depicted in interlocking axes) to be effective, and that clin-
ical education programs that do not achieve symbiosis will be less
effective and less sustainable (Prideaux et al., 2007). Therefore, the
aim of this discussion paper is to determine how well the midwifery
CoC experience performs as a symbiotic clinical education model.
The symbiotic clinical education model will be described and then,
using data from a recent study on one CoC program, the strengths
and weakness of the program as a form of symbiotic clinical educa-
tion will be presented.
Fig. 1. Worley's Symbiotic model, also known as the integrity model: the 4Rs. Reproduced
Symbiotic clinical education (with minor adaptation) from Worley 2002a with kind permission of the copyright owner.

The symbiotic clinical education model, also known as the integri-

ty model: the 4Rs, is a model that has developed from medical educa- relationship in a meaningful way facilitates ‘authentic learning’ and
tion scholarship in Australia (Worley, 2002a). Symbiosis as a clinical enables students to access the multidisciplinary team for their learn-
education concept had previously been raised (Bligh et al., 2001), ing (Worley, 2002a,b; Prideaux et al., 2007). By engaging students in
however it was the work of Worley and Prideaux that developed routine care, authentic learning is occurring within the process of
the symbiotic clinical education model (Prideaux et al., 2007). The health service delivery which creates a mutually beneficial
emphasis of this model is on achieving ‘symbiosis’ or mutual benefit, environment.
whereby clinical education adds value to—and occurs in the context Students’ agency is pivotal to this axis. They need to be prepared
of—clinical practice, health service delivery and personal and profes- and willing to be immersed in practice and focus on their own learn-
sional development. A symbiotic curriculum should become a win- ing needs. Early and continued exposure to practice is important to
win situation among all stakeholders (Prideaux et al., 2007). maintain a person centred care approach (Prideaux et al., 2007). By
The symbiotic clinical education model outlines ideal mutually effectively engaging students in client based learning, they will be
reinforcing relationships across four principal axes: the personal, clin- less inclined to focus on tasks or skills, but rather enabled to apply
ical, institutional and social axes, and highlights the interrelatedness their learning to more complex processes to solve every day clinical
between each of them (Prideaux et al., 2007). The student—or the practice problems.
learner—is embedded in the middle of the model, depicting student
focused teaching and learning (Fig. 1).
Institutional axis
Personal axis
This axis highlights the interdependence of both the health ser-
vices and university for producing quality graduates and improving
The personal axis of the symbiotic model reflects the importance
client care (Prideaux et al., 2007). The health service offers the au-
of individuality in clinical education. It promotes the exploration
thentic learning opportunities, while the university offers scholarship
and consideration of differing personal and professional values, atti-
and research to improve clinical practice and education (Prideaux et
tudes and behaviours, and their influence on teaching and learning
al., 2007). Authentic supported learning is defined as learning that
(Prideaux et al., 2007). One of the most important learning activities
is constructivist, inquiry based and has work value (Prideaux et al.,
for students is to develop their personal principles to align with pro-
2007). For this to be achieved students need to be enabled to make
fessional expectations (Prideaux et al., 2007).
a significant and worthwhile contribution to the work of the clinical
With symbiotic clinical education, effective teaching and learning
teams, while constructing their own learning under the guidance of
is dependent on the development of relationships which takes time
clinicians.
and interactions, and requires mutual support and respect. Therefore
clinical models which afford significant time to develop relationships
offer greater student support and can build the mutual benefit neces- Social axis
sary for symbiosis. When students are enabled to develop effective The social axis reflects the importance of clinical education ensur-
working relationships with clinicians and clients they gain a sense ing it meets the needs of both the community which the institution
of belonging within the community of practice (Worley, 2002a,b). aims to serve and the government policy and priorities(Prideaux et
This assists the development of professional identity. al., 2007). This axis demonstrates how health professional education
is embedded within the broader complexity of society. The relation-
Clinical axis ship between community needs, community involvement, govern-
ment policies and financial support, is fundamental to achieving a
The clinical axis reflects the importance of client based learning in symbiotic curriculum and meeting the learning needs of students
clinical education. Incorporating the student into the clinician-client (Worley, 2002a,b; Prideaux et al., 2007).
264 L.P. Sweet, P. Glover / Nurse Education Today 33 (2013) 262–267

The study than the requisite time in developing these relationships, while stu-
dents later in the program found the time pressure significant and un-
A research study was conducted in 2008/9 that sought to under- dertook only the minimum number of interactions with women.
stand the midwifery learning that occurs through the CoC experience Students felt a need to be useful for the women – to give something
and to identify ways to improve teaching and learning in this innova- back for involving them in their childbearing experience.
tive pedagogic model. A qualitative research approach was used to in-
vestigate the intent and enactment of the CoC experiences for 1st year: If I'm following a woman through I want to attend to her
midwifery students. Ethical approval was obtained from the Universi- enough in the ante-natal period that I feel like I'm actually offering
ty Social and Behavioural Research Ethics Committee and all partici- something in the birth room, not just being the observer who's
pants provided informed consent. learning
All current students in the Bachelor of Midwifery program and
midwifery academic staff at the time of the study were invited to par- Students recognised the need to develop a relationship with the
ticipate through focus group discussions. The 20 graduand students women to be engaged in clinical practice, and in so doing developed
that completed the Bachelor of Midwifery in 2007 were invited to their own agency.
participate through submission of their Midwifery Learning portfoli- Students expressed great challenge in meeting the competing
os. An information sheet, introductory letter and consent form were commitments of the CoC experience, traditional block placements,
provided to all prospective participants to gain informed consent. and ongoing university classroom requirements. In order to balance
Focus groups were conducted with first, second, and third year these, the curriculum requirement was for intermittent interactions
Bachelor of Midwifery students in their year groups to explore their with the pregnant women. Students recognised this as not being rep-
perceptions and experiences of the CoC experience. This step wise ap- resentative of real CoC and challenged the underlying philosophy.
proach enabled us to identify the progression of students’ experiences
across the three year program. Fourteen students took part in these 3rd year: One thing I'll say is that you ask for continuity of care but
focus groups. One focus group was held with four midwifery academ- you only ask us to attend two antenatal and two postnatal so
ic staff to explore their perceptions of the CoC experience. All focus where is the continuity? Because in reality, continuity of care is
groups were audio recorded and transcribed verbatim by a profes- going to every single appointment.
sional secretarial service. The transcripts were then checked for accu-
racy and anonymised (by LS). In addition, reflective portfolios The pedagogical approach of the CoC experience is one of student
recording CoC experiences across the three years of the program led learning. The student negotiates engagement and ongoing inter-
were collected from graduate students. A total of one hundred and actions with the woman and her health care providers. Some students
eighty reflective write-ups were collected from six graduates. struggled with the need to recruit women independently and self
These data were individually and collectively analysed thematical- manage their CoC experiences and learning. Similarly the program
ly to identify pedagogical aspects of the program. All of the data were taught students to negotiate their own learning opportunities with
examined and coded by two researchers individually, and then com- clinicians and women.
pared and discussed collectively, to identify key areas and themes of
pedagogical concern. The software package NVivo 8 was used to assist 3rd year: So first year I was very hesitant and I wouldn't put myself
data management and coding. The primary results of the study are out there. Whereas third year you know you need the experience
described in much detail elsewhere (Sweet and Glover, 2011). The and you know that you need to expose yourself to certain opportuni-
data was further analysed using the symbiotic framework. This ties so you'll find yourself saying to a midwife well this is what I really
paper draws on the data and findings of the study, and applies them need to achieve, can we do that?
to the symbiotic clinical education model as an evaluative framework.
The pedagogical arrangement of the CoC experience resulted in
Continuity of care experience and symbiosis the student being aligned with the woman and not the health care
providers. This is in contrast to the traditional clinical placement
The purpose of this paper is to analyse the CoC experience, as model whereby a student is placed in the health service and provides
accounted throughout the described study, in relation to the symbiot- care to whoever engages with that service. Being with the woman
ic clinical education model. Analysis of the data has demonstrated and her family resulted in strong relationships between the student
some aspects where symbiosis is achieved but also highlights many and the woman. In first year, students often did not have the requisite
areas which do not achieve symbiosis; and warrant further develop- knowledge to understand the physiological and/or pathophysiologi-
ment for improved clinical education. cal conditions of the women they had recruited. This prompted
them into some independent study to find requisite knowledge.
Personal axis Students’ experience with healthcare providers varied depending
on the model of care being used by the woman. Situations where
The CoC experience was effective in providing early student expo- women were seen by different professionals at every visit hindered
sure to midwifery practice. This motivated students to learn, and the development of relationships between the student and health
assisted in developing their professional identities as midwives. care providers, which limited learning opportunities.

1st year: Positive would be that it's hands on and it's mums and 3rd year: If you're on clinical and you're allocated to the midwife, …
babies and it's just what we're going to be doing eventually and she can get a feel for what you're like and then she'll give you a wider
you get to do it straight up. Yeah. It's just exciting. scope whereas if you're with a follow through you've got to work a lot
harder to earn the respect of the midwives because you're an append-
Being actively engaged in the CoC experience did assist students in age of the woman, you're not an appendage of the midwife.
developing and/or confirming a woman centred care philosophy.
Students recognised that the CoC experiences afforded them lon- This intermittent engagement with varied health service pro-
gitudinal involvement with women which enabled them to develop viders hampered regular feedback and limited opportunities for men-
a meaningful relationship to learn about pregnancy and childbirth. toring, coaching and professional socialisation. Students did recognise
Students in the early stages of their program of study invested more that the CoC experience exposed them to many different clinicians
L.P. Sweet, P. Glover / Nurse Education Today 33 (2013) 262–267 265

which allowed them to identify good and bad role models to base varied engagement of the student in routine clinical care but certainly
their own practice. When students found midwives they perceived afforded the students exposure to the complexities of professional
as good role models they often tried to continue engaging with the practice.
women who were cared for by these midwives.
1st year: And you get to see the birthing rather than just read it in a
Clinical axis book and we don't do much of that or we haven't yet talked about
what happens in labour and that sort of stuff. It's very exciting and
The CoC experience requires the midwifery student to engage they're all different.
with the health service through the conduit of pregnant women seek-
ing care. The student experience is therefore dependent firstly on the There were clinicians who afforded them learning opportunities
women, and secondly on the clinicians. The concept of client-based which involved clinical skills and practice beyond their level of com-
learning and client as educator is a strength of the CoC experience. petence. This resulted in ‘out of sync’ learning with the underlying
Students learn from the women themselves, and from the healthcare curriculum but was a positive authentic learning opportunity for the
provided to these women by the clinicians, which consolidates their student.
women centred care philosophy.
Institutional axis
1st year: Because you're seeing the whole range of different models,
different hospitals. … I imagine when you're on clinical you're The CoC experience is designed for midwifery students to be
under the supervision of a particular person and doing things their aligned with women, and as such they are not imbedded in the com-
way; you're not so woman focused. Whereas when you're sitting munity of practice and everyday service provision. Furthermore, the
with a woman and hearing her comments before and after the ap- CoC experience is intended to result in midwives who espouse conti-
pointments, then you're really looking at it from her point of view. nuity of care and a woman centred care philosophy as their ideal for
future professional practice. Second and third year students chal-
Students often described the feedback they received from women lenged these concepts as being unrealistic of many current health ser-
about their own care and that of the clinicians, both of which in- vice contexts.
formed learning.
2nd year: But in the real world when we're midwives, we're not going
2nd year: I think you're in a situation with the women but then you to, unless we are working in continuity of care we're not going to be
also get her feedback afterwards and what your perspective might be able to establish that relationship with the woman anyway. So yeah
at the time might change quite dramatically once you hear what she's I've kind of thought, well, what is it actually for?
thought about it herself, or how it's helped her or not helped her.
This negatively impacted on the authenticity of learning.
This feedback was highly valued by the students and a great moti- The creation of a win-win situation within health service requires
vator for their involvement. students to be engaged longitudinally and become part of the com-
Ideally, clinical education should be based on authentic experien- munity of practice. The CoC experience does not facilitate a sense of
tial learning and not merely observation of practice. Engagement with belonging to a community of practice as the students are always pe-
clinical practice requires the development of relationships between ripheral to routine care. Students expressed frustration about spend-
students and clinicians, which is dependent on time and interactions. ing many hours sitting with women in waiting rooms for a routine
Students spoke of the many clinicians being unaware of the student consultation which they were often not engaged with.
role in the CoC experience, and varied willingness to engage them
in clinical practice. Students expressed significant frustration when 3rd year: I actually tried to go to appointments more often and I
the clinicians ignored their presence and did not engage them in au- found they were an absolute waste of time. You spent a lot of time
thentic learning. waiting to be seen and you actually didn't learn anything.

3rd year: We patchwork what will become our practice from all the Students found negotiating the short term relationships, and the
midwives that we work with and some are great and some are not sheer number of CoC experiences required, time consuming and
so great and some we like the things they do and others we think exhausting over the three years. As a result of this, the students be-
god I would not do that when I'm out there, that's one thing I won't came very strategic in their choice of women to recruit. They looked
do. So not even just what we're learning clinically but it's what for women who had had previous births, a history of short labour
we're learning that we can then pass on when we're in that role. and were near term in their pregnancy.
As students got to know the health care services and clinicians
When a student had frequent and regular contact with the clini- through the CoC and traditional block placements, along with their
cian they were able to develop an effective relationship which sup- advancing knowledge and skills, their individual confidence and
ported their engagement with routine clinical care. Authentic agency improved. As they progressed into third year and became
supported learning was therefore very dependent on their relation- more involved in clinical care for the women they were following,
ship with clinicians. the clinicians recognised the student role and engaged them as a
valuable team member, particularly in intrapartum care.
1st year: Some of them stand out of the crowd yeah definitely. Espe-
cially if you see the same one, and after a few weeks like I saw one Social axis
[midwife] for a few of the visits, and she knew me, so she targeted
me to ask me ‘so remember we did this last time? Now explain it The CoC experience gives students an understanding of the health
me this time’. Then next time she had me do it myself and that was system and the service needs from the perspective of childbearing
with the palpation. … She wanted me to learn. women. Being aligned with women and developing effective relation-
ships with them, affords the students a unique view of midwifery
Midwifery students engage with the CoC experience from the very practice which instills a strong philosophy of women centred care.
beginning of the midwifery degree. The CoC experience resulted in This meets the communities’ desire for preparing a more holistic
266 L.P. Sweet, P. Glover / Nurse Education Today 33 (2013) 262–267

maternity service and aligns with the midwifery profession’ values. development of real and meaningful relationships with the health
The concept of CoC is recognised by midwifery students as ideal but care team is of vital importance for professional learning (Billett,
not reflective of current service provision. 2001).
Bournemouth University have a similar midwifery student clinical
1st year: It reminds us what we're supposed to be doing and provides education model known as student caseloading (Fry et al., 2008;
a contrast with the shift work style of practice. It's the only way that Lewis et al., 2008; Rawson et al., 2008). These authors highlight the
we can get an idea of what it might be like to work in midwifery importance of planning, communication and collaboration in their
group practice or independent practice. model. However there are some key differences between the caseload
model in the United Kingdom and the CoC experience in Australia.
The CoC program therefore provides a unique learning opportuni- First, caseloading does not start at the beginning of the pre-
ty for students to understand what CoC offers women. The CoC expe- registration program, but waits 18 months until the student has de-
rience enables midwifery students to experience many and varied veloped a level of clinical competence to practice autonomously
service providers and different models of care. This gives them the with indirect supervision. It is clear from our study that the early
opportunity to see the full scope of how midwives can practice and al- and continued exposure to midwifery practice offers great benefits
lows them to reflect on their own midwifery identity. Through the to students in developing their own personal midwifery identity
CoC experiences students also see the complexities of health services and philosophy. However, this UK caseload model makes students
and how they interact and impact on outcomes. the primary care provider and in a key authentic learning opportunity
in comparison to the Australian CoC model where the student is often
1st year: You can sort of see how within the system a whole lot of – left as an observer. These differences warrant further research to as-
how one decision can lead to a whole lot of others. sist development and improvements of the educational systems in
both Australia and the UK. The time commitments, and personal
This has the potential to develop a knowledgeable and critically and emotional costs of both models also appear significant and wor-
reflective midwifery workforce that strives to improve maternity thy of further research.
service. This study has highlighted some opportunities to improve the ed-
ucational symbiosis within the CoC experience. Facilitation of more
Discussion effective learning through building stronger relationships with clini-
cians will improve access to authentic supported learning and provi-
Limitations of the study sion of formative feedback. This will enhance midwifery student
learning. It will require the midwifery clinicians and academics work-
This discussion paper has drawn on evidence from a study that ex- ing together to enact the midwifery curricula to ensure that students
plored the CoC experience from the perspectives of midwifery stu- use their clinical reasoning and reflection skills to extend their knowl-
dents and midwifery academic staff from one Australian university. edge and understanding. This improved relationship may then afford
It has not considered the perspective of midwifery clinicians or child- a greater mutual benefit in service provision and give the student a
bearing women (the latter has been presented byRolls and greater sense of belonging and value in the healthcare team.
McGuinnes, 2007). Whilst all enrolled students at the time of the
study were invited to participate in the study, the recruitment was
Conclusion
low (14%) and therefore not representative of all students. Further,
the way in which the CoC experience has been implemented at differ-
The model of symbiotic clinical education is a model that can be
ent universities in Australia varies and the findings of this study may
used to guide clinical education development and evaluation, and fo-
not reflect the enactment and pedagogical issues of other universities.
cuses on the importance of relationship development for learning.
This paper adds significantly to the midwifery literature on strengths
Symbiosis and continuity of care program
and weaknesses of the mandated CoC experiences required in Austra-
lian midwifery education programs. Further, it commences dialogue
This analysis has demonstrated that the CoC experience reviewed
about ways in which to improve this valuable pedagogical approach.
has components of symbiosis. This clinical learning model is appro-
*The term Continuity of Care program replaced Follow Through
priate to build professional values and develop agentic professionals.
Experience in 2009.
The strengths of the current program are the strong focus on relation-
ships between midwifery students and women, and early clinical
exposure to professional practice. Henderson et al. (2006) argue Acknowledgements
that learning requires collaboration and partnership that occurs on a
personal level in the context of a broader social and political environ- This report has come from a wider study which explored
ment in the clinical venue. The need for a sense of belongingness has “Midwifery learning through a continuity model to produce an agen-
also been highlighted (Levett-Jones and Lathlean, 2008). In the CoC tic professional”. It was conducted as part of an Australian Learning
experience there is evidence of some development of a professional and Teaching Council funded Associate Fellowship entitled “Develop-
relationship between the midwifery students and the supervising cli- ing agentic professionals through practice-based pedagogies”
nicians which happens over time however it is evident that there is awarded to Professor Stephen Billett.
significant room for improvement. Furthermore, the participants in
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