Clinical Education Program: 4R Model of Symbiosis

This article discusses the 4R Model of Symbiosis in clinical education programs. It explores the importance of achieving symbiosis or mutual benefit in healthcare and clinical education. The article provides a critical analysis of a clinical education program and identifies areas for improvement.

Running head: CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
Name of the Student:
Name of the University:
Author note:

1CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
Introduction
The symbiotic clinical education model, prevalently known as the 4R model of
symbiosis, developed by Worley and Prideaux for the purpose of teaching potential health
professionals on the importance of achieving symbiosis or mutual benefit in healthcare and
clinical education. In other words, clinical education must be delivered in a way so that it
enhances one’s personal and professional development as well as skills in clinical practice and
deliverance of services across the community (Prideaux, Worley & Bligh, 2007). Clinical
education implies the implementation of educational and training programs across various
departments and health professionals employed in healthcare organizations, hospitals, emergency
centers and community health organizations, via qualified teaching and practitioner professionals
(Flott & Linden, 2016). The following paper will hence comprise of a critical analysis
concerning the experiences associated with the supervision and deliverance of a clinical
educational professional during my professional career, with the help of the 4R Model of
Symbiosis.
The 4R Reflection Model of Symbiosis will be used for critically analyzing the clinical
educational program I am supervising in currently. The symbiotic model of clinical education
was developed by Prideaux, Worley and Bligh (2007), on the principle that clinical educational
delivered to the student, the primary stakeholder embedded within the curriculum, must be such
that it assists in the achievement of a win-win situation across all stakeholders – that is, a
mutually beneficial relationship across stakeholders at the clinical, social and institutional levels.
The principle underlying this model is the concept of ‘symbiosis’ or ‘mutual benefit’. According
to this model, clinical education programs must ensure that every stakeholder benefits from its

2CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
deliverance. A ‘symbiotic’ clinical education program is one, which ensures that teaching the
curriculum is of value to personal development, professional development, clinical service and
deliverance of health services (Sweet & Glover, 2013). With this respect, the chosen clinical
education program will thus be critically analyzed upon the four axes, or mutually benefitting
relationships underlying symbiosis, that is, clinical, personal, social and institutional.
Brief Overview
The clinical education program which will be reflected upon this paper is what I am
currently engaging as a part of my personal employment experience – which is, as an Hourly
Paid Instructor (HPI) Lecturer in Nursing, in TAFE University’s Gilles Plains Campus in
Southern Australia. As a Nursing HPI Lecturer, I am required to deliver clinical education on
various essential concepts to nursing students engaged in Diploma of Nursing course, mainly on,
application of palliative approach in nursing, implementation and monitoring of Diabetes Care
for diabetic patients and nursing strategies underlying correct determination and confirmation of
the physical health status of patients. The clinical education program which is deliver is
experienced across the wards, especially during patient management such as during physical
assessments and care for end-of-life patients. I also teach students in a separate classroom in the
concerned university when teaching on diabetes management and palliative care approach. I
teach 20 nursing students all of whom are current undergoing diploma and have completed their
baccalaureate course.

3CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
Discussion
Personal Axis
The personal reflective axis within the 4R model of symbiosis is based on the need to
emphasize upon the individuality and uniqueness of each student within the clinical education
program. As per the 4R model, identification of such personal values allow nursing students to
align their personal as well as professional characteristics harmoniously (Sweet & Glover, 2013).
My clinical education program as an HPI lecturer in Nursing diploma requires me to teach
nursing students on diabetes care, patient assessments at the physiological level and
implementation of palliative nursing approach, both at the classroom as well as the wards. While
I teach theoretical perspectives on palliative and diabetes management at the classroom via
tutorials and lectures, I am required to deliver a major section of the clinical education program,
such as assessments, patient monitoring, end-of-life care at the bedside and also in situations
where registered nurses are engaging in real life patient care. For each of these components, as a
part of the preliminary requirements, I extensively educate my students on professional standards
like the Nursing and Midwifery Board of Australia, Australian National Diabetes Strategy and
Standards for Providing Quality Palliative Care for all Australians. Teaching such professional
standards demonstrate compliance to symbiosis since it allows students to understand
professional requirements and the ways in which they must align their personal attributes
accordingly (Razdorskaya, 2015). However, the curriculum given to me for teaching did not
mention any session where students be given the opportunity to reflect and communicate their
needs. Even though I am not bound to rigidly follow this curriculum, the lack of the same did
surprise me and to mitigate this limitation, I used to actively encourage my students to reflect
and discuss their reflections which further helped me in analyzing their personal, professional

4CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
and educational needs. This demonstrates a lack of compliance to the personal-professional axis
of the symbiotic model since without practitioner’s understanding of students’ personal
requirements, it will not be possible for professors to understand the professional, academic and
professional needs of students and their key areas of learning - a key prerequisite for establishing
symbiosis (Tierney et al., 2017).
Clinical Axis
The clinical axis within the 4R model of symbiosis, is based on the importance of
adopting a client centered approach to learning so that nursing students learn the importance of
developing therapeutic, empathetic and compassionate relationships with the patient. Such skills
are especially important for my teaching of diabetes and palliative care approaches since these
require consideration of holistic patient needs as well as the nursing engagement in
multidisciplinary teams (Gray & Smith, 2017). In my clinical education program, nurses are
required to engage in practical experience and real life situational learning in patient wards as
nursing students within the associated healthcare organization – an acute care facility located
within the locality. Thus, as a part of my clinical education program, nursing students are
required to gain hands-on learning while observing as well as implementing assessments, patient
centered care, diabetes education and palliative approach across real life patients and with the
supervision of registered nurses. Students were required to engage in such comprehensive
vocational and practical learning for a period of 6 months. This demonstrates a compliance to
symbiosis since it provides nursing students an authentic learning opportunity (Wittick et al.,
2018). However, within my clinical education program, I observed that as per this curriculum,
the admission of my students in such training was considerably delayed and conducted at the end
of my course instead of during the beginning, resulting in my students feeling fearful and

5CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
apprehensive upon professional transition. This demonstrates lack of symbiosis since without,
early, continuous and frequent professional exposure, the clinical axis within this model will not
be achieved (McGahee et al., 2018.
Institutional Axis
The institutional axis within the 4R model of symbiosis is based on the need for
collaboration and cooperation between the healthcare organizations as well as academic
institutes for the purpose of generating skilled nursing graduates and overall improvement within
clinical care services. With respect to my clinical education program, major limitations were not
observed since my nursing students received the opportunity to practically engage in patient care,
education and assessment within the wards of the associated healthcare organization respectively
(Loughland & Nguyen, 2016). However, I observed that there was little interaction between the
university and healthcare organization regarding feedback of learning and performances
demonstrated by the students specific to diabetes, palliative care or physical assessments
respectively, based on which, the learning needs of students can be identified, assessed and
implemented in the clinical education program and curriculum accordingly. This can be
considered as a major limitation in symbiosis since support from both academic and educational
organizations is needed to ensure improvement in clinical practice and education as well as
provision of authentic clinical practice opportunities to students. Even though I do receive
support from both the staff as well as the university during implementation of the curriculum, I
believe that along with inclusion of student reflection, a higher frequency of feedback
discussions involving both educational as well as institutional staff would have further been
beneficial in assessing student needs respectively (Sweet & Glover, 2013).

6CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
Social Axis
The social axis within 4R model of symbiosis requires that the clinical education model
so delivered meets the health recommendations postulated by the community as well as the
government. The clinical education program which I am involved demonstrates some
compliance to the social needs and governmental recommendations such as the Nursing and
Midwifery Board of Australia, Australian National Diabetes Strategy and Standards for
Providing Quality Palliative Care for all Australians (Carter et al., 2015). However, the clinical
education program does not provide any opportunity to students to practically engage in
community nursing - a limitation considering the need for clinical education to symbiotically
benefit the community and national healthcare needs. This is because nurses via deliverance of
healthcare education can increase awareness on health management within individuals and thus
benefit the community. Overall, the government is also responsible for ensuring that citizens
achieve positive health outcomes and thus, must work with healthcare organizations to determine
healthcare needs within the community (Sweet & Glover, 2013).
Findings and Practical Strategies
Thus, from the above observations, it can be implied that the clinical education program
of an HIP lectures in Diploma of Nursing which I am currently delivering is deficient in several
aspects of the 4R model of symbiosis. One of the key limitations which were observed was
within the personal axis, where there seemed to be no mention of considering the identification
and incorporation of personal experiences, opinions and characteristics of students within the
educational program. The absence of the any personal reflection within the teaching curriculum
which was given to me, was a key demonstration of this limitation. Practical strategies which can
assist students in communicating their personal ideas as well as academic universities in

7CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
incorporating the same within academic and professional requirements include: personal
reflection, interpersonal communication and advocacy. To ensure the same, not only do I
encourage students to engage in personal reflection but I also attempt to be role model to them
my communicating on the strategies I used as a student. While reflection is not the only need for
development of personal values, it does allow greater opportunity for students to critically
evaluate their limitations and improve the same respectively (Walker & Mann, 2016).
Encouraging students to be mindful and reflective of their personal experiences in everyday
learning paves the way for development and implementation of critical thinking skills during
future nursing practice. Likewise, interpersonal skills like engaging students’ in empathetic, non-
judgmental and critical group as well as personal discussions allows professors and practitioners
to understand students’ needs and improve the clinical education program accordingly since it
paves the way for modification of the program and inclusion of additional educational
components so as to address gaps in students’ learning (Pai, 2015). I also requested the
management of the educational and local healthcare organizations to alter the curriculum and
encourage clinical education within professional clinical environments by compulsory inclusion
of personal reflection, timely feedback sessions between the university and institution and
inclusion of early practical training for students (Falk et al., 2016).
Critically evaluating my HPI clinical nursing education program based on the clinical
axis of the 4R model of symbiosis also revealed limitations. Engaging students in real life,
authentic clinical practices teaches students the importance of nurse-patient relationships (Flott
& Linden, 2016). The critical analysis revealed that while the opportunity to engage in practice
experiences were present within the university and local healthcare organization I am engaged in,
such engagement was usually delayed and implemented at the end of the program resulting in

8CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
feelings of doubts, fear and uncertainty within my students. Along with advocacy, engaging
nursing students in timely and early authentic clinical environments are beneficial strategies with
which the clinical education program can induce confidence, clinical efficiency and critical
nursing skills within students (Lim & Pajarillo, 2016). After writing a letter to management of
the concerned healthcare organization on the need to restore comprehensive clinical educational
facilities and I have communicated and advocated my students’ concerns with the management
of the educational institution to authorize simulation learning and quicken the time from which
students can engage in nursing internships and practical learning. The management had
previously undertaken this decision due to a lack of funds in including both clinical services as
well as education. However, the management did respond positively to my letter and agreed to
continue with the clinical educational facilities (Heidari & Mardani Hamooleh, 2015).
Significant limitations were not observed within the institutional as well as social axis of
the clinical education program since arrangements were already made within the university with
regards to nursing students gaining practical experience within an associated healthcare
organization. However, a key limitation observed was the absence of any discussion between the
university and healthcare organization in assessing student needs and improving learning nursing
curriculum for the students. A beneficial strategy to improve the same is to facilitate dialogue
between the university and healthcare facility authorities and collaboratively develop a clinical
education plan where students will be given the opportunity to implement theoretical learning
within specified clinical teams (Jayasekara et al., 2018). I also advised the university to
encourage the students to reflect and communicate their needs to professors so that the latter can
communicate the same to the healthcare organization while developing practical nursing learning
curriculum (Jamshidi et al., 2016).

9CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
From the above reflection, limitations, were also observed within the social axis of the 4R
model of symbiosis. While the present clinical education curriculum does require me to teach
governmental and national health policies and frameworks, there is not practical consideration of
how students may implement nursing skills and critical care at the community level. Inclusion of
practical community based activities within the curriculum, where the associated health
organization can conduct community scale health assessments (vital signs assessment) or health
literacy campaigns (like diabetes educator programs) in which nursing students can participate
actively, can prove to be a beneficial strategy for fulfillment of the social axis and positive
community health outcomes. Despite these limitations, the opportunity to provide situational
learning to students as well as receiving positive response on my suggestions are key strengths of
both the university and institution I am engaged in (van Iersel et al., 2018). I have indeed
requested the university as well as the concerned healthcare organization to consider these
strategies and have received positive responses where both stakeholders have commented that
their efforts in implementing the same. Real-life demonstration of clinical nursing skills within
the community care environment will assist nursing students in understanding community needs
and the ways in which individual needs can be considered holistically (Williams, Halstead &
Mitchell, 2016)
Conclusion
Thus, this paper discusses my current clinical education program using the 4R model of
symbiosis. While the clinical education program demonstrated compliance to symbiosis across
aspects like provision of situational learning and practical patient handling experiences, certain
areas required attention. These include the need to explore and implement personal reflection

10CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
within curriculum, incorporate practical and authentic clinical educational experiences for the
patients as well as practical implementation of clinical educational practices required to fulfill
community needs. To conclude this analysis has assisted me in identifying my own potential for
improvement while delivering clinical education to my students.

11CLINICAL EDUCATION PROGRAM: 4R MODEL OF SYMBIOSIS
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