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Aust. J. Rural Health (2014) 22, 172–178
Original Research Undergraduate physiotherapy students’ expectations and perceptions of rural/regional clinical placements Sarah White, Bachelor of Physiotherapy (Hons) and Nicole Humphreys, Bachelor of Physiotherapy Albury Wodonga Health, Albury, New South Wales, Australia
Abstract Objective: To explore undergraduate physiotherapy students’ expectations and preconceptions of undertaking a rural/regional clinical placement and determine if these preconceptions differ between regional and metropolitan-based students. Design: Data was collected via focus groups and analysed via thematic analysis of emerging themes. Setting: All focus groups were undertaken in tutorial rooms at the participating universities between classes at a time convenient to participants. Participants: Undergraduate physiotherapy students yet to complete a major clinical placement were invited to participate. Second year physiotherapy students from regional and metropolitan universities were recruited to form focus groups, allowing comparison between the two groups. Four metropolitan students and nine regional students made up the sample size. Results: Three major themes were identified via thematic analysis of transcripts; socio-cultural factors, education and professional factors. The significance of socio-cultural factors was far beyond what was expected to be found. Regional students did not generally have a more accurate perspective of rural/regional placement and voiced more concerns about missing out on educational opportunities. Conclusions: Rural/regional clinical educators need to be mindful of creating quality experiences with caseloads appropriate for the specific placement’s requirements. The impact of external socio-cultural factors must be acknowledged. Supervision strategies must be put in place to ensure students on rural/regional clinical placements are well supported to achieve a successful outcome for student and educator.
Correspondence: Mrs Sarah White, Albury Wodonga Health, Albury Campus, Borella Road, PO Box 132, Albury, NSW, 2640, Australia. Email: [email protected] Accepted for publication 24 February 2014. © 2014 National Rural Health Alliance Inc.
KEY WORDS: clinical, education, experience, physiotherapy, regional.
Introduction Clinical experiences have been shown to have significant impact on the development of a health professional’s preference for a specific area or location of practice.1 As the majority of health students are from urban backgrounds they are less likely to have an accurate knowledge of life and work in a regional environment and therefore clinical exposure would be of benefit.2 Students who have enjoyable rural clinical experiences are more likely to consider a career in a rural or regional area.3 There is some evidence, however, that mandatory placement is not as beneficial as voluntary placements in future rural vocation decisions.4 Although rural/regional clinical placements are one tool in enhancing workforce capability, minimal information has been gathered regarding students’ perceptions of rural/regional placements. Medical students are the most widely researched due to the establishment of rural clinical schools which have experienced difficulties in recruiting sufficient students for various reasons.5 Less focus has been placed on allied health professionals’ rural/regional clinical education in Australia, although it has been demonstrated that high-quality experiences have been of benefit in recruiting staff to rural workplaces.6 Some concerns have been raised about the ability to deliver quality experiences in regional areas comparable with those obtained in metropolitan settings.7 With growing numbers of physiotherapy students,8 there is a greater demand for core clinical placements to fulfil clinical requirements to obtain registration. Therefore universities are seeking core placements from a wider variety of sources, including rural and regional locations. This means students may be sent to a regional hospital to complete core clinical placements with limited consultation about the logistics involved. doi: 10.1111/ajr.12102
RURAL/REGIONAL CLINICAL PLACEMENT
What is already known on this subject: • Majority of education research is concerned with medical students rather than allied health and physiotherapy students in particular. • Clinical placements in rural/regional settings expose students to this unique work environment and aim to positively influence future career choice in rural/regional areas. • Increasing demand for placements in rural/ regional areas due to growing numbers of physiotherapy students. • Very little is known regarding the physiotherapy students’ expectations and preconceptions of undertaking a rural/regional placement.
The researchers found very limited previous research regarding the expectations and preconceptions undergraduate physiotherapy students have regarding rural/ regional clinical placements. Even less is known about how these notions may impact on willingness to participate in rural/regional clinical placements and consideration of future rural/regional careers. Both authors have significant experience in clinical education of physiotherapy students in the regional setting. Anecdotal evidence gathered by the researchers and peers found that some metropolitan-based students struggled with issues that were uniquely influenced by the placement’s geographical location. The caseload seen compared with peers completing metropolitan placements have also created fear of ‘missing out’ on desirable experiences. It was felt by the researchers that students’ preconceived ideas about rural/regional clinical placements could well impact on how the student approaches and undertakes the placement. The authors sought to explore these ideas by asking; ‘what are undergraduate physiotherapy students’ preconceptions and expectations of undertaking rural/ regional clinical placements?’.
Methods A qualitative approach was chosen to deepen understanding of physiotherapy students’ perceptions of clinical placements in rural/regional areas. Focus groups were employed to explore students’ preconceptions regarding rural/regional clinical placement. Physiotherapy students in their second year of study from one metropolitan and two regional universities © 2014 National Rural Health Alliance Inc.
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What this study adds: • All participants were willing to undertake a rural/regional placement; however all voiced multiple perceived difficulties. • Major issues identified were not specific to the clinical training but related to sociocultural issues such as availability of accommodation and social support networks. • There is ambiguity towards the quality of educational experience on rural/regional placement with some students perceiving a disadvantage compared with peers based in metropolitan placements.
were invited by e-mail to participate in this research. For the purposes of this study metropolitan was defined as a capital city and regional was any town or centre outside of a metropolitan area. Second-year students were chosen as they had not yet completed significant placement experiences that could potentially influence their perceptions of clinical placements. Mid-way through their second year of study it was anticipated that students would have enough knowledge of the physiotherapy profession to make their thoughts and expectations of clinical placement realistic. Three focus groups were undertaken with four metropolitan participants in one group and nine regional participants spread across two groups leading to a total sample size of 13 participants. Focus groups were held on university grounds in tutorial rooms for approximately one hour. The focus group was audio-recorded and transcribed. Standardised stimulus questions relating to living or working in rural/ regional areas compared with metropolitan areas were utilized to generate discussion followed by more specific questions regarding clinical placement and differences or similarities between undertaking a rural/regional or a metropolitan placement (Table 1). Focus group recordings were transcribed verbatim by a research assistant. Transcripts were checked for accuracy against the audio recordings by the principal researchers. Participants were assigned a pseudonym for all reporting of results to attain a sense of humanness and to protect anonymity. Regional participants were assigned a pseudonym beginning with R while metropolitan students were assigned pseudonyms beginning with M. Data was analyzed according to thematic analysis. Each transcript was read by both researcher independently allowing each to individually identify recurring themes. These themes were then cross-checked with the other researcher.
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TABLE 1:
Focus group questions
Standardised 1.
Describe a regional area – people, occupations, languages, facilities. 2. Describe a metropolitan area – people, occupations, languages, facilities. 3. What would you expect to experience on a clinical placement? 4. How do you think regional and metropolitan placements may be similar or different to each other? 5. 6. 7. 8. 9.
10.
What are the benefits of a metropolitan placement from personal and professional viewpoint? What are the benefits of a regional placement from personal and professional viewpoint? What are the negatives of these placement locations from personal and professional viewpoints? Do you have a preference for metropolitan or regional placements? Do other student’s experiences influence your preference for clinical placement? What type of accommodation would you live in on a regional placement versus metropolitan placement?
11.
What would you do on weekends/after hours on a regional placement versus a metropolitan placement? Discuss the positive and negative aspects of both. 12. Do you think that where you do a placement may influence where you chose to work in the future?
The study was approved by The Charles Sturt University Minimal Risk Ethics Committee.
Results Three major thematic groups were revealed: sociocultural, educational and professional. Following analysis it appeared regional students did not have a better perspective of rural/regional placement compared with their metropolitan counterparts as illustrated below. Please see Table 2 for comprehensive summary of findings.
Socio-cultural External factors of regional placement were considered a major stressor with significant time spent discussing these issues in order to seek insight into the causative factors. Accommodation, financial considerations and available community facilities were all identified as concerns; however, accommodation was a recurring theme from all groups.
Rationale Designed to develop understanding of what students perceive as a typical regional or metropolitan setting and what they may encounter in such settings. Develop understanding of what students envisage a clinical placement entailing. Designed to start to explore if students have perceptions of differences between clinical placement settings and what these may be. Allows students to verbalise positive aspects of placements in different setting and consider the impact of placement location both personally and professionally. Explores the alternate views to questions 5 and 6. Start to explore if the students have a bias towards any particular location. Explores the degree of weight that students place on their peers opinions and how this may develop preconceptions about placement locations. From past experience with students it was felt that accommodation was an issue worth exploring in greater detail. From past experience with students it was felt that available entertainment/activities outside of placement were issues worth exploring in greater detail. Explores in more detail the significance of placement location on future work force factors.
Accommodation availability and cost was raised by both metropolitan and regional students as the primary concern of undertaking a rural/regional placement. Students identified more senior students as informants regarding specific site accommodation and held these students’ opinions in high regard. Regional students were more concerned about quality and safety of accommodation while metropolitan students discussed being away from family as a cause for concern. ‘Accommodation matters more than the location of the placement’ (Ryan)
The perception of available community facilities was raised as a source of concern. All students were worried about feeling isolated and bored after hours. Metropolitan students believed having friends on placement would be beneficial, while both regional and metropolitan students felt regional workplaces would be more inclusive in social outings. Despite this, students still considered travelling home each weekend. © 2014 National Rural Health Alliance Inc.
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TABLE 2:
Summary of findings by theme and student location (regional or metropolitan)
Theme
Regional
Metropolitan
Socio-cultural 1. Accommodation 2. Cost 3. Travel 4. Community
‘Accommodation can affect your placement, like being scared to go to sleep. . . . stressed about living conditions’ ‘Accommodation matters more than the location of the placement’ ‘Bigger hospitals [metro] have accommodation available . . . but often not good quality’ ‘Rural areas lack accommodation, you have to find it yourself’ ‘Money is definitely a big problem’ ‘. . . have to save a certain amount to be able to afford placement. . .extra scholarships would be beneficial’ ‘. . . have to pay for accommodation on placement, rent back home [if sent away from home], food, transport . . . have to save up for placement’ ‘If you can’t get onsite accommodation you need to factor in travel and cost of travel’ ‘Public transport not as often available in regional areas’ ‘I would feel isolated after hours [in regional setting]’ ‘I would expect to go home more because there would not be a lot to do on weekends [in regional setting]’ ‘Other student say they don’t want [placement] certain towns as there’s nothing to do’ ‘When you are by yourself you might not feel comfortable if the pub is the only thing to do’ ‘People are more likely to invite us out’
‘I think actually having to pay for accommodation is a big factor to stop me from doing more than one (rural/regional) clinical placement.’ ‘It would be nice to stay close to family so that if anything goes wrong it makes it a lot easier’ ‘Finding accommodation is a struggle. If you are close to home it’s easier’ ‘Incentives with accommodation. . .putting money towards it would help’ ‘It’s not just accommodation. food, travel, can’t work your normal job if away from home’ ‘Some locations more expensive than others such as Byron Bay more expensive to go to than Wagga Wagga’ ‘Cost with clinical placement is a big issue, but lessened by being closer to home’ ‘I’d prefer something closer like Byron or Ballina rather than way out west.’ ‘Depending on how far away it was, I would go back home for the weekend’ ‘5 weeks somewhere by yourself where you know no-one is a really long time’ ‘Try to arrange with friends to go to the same place together’ ‘I imagine it [regional] would be close-knit environment compared to the city. . .they might invite you home for dinner?’ ‘I’d make more of an effort to get to know the people I am working with in a regional place’
Educational 1. Workload 2. Supervision 3. Case mix 4. Resources
‘Would see less patients rurally but may have more time with them . . . so you get a chance to process your thoughts’ ‘Definitely see more patients in the metro setting’ ‘In the bigger hospitals you can transfer to different areas and see different types of patients’ ‘Would do more home visits in the rural place . . . I think you would learn more in the hospital setting’ ‘Might get conflicting information if you have too many supervisors’ ‘More one on one time with regional supervisor and less students and there would not be as many patients’ ‘Metro educators very specialised rather than the jack of all trades in the country’ ‘If you go to a regional setting for a specific clinic, you may not actually have any patients of the type you are supposed to see’ ‘My overall feeling is that you would learn and see more in metro setting’ ‘Bigger hospitals are going to have more resources and facilities for treating patients’ ‘Professional development events . . . not going to have regionally’
‘Regional ok for the experience but would prefer metro’ ‘Metro would be a better experience’ ‘I don’t think the clinical difference would be that big a factor between regional and metro’ ‘Clinically it [regional] would be a bit different but a good experience’ ‘Less people and less to do [regionally]’ ‘The type of supervisor makes a big difference regardless of if they are regional or metro based’ ‘I think supervisors would be the same across the board’ ‘I think regional supervisors would be a bit more relaxed and down to earth’ ‘Regionally you’re not getting as wide a range of patients just cause there’s less people’ ‘Regionally there would be a more personal relationship with each patient due to less time pressure’
Professional 1. Employment opportunities 2. Financial reward
‘Metro hospitals . . . more facilities so more chance of work’ ‘Bigger hospitals, more opportunities for jobs. . . more positions available’ ‘Metro clinicians better paid as they are better clinical people’ ‘I thought you would get paid more in rural setting to encourage you to work there’
‘You might enjoy working in the country whereas previously you thought you’d rather just stay in Sydney’ ‘I think it [placement] definitely has the potential to change where you want to work’
© 2014 National Rural Health Alliance Inc.
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•
•
‘. . . in a rural/regional setting I would expect to go home more because I don’t expect there’d be a lot more to do on weekends.’ (Ryan) ‘I’d make an effort to get to know the people I am working with in a regional place’ (Martin)
All students were concerned about financial impacts of doing clinical placements away from home and all felt that financial incentives may help encourage participation.
Educational Students want to ensure they have equitable educational experiences. Understanding of the caseload and casemix experienced in a rural/regional clinical placement was varied between participants. However, both regional and metropolitan students perceived that a rural/regional clinical placement would offer a more general case-mix (e.g. medical/surgical) compared with a metropolitan placement offering a more specialised experience (e.g. organ transplantation, ICU, multitrauma). Students also believed that the caseload would be less in a regional clinic due to less patients and a less demanding schedule. Some students believed a quieter caseload in regional clinics would benefit their learning as it would enable them to spend more time with each patient, while others felt they would be disadvantaged as they may not see the range of patients that peers in metropolitan clinics may see. There was no clear distinction between regional and metropolitan students on this issue. Quality of supervision and clinical expertise of the educator in rural/regional areas was another source of conflict during the discussion. Some students, especially from regional settings, were concerned that their regional educators may lack the skills of their metropolitan counterparts, while most students perceived regional supervisors as more relaxed and friendly. •
‘I think supervisors would be the same across the board. . . a bit more relaxed and down to earth [regionally]. . .but I don’t think you would be disadvantaged. . .’ (Michael)
Professional Participants felt there would be less employment positions available and less of a career ladder to climb in rural/regional areas. It was interesting to note that even at this early stage all students were considering graduate employment opportunities. All students felt that metropolitan settings offered a greater scope of employment opportunities and metropolitan jobs would attract more
S. WHITE AND N. HUMPHREYS
skilled clinicians. Discussions demonstrated confusion amongst participants regarding remuneration of being employed in a rural/regional facility with regional students believing that metropolitan jobs would be higher paid due to the perceived greater skills of the clinician. •
•
‘. . . I think less people want to work in the rural setting. . . in the city there is competition and career ladders to climb. . .’ (Max) ‘. . . also I thought they would be higher paid as they. . . are better clinical people [in a metropolitan setting]’ (Rachel)
It was interesting to note that students were constantly evaluating the placement as a potential future employment location. All students regardless of background stated that an enjoyable placement would lead to consideration of working in that area on completion of the degree. •
‘. . . yeah I think it [clinical placement] definitely has the potential to change where you want to work.’ (Mary)
Discussion This study aimed to explore regional and metropolitan physiotherapy students’ preconceptions and expectations regarding rural/regional clinical placements. Some known and other previously unconsidered concerns were highlighted by participants, leading to the identification of the major thematic groups. Socio-cultural issues were the major concern rather than the actual clinical placement and location. However, it was apparent these issues could then impact on perceptions of the clinical placement. Students repeatedly highlighted significant stress and apprehension regarding accommodation arrangements whilst on clinical placement. Students were less willing to undertake placements in locations with sub-standard or difficult to access accommodation. They frequently relied on information from previous students regarding facilities. No differences were identified between regional- or metropolitan-based students regarding their anxiety specific to accommodation. Universities need to be mindful of this significant issue when allocating placements and need to offer additional support to students sent to rural/regional locations. At the author’s regional facility, suggestions regarding comfortable and secure accommodation are now provided via a preplacement information pack. Students were concerned about financial implications of undertaking clinical placements away from home. All students believed undertaking a placement close to home or centre of study would be financially beneficial. © 2014 National Rural Health Alliance Inc.
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RURAL/REGIONAL CLINICAL PLACEMENT
Both universities and external funding bodies need to actively promote opportunities for financial support of clinical placements. Regional clinicians could capitalize by advocating for students to apply for scholarships available for rural/regional placements. Surprisingly, the perceptions of regional and metropolitan students regarding the availability of afterhours facilities were the reverse of the author’s expectations. Metropolitan students felt the rural/ regional community would be welcoming and they would easily become involved in social functions. They did acknowledge this was a stereotypical view and were not sure what had influenced this view. Regional students believed that undertaking placement away from home would be socially limiting, especially on weekends and would be unlikely to engage in the community. Regional educators should consider including students in departmental social activities or provide information on community events for weekend entertainment. The author’s facility now ensures students are matched with a junior staff member to facilitate engagement in local social activities. Given the time spent discussing socio-cultural concerns, clinical educators should remain mindful of how strongly students value these factors. Therefore, if students experience adversity in one of these areas, it could negatively impact on their clinical performance. If a student is performing poorly on placement, the educator should consider exploring the above factors rather than assuming the problem is entirely competency-based. A discussion of educational issues elicited some conflicting opinions. All students believed that rural/ regional clinical placements would have less demanding caseloads regarding both patient numbers and level of acuity compared to metropolitan placements. This was not always deemed detrimental to learning as it would allow for more time to be spent with each patient to develop clinical reasoning skills. Regional participants conveyed a fear of ‘missing out’ on desirable clinical experiences if the rural/regional placement was more generalised than that being experienced by peers in a metropolitan placement. Universities need to ensure that desired placement experiences are achievable across a wide variety of settings to allay fears and capitalise on the available learning experience. As regional students appeared to be more concerned with undertaking a rural/regional placement, universities also need to ensure regional students have realistic expectations of the regional healthcare setting rather than assuming this is already known due to study location. Clinical educators should attempt to provide students with a meaningful caseload in line with placement guidelines. Varying opinions were held regarding the quality of supervision experienced on a rural/regional clinical placement. Regional participants again feared disadvan© 2014 National Rural Health Alliance Inc.
tage as their educators would be more a ‘jack of all trades’ and less able to impart specialised skills than a metropolitan educator. Metropolitan participants did not perceive this to be an issue of concern. All students felt they would have more quality time with regional supervisors and that this would be advantageous for their learning. This research has confirmed current literature relating to clinical placements and regional recruitment that highlights the value of positive clinical experiences in recruiting health professionals to rural/regional areas. Group discussions explored students’ desire to be employed regionally upon graduation. Students were uncertain as to employment opportunities being available due to size of facilities and hence positions available. Furthermore, students expressed confusion regarding remuneration, with some believing metropolitan clinicians would be paid more due to their perceived greater skill, whilst others believed financial incentives to entice health professionals to rural/regional areas existed. It was not clear how these perceptions were formed; the authors are unsure whether these perceptions are altered in later years by exposure to university course content, job expos or career counselling. If these perceptions are not corrected upon graduation, this could well have a negative impact on ability to recruit graduates to rural/regional facilities.
Limitations Recruitment of participants was significantly more difficult than anticipated. The process was lengthy and required multiple attempts at several universities before focus groups commenced. This impacted on sample size and diversity of university locations as ideally the researchers would have liked a greater number of participating universities and larger sample sizes to enhance transferability of results. Potential for bias in the outcomes exists as only participants interested in this research topic were recruited as participation was entirely voluntary with no monetary/gift incentive provided. Therefore, the outcomes could be different if participants were a more random sample from university cohorts.
Conclusion This research has highlighted the significance of external factors that have the potential to impact on the perceived clinical expectations and experiences of the student whilst on placement. At our regional hospital, the authors endeavour to improve their clinical educational experience with a number of new initiatives; a buddy system with junior staff; information package including general regional information, accommoda-
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tion, location of facilities, transport; and an enhanced awareness of regularly checking that the student is coping and feels supported out of hours. The authors strongly believe that this will have a beneficial impact on the overall clinical experience and hence also has the potential to impact positively on recruitment of graduates as students are frequently re-evaluating the clinical experience and considering its potential as an employer.
Acknowledgements The authors would like to thank Narelle Patton for her very generous assistance in helping novice researchers to develop and implement this project. Her time, expertise and calming influence was greatly appreciated and without her you would not be reading this. Thanks also to Physiotherapy Manager Melissa Lucas (Albury Wodonga Health) for her patience and support of this project.
Author contributions Conception: Nicole Humphreys and Sarah White. Data Collection: Nicole Humphreys and Sarah White. Analysis: Nicole Humphreys and Sarah White Discussion and writing paper: Nicole Humphreys and Sarah White
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2 McAllister L, McEwen E, Williams V, Frost N. Rural attachments for students in the health professions: are they worthwhile? The Australian Journal of Rural Health 1998; 6: 194–201. 3 Webster S, Lopez V, Allnut J, Clague L, Jones D, Bennett P. Undergraduate nursing students’ experiences in a rural clinical placement. The Australian Journal of Rural Health 2010; 18: 194–198. 4 Orpin P, Gabriel M. Recruiting undergraduates to rural practice: what the students can tell us. Rural and Remote Health 2005; 5: 412. 5 Jones G, DeWitt D, Cross M. Medical students’ perceptions of barriers to training at a rural clinical school. Rural and Remote Health 2007; 7: 685. 6 Playford D, Larson A, Wheatland B. Going country: rural student placement factors associated with future rural employment in nursing and allied health. The Australian Journal of Rural Health 2006; 14: 14–19. 7 Jones G, Alford K, Russell U, Simmons D. Removing the roadblocks to medical and health student training in rural hospitals in Victoria. The Australian Journal of Rural Health 2003; 11: 218–223. 8 McMeeken J, Grant R, Webb G, Krause K, Garnett R. Australian physiotherapy student intake is increasing and attrition remains lower than the university average: a demographic study. Australian Journal of Physiotherapy 2008; 54: 65–71.
References 1 Barney T, Russell M, Clark M. Evaluation of the provision of fieldwork training through a rural student unit. The Australian Journal of Rural Health 1998; 6: 202–207.
© 2014 National Rural Health Alliance Inc.
Aust. J. Rural Health (2014) 22, 172–178
Original Research Undergraduate physiotherapy students’ expectations and perceptions of rural/regional clinical placements Sarah White, Bachelor of Physiotherapy (Hons) and Nicole Humphreys, Bachelor of Physiotherapy Albury Wodonga Health, Albury, New South Wales, Australia
Abstract Objective: To explore undergraduate physiotherapy students’ expectations and preconceptions of undertaking a rural/regional clinical placement and determine if these preconceptions differ between regional and metropolitan-based students. Design: Data was collected via focus groups and analysed via thematic analysis of emerging themes. Setting: All focus groups were undertaken in tutorial rooms at the participating universities between classes at a time convenient to participants. Participants: Undergraduate physiotherapy students yet to complete a major clinical placement were invited to participate. Second year physiotherapy students from regional and metropolitan universities were recruited to form focus groups, allowing comparison between the two groups. Four metropolitan students and nine regional students made up the sample size. Results: Three major themes were identified via thematic analysis of transcripts; socio-cultural factors, education and professional factors. The significance of socio-cultural factors was far beyond what was expected to be found. Regional students did not generally have a more accurate perspective of rural/regional placement and voiced more concerns about missing out on educational opportunities. Conclusions: Rural/regional clinical educators need to be mindful of creating quality experiences with caseloads appropriate for the specific placement’s requirements. The impact of external socio-cultural factors must be acknowledged. Supervision strategies must be put in place to ensure students on rural/regional clinical placements are well supported to achieve a successful outcome for student and educator.
Correspondence: Mrs Sarah White, Albury Wodonga Health, Albury Campus, Borella Road, PO Box 132, Albury, NSW, 2640, Australia. Email: [email protected] Accepted for publication 24 February 2014. © 2014 National Rural Health Alliance Inc.
KEY WORDS: clinical, education, experience, physiotherapy, regional.
Introduction Clinical experiences have been shown to have significant impact on the development of a health professional’s preference for a specific area or location of practice.1 As the majority of health students are from urban backgrounds they are less likely to have an accurate knowledge of life and work in a regional environment and therefore clinical exposure would be of benefit.2 Students who have enjoyable rural clinical experiences are more likely to consider a career in a rural or regional area.3 There is some evidence, however, that mandatory placement is not as beneficial as voluntary placements in future rural vocation decisions.4 Although rural/regional clinical placements are one tool in enhancing workforce capability, minimal information has been gathered regarding students’ perceptions of rural/regional placements. Medical students are the most widely researched due to the establishment of rural clinical schools which have experienced difficulties in recruiting sufficient students for various reasons.5 Less focus has been placed on allied health professionals’ rural/regional clinical education in Australia, although it has been demonstrated that high-quality experiences have been of benefit in recruiting staff to rural workplaces.6 Some concerns have been raised about the ability to deliver quality experiences in regional areas comparable with those obtained in metropolitan settings.7 With growing numbers of physiotherapy students,8 there is a greater demand for core clinical placements to fulfil clinical requirements to obtain registration. Therefore universities are seeking core placements from a wider variety of sources, including rural and regional locations. This means students may be sent to a regional hospital to complete core clinical placements with limited consultation about the logistics involved. doi: 10.1111/ajr.12102
RURAL/REGIONAL CLINICAL PLACEMENT
What is already known on this subject: • Majority of education research is concerned with medical students rather than allied health and physiotherapy students in particular. • Clinical placements in rural/regional settings expose students to this unique work environment and aim to positively influence future career choice in rural/regional areas. • Increasing demand for placements in rural/ regional areas due to growing numbers of physiotherapy students. • Very little is known regarding the physiotherapy students’ expectations and preconceptions of undertaking a rural/regional placement.
The researchers found very limited previous research regarding the expectations and preconceptions undergraduate physiotherapy students have regarding rural/ regional clinical placements. Even less is known about how these notions may impact on willingness to participate in rural/regional clinical placements and consideration of future rural/regional careers. Both authors have significant experience in clinical education of physiotherapy students in the regional setting. Anecdotal evidence gathered by the researchers and peers found that some metropolitan-based students struggled with issues that were uniquely influenced by the placement’s geographical location. The caseload seen compared with peers completing metropolitan placements have also created fear of ‘missing out’ on desirable experiences. It was felt by the researchers that students’ preconceived ideas about rural/regional clinical placements could well impact on how the student approaches and undertakes the placement. The authors sought to explore these ideas by asking; ‘what are undergraduate physiotherapy students’ preconceptions and expectations of undertaking rural/ regional clinical placements?’.
Methods A qualitative approach was chosen to deepen understanding of physiotherapy students’ perceptions of clinical placements in rural/regional areas. Focus groups were employed to explore students’ preconceptions regarding rural/regional clinical placement. Physiotherapy students in their second year of study from one metropolitan and two regional universities © 2014 National Rural Health Alliance Inc.
173
What this study adds: • All participants were willing to undertake a rural/regional placement; however all voiced multiple perceived difficulties. • Major issues identified were not specific to the clinical training but related to sociocultural issues such as availability of accommodation and social support networks. • There is ambiguity towards the quality of educational experience on rural/regional placement with some students perceiving a disadvantage compared with peers based in metropolitan placements.
were invited by e-mail to participate in this research. For the purposes of this study metropolitan was defined as a capital city and regional was any town or centre outside of a metropolitan area. Second-year students were chosen as they had not yet completed significant placement experiences that could potentially influence their perceptions of clinical placements. Mid-way through their second year of study it was anticipated that students would have enough knowledge of the physiotherapy profession to make their thoughts and expectations of clinical placement realistic. Three focus groups were undertaken with four metropolitan participants in one group and nine regional participants spread across two groups leading to a total sample size of 13 participants. Focus groups were held on university grounds in tutorial rooms for approximately one hour. The focus group was audio-recorded and transcribed. Standardised stimulus questions relating to living or working in rural/ regional areas compared with metropolitan areas were utilized to generate discussion followed by more specific questions regarding clinical placement and differences or similarities between undertaking a rural/regional or a metropolitan placement (Table 1). Focus group recordings were transcribed verbatim by a research assistant. Transcripts were checked for accuracy against the audio recordings by the principal researchers. Participants were assigned a pseudonym for all reporting of results to attain a sense of humanness and to protect anonymity. Regional participants were assigned a pseudonym beginning with R while metropolitan students were assigned pseudonyms beginning with M. Data was analyzed according to thematic analysis. Each transcript was read by both researcher independently allowing each to individually identify recurring themes. These themes were then cross-checked with the other researcher.
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TABLE 1:
Focus group questions
Standardised 1.
Describe a regional area – people, occupations, languages, facilities. 2. Describe a metropolitan area – people, occupations, languages, facilities. 3. What would you expect to experience on a clinical placement? 4. How do you think regional and metropolitan placements may be similar or different to each other? 5. 6. 7. 8. 9.
10.
What are the benefits of a metropolitan placement from personal and professional viewpoint? What are the benefits of a regional placement from personal and professional viewpoint? What are the negatives of these placement locations from personal and professional viewpoints? Do you have a preference for metropolitan or regional placements? Do other student’s experiences influence your preference for clinical placement? What type of accommodation would you live in on a regional placement versus metropolitan placement?
11.
What would you do on weekends/after hours on a regional placement versus a metropolitan placement? Discuss the positive and negative aspects of both. 12. Do you think that where you do a placement may influence where you chose to work in the future?
The study was approved by The Charles Sturt University Minimal Risk Ethics Committee.
Results Three major thematic groups were revealed: sociocultural, educational and professional. Following analysis it appeared regional students did not have a better perspective of rural/regional placement compared with their metropolitan counterparts as illustrated below. Please see Table 2 for comprehensive summary of findings.
Socio-cultural External factors of regional placement were considered a major stressor with significant time spent discussing these issues in order to seek insight into the causative factors. Accommodation, financial considerations and available community facilities were all identified as concerns; however, accommodation was a recurring theme from all groups.
Rationale Designed to develop understanding of what students perceive as a typical regional or metropolitan setting and what they may encounter in such settings. Develop understanding of what students envisage a clinical placement entailing. Designed to start to explore if students have perceptions of differences between clinical placement settings and what these may be. Allows students to verbalise positive aspects of placements in different setting and consider the impact of placement location both personally and professionally. Explores the alternate views to questions 5 and 6. Start to explore if the students have a bias towards any particular location. Explores the degree of weight that students place on their peers opinions and how this may develop preconceptions about placement locations. From past experience with students it was felt that accommodation was an issue worth exploring in greater detail. From past experience with students it was felt that available entertainment/activities outside of placement were issues worth exploring in greater detail. Explores in more detail the significance of placement location on future work force factors.
Accommodation availability and cost was raised by both metropolitan and regional students as the primary concern of undertaking a rural/regional placement. Students identified more senior students as informants regarding specific site accommodation and held these students’ opinions in high regard. Regional students were more concerned about quality and safety of accommodation while metropolitan students discussed being away from family as a cause for concern. ‘Accommodation matters more than the location of the placement’ (Ryan)
The perception of available community facilities was raised as a source of concern. All students were worried about feeling isolated and bored after hours. Metropolitan students believed having friends on placement would be beneficial, while both regional and metropolitan students felt regional workplaces would be more inclusive in social outings. Despite this, students still considered travelling home each weekend. © 2014 National Rural Health Alliance Inc.
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TABLE 2:
Summary of findings by theme and student location (regional or metropolitan)
Theme
Regional
Metropolitan
Socio-cultural 1. Accommodation 2. Cost 3. Travel 4. Community
‘Accommodation can affect your placement, like being scared to go to sleep. . . . stressed about living conditions’ ‘Accommodation matters more than the location of the placement’ ‘Bigger hospitals [metro] have accommodation available . . . but often not good quality’ ‘Rural areas lack accommodation, you have to find it yourself’ ‘Money is definitely a big problem’ ‘. . . have to save a certain amount to be able to afford placement. . .extra scholarships would be beneficial’ ‘. . . have to pay for accommodation on placement, rent back home [if sent away from home], food, transport . . . have to save up for placement’ ‘If you can’t get onsite accommodation you need to factor in travel and cost of travel’ ‘Public transport not as often available in regional areas’ ‘I would feel isolated after hours [in regional setting]’ ‘I would expect to go home more because there would not be a lot to do on weekends [in regional setting]’ ‘Other student say they don’t want [placement] certain towns as there’s nothing to do’ ‘When you are by yourself you might not feel comfortable if the pub is the only thing to do’ ‘People are more likely to invite us out’
‘I think actually having to pay for accommodation is a big factor to stop me from doing more than one (rural/regional) clinical placement.’ ‘It would be nice to stay close to family so that if anything goes wrong it makes it a lot easier’ ‘Finding accommodation is a struggle. If you are close to home it’s easier’ ‘Incentives with accommodation. . .putting money towards it would help’ ‘It’s not just accommodation. food, travel, can’t work your normal job if away from home’ ‘Some locations more expensive than others such as Byron Bay more expensive to go to than Wagga Wagga’ ‘Cost with clinical placement is a big issue, but lessened by being closer to home’ ‘I’d prefer something closer like Byron or Ballina rather than way out west.’ ‘Depending on how far away it was, I would go back home for the weekend’ ‘5 weeks somewhere by yourself where you know no-one is a really long time’ ‘Try to arrange with friends to go to the same place together’ ‘I imagine it [regional] would be close-knit environment compared to the city. . .they might invite you home for dinner?’ ‘I’d make more of an effort to get to know the people I am working with in a regional place’
Educational 1. Workload 2. Supervision 3. Case mix 4. Resources
‘Would see less patients rurally but may have more time with them . . . so you get a chance to process your thoughts’ ‘Definitely see more patients in the metro setting’ ‘In the bigger hospitals you can transfer to different areas and see different types of patients’ ‘Would do more home visits in the rural place . . . I think you would learn more in the hospital setting’ ‘Might get conflicting information if you have too many supervisors’ ‘More one on one time with regional supervisor and less students and there would not be as many patients’ ‘Metro educators very specialised rather than the jack of all trades in the country’ ‘If you go to a regional setting for a specific clinic, you may not actually have any patients of the type you are supposed to see’ ‘My overall feeling is that you would learn and see more in metro setting’ ‘Bigger hospitals are going to have more resources and facilities for treating patients’ ‘Professional development events . . . not going to have regionally’
‘Regional ok for the experience but would prefer metro’ ‘Metro would be a better experience’ ‘I don’t think the clinical difference would be that big a factor between regional and metro’ ‘Clinically it [regional] would be a bit different but a good experience’ ‘Less people and less to do [regionally]’ ‘The type of supervisor makes a big difference regardless of if they are regional or metro based’ ‘I think supervisors would be the same across the board’ ‘I think regional supervisors would be a bit more relaxed and down to earth’ ‘Regionally you’re not getting as wide a range of patients just cause there’s less people’ ‘Regionally there would be a more personal relationship with each patient due to less time pressure’
Professional 1. Employment opportunities 2. Financial reward
‘Metro hospitals . . . more facilities so more chance of work’ ‘Bigger hospitals, more opportunities for jobs. . . more positions available’ ‘Metro clinicians better paid as they are better clinical people’ ‘I thought you would get paid more in rural setting to encourage you to work there’
‘You might enjoy working in the country whereas previously you thought you’d rather just stay in Sydney’ ‘I think it [placement] definitely has the potential to change where you want to work’
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•
•
‘. . . in a rural/regional setting I would expect to go home more because I don’t expect there’d be a lot more to do on weekends.’ (Ryan) ‘I’d make an effort to get to know the people I am working with in a regional place’ (Martin)
All students were concerned about financial impacts of doing clinical placements away from home and all felt that financial incentives may help encourage participation.
Educational Students want to ensure they have equitable educational experiences. Understanding of the caseload and casemix experienced in a rural/regional clinical placement was varied between participants. However, both regional and metropolitan students perceived that a rural/regional clinical placement would offer a more general case-mix (e.g. medical/surgical) compared with a metropolitan placement offering a more specialised experience (e.g. organ transplantation, ICU, multitrauma). Students also believed that the caseload would be less in a regional clinic due to less patients and a less demanding schedule. Some students believed a quieter caseload in regional clinics would benefit their learning as it would enable them to spend more time with each patient, while others felt they would be disadvantaged as they may not see the range of patients that peers in metropolitan clinics may see. There was no clear distinction between regional and metropolitan students on this issue. Quality of supervision and clinical expertise of the educator in rural/regional areas was another source of conflict during the discussion. Some students, especially from regional settings, were concerned that their regional educators may lack the skills of their metropolitan counterparts, while most students perceived regional supervisors as more relaxed and friendly. •
‘I think supervisors would be the same across the board. . . a bit more relaxed and down to earth [regionally]. . .but I don’t think you would be disadvantaged. . .’ (Michael)
Professional Participants felt there would be less employment positions available and less of a career ladder to climb in rural/regional areas. It was interesting to note that even at this early stage all students were considering graduate employment opportunities. All students felt that metropolitan settings offered a greater scope of employment opportunities and metropolitan jobs would attract more
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skilled clinicians. Discussions demonstrated confusion amongst participants regarding remuneration of being employed in a rural/regional facility with regional students believing that metropolitan jobs would be higher paid due to the perceived greater skills of the clinician. •
•
‘. . . I think less people want to work in the rural setting. . . in the city there is competition and career ladders to climb. . .’ (Max) ‘. . . also I thought they would be higher paid as they. . . are better clinical people [in a metropolitan setting]’ (Rachel)
It was interesting to note that students were constantly evaluating the placement as a potential future employment location. All students regardless of background stated that an enjoyable placement would lead to consideration of working in that area on completion of the degree. •
‘. . . yeah I think it [clinical placement] definitely has the potential to change where you want to work.’ (Mary)
Discussion This study aimed to explore regional and metropolitan physiotherapy students’ preconceptions and expectations regarding rural/regional clinical placements. Some known and other previously unconsidered concerns were highlighted by participants, leading to the identification of the major thematic groups. Socio-cultural issues were the major concern rather than the actual clinical placement and location. However, it was apparent these issues could then impact on perceptions of the clinical placement. Students repeatedly highlighted significant stress and apprehension regarding accommodation arrangements whilst on clinical placement. Students were less willing to undertake placements in locations with sub-standard or difficult to access accommodation. They frequently relied on information from previous students regarding facilities. No differences were identified between regional- or metropolitan-based students regarding their anxiety specific to accommodation. Universities need to be mindful of this significant issue when allocating placements and need to offer additional support to students sent to rural/regional locations. At the author’s regional facility, suggestions regarding comfortable and secure accommodation are now provided via a preplacement information pack. Students were concerned about financial implications of undertaking clinical placements away from home. All students believed undertaking a placement close to home or centre of study would be financially beneficial. © 2014 National Rural Health Alliance Inc.
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Both universities and external funding bodies need to actively promote opportunities for financial support of clinical placements. Regional clinicians could capitalize by advocating for students to apply for scholarships available for rural/regional placements. Surprisingly, the perceptions of regional and metropolitan students regarding the availability of afterhours facilities were the reverse of the author’s expectations. Metropolitan students felt the rural/ regional community would be welcoming and they would easily become involved in social functions. They did acknowledge this was a stereotypical view and were not sure what had influenced this view. Regional students believed that undertaking placement away from home would be socially limiting, especially on weekends and would be unlikely to engage in the community. Regional educators should consider including students in departmental social activities or provide information on community events for weekend entertainment. The author’s facility now ensures students are matched with a junior staff member to facilitate engagement in local social activities. Given the time spent discussing socio-cultural concerns, clinical educators should remain mindful of how strongly students value these factors. Therefore, if students experience adversity in one of these areas, it could negatively impact on their clinical performance. If a student is performing poorly on placement, the educator should consider exploring the above factors rather than assuming the problem is entirely competency-based. A discussion of educational issues elicited some conflicting opinions. All students believed that rural/ regional clinical placements would have less demanding caseloads regarding both patient numbers and level of acuity compared to metropolitan placements. This was not always deemed detrimental to learning as it would allow for more time to be spent with each patient to develop clinical reasoning skills. Regional participants conveyed a fear of ‘missing out’ on desirable clinical experiences if the rural/regional placement was more generalised than that being experienced by peers in a metropolitan placement. Universities need to ensure that desired placement experiences are achievable across a wide variety of settings to allay fears and capitalise on the available learning experience. As regional students appeared to be more concerned with undertaking a rural/regional placement, universities also need to ensure regional students have realistic expectations of the regional healthcare setting rather than assuming this is already known due to study location. Clinical educators should attempt to provide students with a meaningful caseload in line with placement guidelines. Varying opinions were held regarding the quality of supervision experienced on a rural/regional clinical placement. Regional participants again feared disadvan© 2014 National Rural Health Alliance Inc.
tage as their educators would be more a ‘jack of all trades’ and less able to impart specialised skills than a metropolitan educator. Metropolitan participants did not perceive this to be an issue of concern. All students felt they would have more quality time with regional supervisors and that this would be advantageous for their learning. This research has confirmed current literature relating to clinical placements and regional recruitment that highlights the value of positive clinical experiences in recruiting health professionals to rural/regional areas. Group discussions explored students’ desire to be employed regionally upon graduation. Students were uncertain as to employment opportunities being available due to size of facilities and hence positions available. Furthermore, students expressed confusion regarding remuneration, with some believing metropolitan clinicians would be paid more due to their perceived greater skill, whilst others believed financial incentives to entice health professionals to rural/regional areas existed. It was not clear how these perceptions were formed; the authors are unsure whether these perceptions are altered in later years by exposure to university course content, job expos or career counselling. If these perceptions are not corrected upon graduation, this could well have a negative impact on ability to recruit graduates to rural/regional facilities.
Limitations Recruitment of participants was significantly more difficult than anticipated. The process was lengthy and required multiple attempts at several universities before focus groups commenced. This impacted on sample size and diversity of university locations as ideally the researchers would have liked a greater number of participating universities and larger sample sizes to enhance transferability of results. Potential for bias in the outcomes exists as only participants interested in this research topic were recruited as participation was entirely voluntary with no monetary/gift incentive provided. Therefore, the outcomes could be different if participants were a more random sample from university cohorts.
Conclusion This research has highlighted the significance of external factors that have the potential to impact on the perceived clinical expectations and experiences of the student whilst on placement. At our regional hospital, the authors endeavour to improve their clinical educational experience with a number of new initiatives; a buddy system with junior staff; information package including general regional information, accommoda-
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tion, location of facilities, transport; and an enhanced awareness of regularly checking that the student is coping and feels supported out of hours. The authors strongly believe that this will have a beneficial impact on the overall clinical experience and hence also has the potential to impact positively on recruitment of graduates as students are frequently re-evaluating the clinical experience and considering its potential as an employer.
Acknowledgements The authors would like to thank Narelle Patton for her very generous assistance in helping novice researchers to develop and implement this project. Her time, expertise and calming influence was greatly appreciated and without her you would not be reading this. Thanks also to Physiotherapy Manager Melissa Lucas (Albury Wodonga Health) for her patience and support of this project.
Author contributions Conception: Nicole Humphreys and Sarah White. Data Collection: Nicole Humphreys and Sarah White. Analysis: Nicole Humphreys and Sarah White Discussion and writing paper: Nicole Humphreys and Sarah White
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2 McAllister L, McEwen E, Williams V, Frost N. Rural attachments for students in the health professions: are they worthwhile? The Australian Journal of Rural Health 1998; 6: 194–201. 3 Webster S, Lopez V, Allnut J, Clague L, Jones D, Bennett P. Undergraduate nursing students’ experiences in a rural clinical placement. The Australian Journal of Rural Health 2010; 18: 194–198. 4 Orpin P, Gabriel M. Recruiting undergraduates to rural practice: what the students can tell us. Rural and Remote Health 2005; 5: 412. 5 Jones G, DeWitt D, Cross M. Medical students’ perceptions of barriers to training at a rural clinical school. Rural and Remote Health 2007; 7: 685. 6 Playford D, Larson A, Wheatland B. Going country: rural student placement factors associated with future rural employment in nursing and allied health. The Australian Journal of Rural Health 2006; 14: 14–19. 7 Jones G, Alford K, Russell U, Simmons D. Removing the roadblocks to medical and health student training in rural hospitals in Victoria. The Australian Journal of Rural Health 2003; 11: 218–223. 8 McMeeken J, Grant R, Webb G, Krause K, Garnett R. Australian physiotherapy student intake is increasing and attrition remains lower than the university average: a demographic study. Australian Journal of Physiotherapy 2008; 54: 65–71.
References 1 Barney T, Russell M, Clark M. Evaluation of the provision of fieldwork training through a rural student unit. The Australian Journal of Rural Health 1998; 6: 202–207.
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