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Teaching and Learning Forum 2007 [ Refereed papers ]
Engaging students in a rewarding educational experience through rural clinical placements

Tania Wiley and Angela Durey
Combined Universities Centre for Rural Health
The University of Western Australia

This paper examines how rural clinical placements engage students in a rich and varied learning experience on several levels. Such placements offer students opportunities to deepen their understanding of issues related to rural health in clinical, professional, social and community contexts. In 2005, students across health disciplines from five Western Australian universities participated in rural placements lasting from two weeks to several months. All students responded to a survey about their experiences. Findings showed that contextualised learning engaged students on many levels and deepened their understanding of rural communities and issues related to rural health. Ninety five percent of students experienced rural clinical placements as a positive learning experience.


This paper examines how rural clinical placements engage students across health science disciplines by offering enriching educational experiences that deepen their understanding of health and service delivery in a rural context. Authentic learning involves the 'alignment of student learning experiences with the world for which they are being prepared' (McKenzie, Morgan, Cochrane, Watson, & Roberts, 2002: 427). The 2002 Edith Cowan Authentic Learning Award suggests that this type of learning occurs when the activities students undertake are contextualised and reflect those of health professionals working in the field (McKenzie et al., 2002). Clinical placements in rural settings offer students an authentic learning experience in a natural setting that facilitates the creation of a critical 'space' where students' 'global understanding, their worldviews and values are confirmed or challenged' (McKenzie et al., 2002: 433). This suggests that in this type of environment students become 'active' learners. According to Mummery, 'it is only as active learners that students become critical thinkers' (Mummery, 2002: 466).

In universities throughout Western Australia, rural clinical placements are offered as part of students' undergraduate education in various health disciplines and are awarded accreditation points towards their final degree. Eleven University Departments of Rural Heath (UDRH) throughout Australia offer infrastructure, financial and supervisory support to students undertaking rural clinical placements. The Combined Universities Centre for Rural Health (CUCRH), the only Western Australian UDRH, was established in Geraldton in 1999 and is funded by the Commonwealth Department Health and Ageing.

CUCRH's mission is to make a significant contribution to improving the health of rural and remote Western Australian communities. One way it does this is to encourage undergraduate health science students to engage in rural clinical placements as part of their learning process. Such placements offer an innovative and effective way for students to become aware of, and deepen their understanding of issues related to rural health and service delivery. Given the difficulties recruiting health professionals to work in rural areas, research indicates that students who experience a positive rural placement are more likely to seek employment in rural areas after graduation (Lea & Cruickshank, 2005; Paterson, McColl, & Paterson, 2004; Playford, Larson, & Wheatland, 2006).

Rural clinical placements are organised through universities, health care providers, and local communities collaborating. Such placements enable students to participate in rural and remote practice and are facilitated by the enthusiasm and commitment of local health care providers who take on the important tasks of supervising or precepting students' clinical experiences. Throughout rural Western Australia, health care providers rise to this challenge by supervising hundreds of students each year. As students live in rural communities from between two weeks to several months they are able to experience rural life and professional practice first hand which helps to contextualise their clinical experience.

In 2005, 247 health science students participated in and completed their rural clinical placements. Sixty percent had never lived in a rural area before. To find out how they managed such a learning experience, CUCRH designed and conducted a survey and analysed students' responses. The aim of this paper is to draw on survey findings and analyse students' comments to demonstrate what aspects of rural clinical placements were effective in engaging students in the learning process.

Student placement program

The student clinical placement program was introduced to assist with recruiting health professionals to rural and remote areas. CUCRH allocates funding from its core budget to support students from various health disciplines to undertake rural clinical placements. This funding contributes to students' travel and accommodation expenses. Eligibility for funding requires students' involvement in a rural clinical placement within the CUCRH and the Western Australian Country Health Service (WACHS) catchment areas for at least two weeks. The WACHS catchment areas are the Kimberley, Goldfields, South West and the Wheatbelt with CUCRH covering the Midwest, Goldfields, Gascoyne, Murchison and Pilbara. In 2005, students' rural placement sites were located at distances of 100-1500 kilometres from Perth. Over 100 organisations and 130 supervisors were involved in the education of the 247 students around rural and remote Western Australia.

Methods

Students are reimbursed financially after they fill in an online survey on the CUCRH website following the completion of their placement. In 2005, all 247 health science students completed the survey. The aim of the survey was to examine students' experiences in clinical, professional, and social contexts (See Appendix 1) and determine whether students were more likely, as a result of their rural placement, to work in a rural area once they graduated. Raw data from the questionnaire were collated and analysed in Microsoft Access where descriptive statistics including frequencies and percentages were calculated. Students' comments in response to survey questions were organised into themes and analysed around the issue of student engagement and supported by results from the quantitative analysis.

Findings and discussion

Several factors engaged students in the learning process and contributed to rural clinical placements being an enriching educational experience. These included students having positive professional relationships with clinical supervisors and health professionals, social support from peers, adequate preparation for their placement, infrastructure support such as accommodation and technological resources, as well as opportunities to broaden their knowledge and understanding by working in Indigenous settings. Survey responses showed that 95% of students labelled their rural placement as positive. While 21% of students had difficulty "being away from family and friends", it is interesting to note the change in students' attitudes once they completed their placement. Seventy four percent indicated they would consider rural practice once they graduated as a result of their placement experience.

Preparation

Students who feel adequately prepared for their rural placement are often better placed to engage with the learning process. Such students have often researched information about the community and their placement site:
I think that if students are well informed about the placement before they arrive, then generally this assists in making for an enjoyable prac experience
While 14% students "felt very prepared for their placement", 8% requested "more information about towns [and] accommodation" before their arrival. Generally students expected their lecturers to provide this information. Not being prepared prior to going on placement may link to student's not engaging as effectively in the learning process:
It's a very different environment. It's the outback and very isolated with different weather conditions.

Many activities had closed down for the wet season.

Learning about the town in which they are working informed students of available community activities and services. Some towns do not have mobile reception or alternative transport for students to get from 'A' to 'B' while on placement which was sometimes a problem:
If I didn't drive to Karratha I would have had no transport and it is too hot and too far to walk everywhere. There is no public transport, only taxis which are expensive.
Living in a rural town offers students experiences to enhance their understanding and knowledge of rural communities and issues related to rural health:
It's great to be here for two months, long enough to get involved in the town and get a taste of rural practice.
Part of this knowledge of rural practice includes students increasing their awareness of cross-cultural issues when working in Indigenous communities. Twenty three per cent of students benefited from working in a cross-cultural context with some specifically commenting on the positive aspect of social interaction in this setting.

Cross-cultural awareness

Becoming aware of cultural differences allows students to learn how to communicate appropriately with Indigenous people while respecting their cultural differences. This is important in the context of good health outcomes. Some students wanted more preparation:
I would have liked more exposure to Indigenous health issues
whilst another commented that:
... tips on dealing with the Aboriginal community [were] much needed.
Meeting and working with Indigenous people offers students the opportunity to engage with them in a way that critically questions negative stereotypes and generates new ways to learn and understand more about Indigenous culture.
Being involved and learning about the Indigenous population and culture was a positive experience.

I have learnt cultural sensitivity and respect for Indigenous Australians.

Another aspect of students' positive experiences was attributed to their relationships with rural health professionals and peers.

Professional relationships

Good relationships with supervisors and other health professionals working in a rural setting effectively engaged students in the learning process with 57% commenting that staff and supervisors were "fantastic".
They enhanced my learning by giving me experiences that I hadn't had on my other placements.

I had extremely supportive clinical and prison staff [that] provided an environment that was positive to learning.

My supervisor was fantastic, supportive and very friendly and welcoming to the town.

[I had] extensive interaction with other health care professionals, [it was] extremely beneficial and an eye-opener.

Clinical practice

Opportunities to broaden clinical experience were also a factor engaging students and deepening their understanding of rural health. Forty seven percent considered that the opportunity to work in a rural clinical setting offered new experiences at the level of practice:
[I had a] broad diversity of client caseload that was able to be seen due to the variety available in rural occupational therapy.

I was able to develop and consolidate a wider range of clinical skills because of the hands-on nature of a rural placement. I do not believe that I would have had the same opportunity in a metropolitan setting.

As students became more confident, they felt a sense of achievement when theory and practice entwined:
I saw a wide range of patients which I feel improved my confidence and clinical reasoning skills.

Everything worked well for me, [as it] was educational, [I had] one on one with my preceptor and I was able to achieve my clinical objectives and demonstrate competence.

Four weeks was not long enough! I felt that I was beginning to feel part of the team and my skills were at a level which enabled me to work independently by the end of the clinical placement.

Students' participation in a variety of programs on placement engaged them in furthering their knowledge and understanding of different aspects of rural health and professional practice:
I had to organise a variety of placements myself [such as] sexual health so that each day was more interesting. I was involved in a multi disciplinary program with other students run through CUCRH; this allowed me to learn more about Indigenous health and aspects of other health professions.
While a clinical focus is an important part of students' placement, so too was the social aspect.

Social life on rural placements

Twenty one percent of students indicated being away from family and friends was difficult with some struggling with feeling alone and isolated:
Not having family support while away was hard.

It was hard being away from my husband and children.

As students met other students and locals the feelings of homesickness often lessened:
My 'housemates' included nurses with nursing experience all over Australia and they were tremendously supportive of student nurses as was the staff.
Often as a result of meeting new people students developed confidence and a sense of independence:
[I] learnt about fitting into a new town and making new friends.
Viewing rural placements from a holistic perspective integrates the importance of experiences outside the clinical setting that facilitate students' engagement in learning about rural living from different perspectives. This social contact was important in contributing to students' enjoyment of their rural placement:
Social life and travelling around on the weekends was fantastic.
As students share living quarters, go out to local clubs or visit tourist destinations in the area., opportunities arise to build friendships:
I enjoyed meeting great people and having excellent accommodation.

I made lots of social contacts and life-long friends.

Students also shared their learning experiences of their placement, helped each other with university assignments, debriefed each day and generally supported each other:
Fellow students provided substantial support for me during my placement.
While rural clinical placements offered students unique opportunities to gain a rich and varied learning experience, there were constraints such as financial costs during a rural placement.

Structural issues

Thirty percent of students found meeting the "financial expense going on a rural placement" challenging and 18% wanted more financial support:
We need more funding for students going to rural placements as out of pocket expenses are too high for students who have limited finances available to them. If the funding was high I know more people would have taken the opportunity to experience rural placements.
Infrastructure and technological resources were also an important factor in engaging students. Twelve percent of students had difficulty completing assignments and contacting family members due to a "lack of resources" such as computer, Internet, phone and library.

Workforce issues were also a factor undermining student engagement with 21% commenting about the "lack of workload at the placement site". Workforce shortages are not easily controlled and supervisors may experience staff shortages while a student is on a clinical placement, making them less available to students. While students may understand, some felt that this limited their learning experience as a result:

The hospital was understaffed and clinical teaching was sometimes limited due to this factor.

I didn't get a lot of hands on experience

CUCRH supports students through agreements with major hospitals to provide free accommodation for students at staff quarters. However, not all sites can offer such accommodation, and students may incur an extra financial burden for accommodation costs which could affect their engagement in the learning process. Even if accommodation was free, transport was sometimes a problem:
My accommodation was free, but it was a fair way from town and the health centre. It was about 10 kilometres and it was not safe or practical to cycle home.

Conclusion

Difficulties recruiting health professionals to work in rural areas are well documented. Engaging students in enriching and positive rural clinical placements so they want to return is one way to address the problem. This study highlights that, while students generally enjoy their rural experience, clinically and socially, there is room for improvement. Strategies to effectively prepare, orientate and support students in their placement and provide opportunities to learn about culturally appropriate health care in Indigenous settings need to be developed in order to deepen students' engagement in the learning process. No less important is highlighting that structural factors can constrain student engagement such as limited staffing and access to technology in some rural centres and inadequate accommodation and funding for students.

Nonetheless, rural clinical placements are an effective way to engage students in an enriching educational experience. Students participate in contextualised learning which offers opportunities to locate health in a broader social setting, to become aware of issues related to Aboriginal health and service delivery, to work in a multi-disciplinary setting, and to experience life in a rural community. These experiences help to broaden students' understanding of issues related to rural health and service delivery. Despite constraints, 95% of students, many of whom had never lived in a rural area, effectively engaged in the process of learning and practice and considered their rural clinical placement a positive experience: I think that rural placements need to be encouraged and advertised more within the university as I believe they are extremely rewarding and enable you to become a competent professional by exposing you to situations which you may not encounter in a metro setting.

References

Lea, J. & Cruickshank, M. (2005). Factors that influence the recruitment and retention of graduate nurses in rural health care facilities. Collegian, 12(2).

McKenzie, A., Morgan, C., Cochrane, K., Watson, G. & Roberts, D. (2002). Authentic learning: What is it and what are the ideal curriculum conditions to cultivate it? Paper presented at the Annual International Conference of the Higher Education Research and Development Society of Australasia, Perth, Western Australia. http://www.ecu.edu.au/conferences/herdsa/main/papers/ref/pdf/McKenzieA.pdf

Mummery, J. (2002). Facilitating critical thinking in an online environment. Paper presented at the Annual International Conference of the Higher Education Research and Development Society of Australasia, Perth, Western Australia. http://www.ecu.edu.au/conferences/herdsa/main/papers/ref/pdf/Mummery.pdf

Paterson, M., McColl, M. & Paterson, J. (2004). Preparing allied health students for fieldwork in smaller communities. Australian Journal of Rural Health, 12, 32-33.

Playford, D., Larson, A. & Wheatland, B. (2006). Going country: Rural student placement factors associated with future rural employment in nursing and allied health. Australian Journal of Rural Health, 14, 14-19.

Appendix: Student Placement Survey appears in separate file in PDF format [Appendix]

Authors: Tania Wiley works as the Student Support Officer at Combined Universities for Rural Health (CUCRH). This diverse role includes providing support for students undergoing rural clinical placements. Tania has worked for many years in community development and is currently completing her university studies in this area. Postal: Ms Tania Wiley, Combined Universities Centre for Rural Health (CUCRH), PO Box 109, Geraldton WA 6031. Email: taniaw@cucrh.uwa.edu.au

Angela Durey PhD is a Lecturer in Teaching and Learning at the Combined Universities Centre for Rural Health (CUCRH), The University of Western Australia, with a background in anthropology and sociology. Her interests include recruitment and retention of rural health professionals, inter-professional education and finding ways to deepen students' understanding of issues related to rural health.

Please cite as: Wiley, T. and Durey, A. (2007). Engaging students in a rewarding educational experience through rural clinical placements. In Student Engagement. Proceedings of the 16th Annual Teaching Learning Forum, 30-31 January 2007. Perth: The University of Western Australia. http://lsn.curtin.edu.au/tlf/tlf2007/refereed/wiley.html

Copyright 2007 Tania Wiley and Angela Durey. The authors assign to the TL Forum and not for profit educational institutions a non-exclusive licence to reproduce this article for personal use or for institutional teaching and learning purposes, in any format (including website mirrors), provided that the article is used and cited in accordance with the usual academic conventions.


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