Tracks to Postgraduate Rural Practice: Longitudinal Qualitative Follow-Up of Nursing Students Who Undertook a Rural Placement in Western Australia

Abstract

• The nursing workforce is the backbone of healthcare in rural and remote Australia.
• Rural clinical placements for student nurses are a strategy to address healthcare worker shortages outside major cities.
• Aims to improve training, recruitment, and retention of nurses in rural areas.
• The qualitative, longitudinal study aimed to understand personal and professional decision-making around rural nursing practice intentions and subsequent rural employment and retention.
• Methodology: Repeated semi-structured interviews with student nurses who completed at least one rural placement, following them over six years to becoming graduate nurses.
• Thematic longitudinal analysis developed three main themes:
  • Participants’ satisfaction with rural placements.
  • Challenges with gaining employment.
  • Considerations regarding ‘going rural’ for work.
• Participants reflected on professional, personal, and systemic barriers and enablers to rural practice.
• Insights can assist in developing a sustainable rural nursing workforce through informing rural workforce programs, strategies, and policies.

Introduction

• Improving the rural health workforce is crucial for sustaining good health outcomes in rural Australian communities.
• Rural communities have higher rates of chronic disease due to social determinants of health, requiring equitable and sustainable healthcare.
• Nurses are the largest healthcare profession in rural and remote Australia.
• Health Workforce Australia predicted a nursing shortfall of 85,000 by 2025, worsening to 123,000 by 2030.
• Domestic attrition rates were recorded at 34% in 2012, indicating a need for robust nursing workforce planning.
• Efforts to address the shortfall should include training nurses with the desire and capability to work in rural health settings.
• The Australian Government established University Departments of Rural Health (UDRHs) in rural sites across Australia.
• A core aim of UDRHs is to develop the rural health workforce and promote rural and remote health workforce strategies.
• In Western Australia, rural areas are defined as those outside the metropolitan area, based on remoteness, access, and population size.
• Well-supported rural clinical placements increase interest in rural health careers and the likelihood of graduates entering the rural workforce.
• A rural background and previous rural living are factors that increase the likelihood of later working rurally.
• Australian nursing students must complete a minimum of 20 weeks or 800 hours of professional experience placement for registration with AHPRA.
• Rural placements are not currently mandatory.
• The Western Australian Centre for Rural Health (WACRH) was the only UDRH in Western Australia when the study commenced and supported nursing students from various WA universities.
• During clinical placements, students are assisted by preceptors and clinical facilitators in:
  • Acquiring necessary nursing skills.
  • Linking theory to practice.
  • Meeting required nursing competencies.
• A preceptor is an experienced registered nurse (RN) who:
  • Supervises nursing students during clinical rotation.
  • Is accountable and responsible for day-to-day oversight.
  • Formally assesses required clinical competencies, including NMBA Standards.
• A clinical facilitator (CF) is a registered nurse who:
  • Facilitates student learning on-site and remotely.
  • Liaises between the university, placement site, and students.
  • Helps students become familiar with objectives, assessment processes, and the clinical experience.
  • Advocates for the student and supports the facility if problems arise.
• Research indicates multiple influences on a nurse’s choice of work location.
• A recent systematic review found three key dimensions:
  • Personal factors.
  • Professional factors.
  • The place itself.
• Recommended the use of autobiographical approaches to understand the interplay between these domains.
• Terry’s model of ‘Rural Nursing Workforce Hierarchy of Needs’ showed that clinical-related factors were ranked most highly by students.
• These included patient safety, positive relationships among nursing generations, supportive working environments, job satisfaction, autonomy, and respect.
• Other studies indicated the importance of social factors related to rural student placements and becoming part of the community.
• The study aimed to address gaps in the literature and build on current knowledge to:
  • Establish the extent to which a student nurse’s clinical rural placement, course choice, support level, and employment opportunities influence their career pathway.
  • Illuminate factors acting as barriers or enablers to working rurally and staying in rural practice.
  • Enhance the development of a sustainable rural nursing workforce through informing rural workforce programs, strategies, and policies.

Materials and Methods

• Qualitative, longitudinal study using semi-structured interviews over a 6-year period (2015–2021).
• Participants: Students from four universities (three metropolitan-based, one eastern state).
• Followed a career trajectory from rural clinical placement in WA to qualification and beyond.

Ethical Considerations

• Ethics approval was provided by the University of Western Australia (UWA) Human Research Ethics Committee in 2015 (RA/4/1/7231).
• Nursing students’ enrolling universities agreed to student participation.
• Informed consent was obtained from participants; they were aware of the audio-recording of interviews if they consented.
• Interviews were conducted by research staff not involved in the student’s supervision or assessment.
• Students were reassured that their decision regarding involvement in the study would have no bearing on academic results; enrolment proceeded after unit assessments had been completed.

Data Collection and Analysis

• Participants were selected using purposive sampling.
• Nursing students were invited via email to participate following a rural clinical placement.
• Each participant was phoned individually; the first interview occurred shortly after their rural student placement.
• Interviews were conducted in a one-to-one telephone format by academic nursing and medical staff based at WACRH.
• Interviews began with demographic data collection (degree course, age, marital status, dependents).
• Interviewers used pre-designed interview checklists with defined and emerging questions.
• Interview length varied, generally up to an hour.
• Participants who agreed to further follow-up were contacted by email and phone.
• A maximum of three interviews per participant occurred over six years.
• Of the twenty-three participants who completed an initial interview, ten completed at least two interviews, with seven participants completing all three interviews.
• Only participants who completed either two or three interviews were included in this analysis.
• Responses to the first round of interviews were recorded using field notes; subsequent interviews were audio-recorded and transcribed.
• Qualitative grounded theory with inductive reasoning underpinned our analysis.
• This involved systematic immersion in the data through multiple readings, detailed coding, and identification of emerging themes by three researchers.
• Collaboration and communication within the research team refined the identified themes.
• Saturation of the responses appeared to be reached by the time of the final interviews.
• Data were triangulated over time, with interviewers accessing prior interviews before the completion of subsequent interviews.
• Investigator triangulation was also utilized to minimize the risk of bias during the analysis of the data.
• For quick identification, quotes are annotated as ParticipantUniversityInterview number_Year of a university course (UC) or years post-graduation (PG).
• Low-population locations mentioned in quotes are concealed for anonymity as

Results

Participant and Course Information

• All participants were female, ages ranging from 19 to 48 years at the first interview.
• Four participants attended the University of Notre Dame (UND), two each from the University of Western Australia (UWA), Edith Cowan University (ECU), and the University of Southern Queensland (USQ).
• ECU and UND courses are three-year undergraduate courses based in Western Australia.
• The ECU course can be completed partially online.
• USQ has an online nursing degree course completed by students at a regional university center.
• The UWA course was a Masters-level two-year degree and has since been discontinued.

Summary of Work Locations at Final Interview

• Three participants (B, D, G) were rurally based at the beginning of the study (Southwest and Midwest regions of WA) and remained rural at the end.
• Of the seven participants (A, C, E, F, H, I, J) based in the metropolitan area initially, two had moved into metropolitan-based fly-in fly-out rural roles by their final interviews (E, H).
• One other participant had worked rurally for some time after graduating but had relocated back to the metropolitan area (F).
• Of the five participants working solely in the metropolitan area at the end of the study:
  • Three would consider working rurally if their circumstances were different.
  • One would definitely be rurally based if not for further city-based study.
  • One would not consider working rurally unless it was a last resort (I).

Thematic Analysis

• Three main themes from the longitudinal analysis:
  1. Participants’ satisfaction with rural placements.
  2. Their challenges with employment in general.
  3. Their considerations regarding ‘going rural’ for work.

Satisfaction with Rural Placements

• Five identified subthemes:
  • A. Feeling valued
  • B. Support mechanisms
  • C. Professional skill development
  • D. Personal skill development
  • E. Considerations of rural placements

Feeling Valued

• Participants benefited from feeling valued as part of the team and community during their rural placement.
• Rural culture and mentality differed from metropolitan hospital placements, with a welcoming, friendly, and supportive atmosphere.
• On-site RN preceptors seemed to trust them to complete tasks more autonomously while providing support.
• The rural setting had less hierarchical structures.
• Participants valued rural nurses having more time for them and taking the time to teach them.
• Students appreciated inclusion in activities and invitations to social events by hospital staff.

Support Mechanisms

• Mixed views were expressed about the support of onsite RN preceptors.
• Some spoke of ample opportunities to attempt different skills with support and encouragement.
• This support helped them overcome initial fears and was an affirming experience.
• Being able to contact both their home university and local support was valued.
• Some participants described difficulties due to the small rural setting and clinical load.
• Two reported experiencing ‘quiet’ times during placement, with staff unable to support their move to another area of the hospital.
• Discontinuity of preceptors was a recurring issue, making it difficult for students to complete assessment paperwork.
• Difficulties with computer access also impeded their feeling supported and impacted remote placement facilitation.

Professional Skill Development

• Rural placements exposed participants to more holistic and diverse skill development compared to specialized tertiary settings.
• Learning included performing procedures, understanding team dynamics, and communication skills.
• Nurses generally had time to teach and assess them and had a high level of knowledge.
• Students were better able to perform and consolidate their skills rather than just watching.
• Students working in metropolitan settings spoke of the long-term benefits of understanding the different health needs and perspectives of people from rural areas and their improved understanding of Aboriginal culture.
• Participants described being able to see how staff communicated with patients in rural settings as beneficial.

Personal Skill Development

• Participants spoke of personal changes and breakthroughs, including enhanced cultural understanding, feeling more self-assured, and increased confidence to work rurally.
• Some spoke of their experience living in a shared house during their placement, in which they learnt more about themselves and others.
• Some younger participants described their placement as ‘pivotal’ and life-changing.
• Living on their own for the first time necessitated independence away from their usual friends and family.
• They learnt to be proactive and organized, with enhanced confidence to try new things.

Considerations of Rural Placements

• Financial considerations were mentioned by several participants.
• Accommodation being organized and free was a valued aspect.
• Other key considerations were being away from family, particularly for those with children, the difficulty of driving long distances alone, and the benefits of living with other students.
• Some participants expressed the view that rural placements should be a requirement for all nursing courses.

Challenges of Employment over Time

Graduate Programs

• Most participants spoke of difficulties gaining employment as a nurse after graduation, particularly gaining a ‘graduate program’.
• All participants were eventually offered graduate programs, but only one was successful immediately after graduation.
• Participants spoke of the importance of being known to staff at the site at which they applied.
• One nurse later considered herself ‘stuck between a rock and a hard place’ as she was still trying to gain a graduate program but was no longer considered a new graduate.
• Another spoke of how she found it very hard to turn down an offer of a graduate program due to the ‘mentality and pressure’ around it but did so as she had been offered a community nursing job.
• Participants spoke of the competitive nature of the graduate program application system and the complexities of placing rural and regional sites as preferred locations.
• One participant reported that her university encouraged students only to apply for tertiary hospital graduate programs and was unaware of the options available in regional and rural locations.
• Three participants completed their graduate programs in a regional or rural area and later expressed concerns that they were lacking certain clinical skills.
• They suggested that opportunities for rural nurses to work within metropolitan hospitals for short periods of time would allow for more learning.

Insecurity of Employment

• Participants spoke of their difficulties gaining employment due to the competitiveness of both rural and metropolitan jobs.
• After the completion of their graduate program, many spoke of the difficulties of gaining permanent employment, with all the nurses interviewed after their graduate program being on casual, temporary, or short-term rolling contracts immediately after completion.
• Many had to join a casual pool at the same hospital where they had completed their graduate program.
• Only three nurses had been offered permanent roles by the time of their final interviews.
• Many had a preferred employment location but had to work elsewhere.
• Two of the participants spoke of how they had gained employment rurally through networking and phone calls rather than through more formal channels.
• Others described their efforts to continually upskill and network to eventually obtain a job in an area of interest.

Considerations Regarding ‘Going Rural’ for Work

Family Considerations

• Some participants expressed their desire to work rurally but found that they were unable to do so due to family commitments.
• These commitments included partners, children, and other family members being based in a metropolitan area for work or schooling.
• Another spoke of how she is not currently able to complete the upskilling that she would need to be able to work more rurally due to childcare commitments.
• One participant reported contributing to the rural nursing workforce through a fly-in-fly-out rural role despite the challenge related to her metropolitan-based partner.
• Another who was interested in rural working had wanted a graduate program in the city, as she felt that she needed to be around family in her first year of nursing for support.
• Another participant commented that rural working would compromise certain aspects of her lifestyle, such as specialist sports and activities.
• The three participants who completed their studies in regional areas all remained working in regional or rural areas for similar reasons, including family needs affecting their options.

Skill Requirements to Work Rurally

• Many participants spoke of feeling underqualified for rural positions and the need to work in the city initially to upskill.
• Participants’ views of the skills needed to work rurally changed over time.
• For example, the three nurses who had trained and only worked rurally in their first interviews spoke of how they felt working and completing a graduate program rurally would be beneficial due to the greater variety of presentations and country nurses being ‘good educators’.
• However, by the final interview, two spoke of how they felt their professional development would be enhanced by being able to further upskill at one of the tertiary hospitals in the city.
• Although both initially spoke of the possibility of working more remotely, in their third interviews, both also felt that they needed more experience before being confident enough to do so.
• One nurse who trained at a metropolitan campus took a rural position just after graduating (because she could not find any other work) and described it as being ‘thrown in the deep end,’ although she felt that she had been well supported by other staff.
• Another nurse working in the city at the time of her final interview commented that she would have liked to gain more advanced skills as a student so that she felt able to go rural sooner after graduation.

Influence of Rural Placement

• Participants spoke of the positive impacts of their rural placement on their interest in rural work.
• These included understanding the diversity of roles in rural hospitals, enjoying the feel of the community and the quality of life, and the respect and time given to them when they were students.
• For some, their rural placement consolidated that rural work was something that they aspire to do, despite their better understanding of the challenges of that environment.
• Some described that a rural placement enhanced their confidence to apply for and accept rural roles after qualification, thereby expanding the range of career options available to them.
• For some, their rural placement had more profound effects on their career path.
• They described how their rural placement reassured them that rural work would be a good opportunity and something that they were capable of with support systems.
• Other insights were gained, as in the case of a nurse who had noticed on her placement the transient nature of rural workers and found that knowing that she did not have to commit to long-term rural work made it more attractive.
• Those nurses who had completed their training and graduate program in the same rural setting spoke of how it was more comfortable and less daunting to complete their graduate program in a place where they already knew the ward and staff.

Discussion

• Rural placements are used as part of a long-term strategy to address the shortage of healthcare workers outside of major cities to overcome healthcare disparities between rural and metropolitan populations.
• The study explores the mechanism by which rural placements influence rural practice intentions and the subsequent transition into rural employment.
• This long-term perspective is important given that recruitment to rural areas does not automatically lead to retention.

Satisfaction with Rural Placements

• Well-supported, well-planned, and appropriately funded rural placements have been shown to increase rural practice intentions.
• Participants described feeling welcomed, valued, and supported on their rural placement.
• Health student satisfaction and rural practice intentions are related to a ‘positive, friendly, and supportive’ working environment and community engagement opportunities.
• Participants valued the autonomy and independence that their rural placement allowed them, as well as the development of a diverse clinical skill set.
• Terry’s model showed that clinical-related factors were ranked most highly by students in their decision to undertake rural practice after graduating.
• Clinical facilitators and preceptors who focus on these factors during a rural placement experience could potentially enhance placement satisfaction and the subsequent intention to work rurally.
• The two main negative issues described by students were quiet periods and the discontinuity of preceptors.
• The ability to move students to other areas is dependent on individual preceptors on-site.
• Preceptor discontinuity is a well-known issue; some preceptors were not well prepared for the completion of student paperwork.
• Improved communication and information provision about students attending rural clinical placements are important issues to address.
• The longitudinal nature of the study highlighted the value and satisfaction of the rural placement experience, even for those who did not take up rural work.
• Participants reflected on the benefit they derived from understanding the differing health needs, perspectives, and priorities of patients from rural areas, even when working in metropolitan areas.

Decision-Making: Influences on Rural Practice

Influence of Rural Placement on Rural Practice

• Participants looked back on their rural placement and spoke of the community feel, quality of life, and respect as encouraging drawcards for rural practice.
• A sense of belonging or connectedness to rural life influences the attraction of nurses to rural areas.
• The study noted the longer-term effects of a rural undergraduate placement on personal and professional growth.
• Participants spoke of their enhanced confidence to move away from home, ‘give things a go’, and meet new people.
• Experiencing the challenges of rural practice during placement is not necessarily a negative; rather, it can potentially encourage people who will be more likely to stay in rural areas because they understand the nature of the role.
• Of those participants who had trained entirely rurally, all of them remained rurally employed at the end of the study.
• They explained that being familiar with the location and staff meant it was less daunting to continue practicing rurally following graduation.
• This shows the positive implications of encouraging and enabling healthcare training for those who already reside rurally.

Professional Considerations

• Many participants spoke of difficulties in finding rural employment, despite staffing difficulties in regional areas, and described obtaining work through networking rather than formal job application channels.
• Rural positions require generalist skills and a flexible approach due to the larger variety of work and the fewer resources available.
• Rural development pathways are needed for early career health professionals because most participants spoke of difficulties obtaining a graduate program and the competitive nature of the application process.
• Applying for a regional or rural site was seen as risky by some from urban backgrounds.
• The fact that rural graduate programs may not have been encouraged as a valuable option for students by at least one metropolitan university suggests that a closer relationship between universities and the nursing workforce area within WA Country Health Services is required.
• The availability and ease of submitting applications for rural locations may need review.
• All three rural origin participants who completed their graduate program in a rural area had completed their undergraduate training at a rural university site, because rural graduates had felt that completing a graduate program in the area where they had trained would be beneficial.
• In retrospect, although they had valued the support of their fellow graduates and staff, who had been known to them throughout their rural training, two of the graduates felt that they lacked certain clinical skills compared to their metropolitan counterparts.
• This finding warrants further investigation because job satisfaction, professional support, and career development opportunities are all associated with retention in the rural workforce.
• Suggestions for novel professional development experiences using telehealth, clinical exchange, and service collaboration have been suggested as ways of enhancing long-term rural retention.
• A previously trialled program included the opportunity to develop networks between metropolitan-based and rural-based staff.
• Another substantive issue raised by the participants relates to the high numbers of casual and short-term contracts in the nursing sector.
• Along with professional support and development opportunities, job security has been shown to influence the continuation of rural practice.

Personal Considerations

• Social, cultural, and family ties influence the retention of rural health workforces.
• For those without a rural background, opportunities to develop social networks in the community are important.
• Immersion in rural culture has been shown to be a major motivator for remaining in rural and remote communities.
• Family considerations were mentioned by most participants with respect to making decisions about employment locations, whether they were of urban or rural origin.
• A partner’s work was a frequent consideration.
• This indicates that a partner’s needs have a large influence on the ability of health workers to take up rural employment, regardless of rural interest or intention.

Summary Table

• Key findings, barriers, and enablers, along with their implications for policy and practice.

Rural Intention

• Satisfaction with a rural placement was enhanced by diverse skill development, autonomy of practice, and by social and professional support.
• Clinical facilitators and preceptors should focus on those factors known to enhance placement satisfaction and confidence.
• Quiet periods and discontinuity of preceptors adversely impacted rural placement satisfaction.
• Provide professional development opportunities for rural preceptor roles.
• Increase continuity of preceptors for those on rural placement.
• Participants spoke of their rural placement as an enabler of confidence to move away from their place of origin.
• Enable broader immersion in rural ‘lifestyle,’ including opportunities to ‘give things a go’ and to meet new people.
• Incorporate social experiences and opportunities for longer placements.

Rural Employment

• Rural graduate programs did not seem to be encouraged as a valuable option for some students.
• Enhance relationships in rural nurse recruitment pathways.
• Some students and graduates from metropolitan areas perceived they lacked the necessary skills and experience to work rurally.
• Ensure that rural practice opportunities are seen as attainable and valuable.
• Nurses had difficulties applying for rural graduate programs without compromising alternative graduate program opportunities.
• Improve the graduate program application process.

Family and partner education and work considerations

• Family and partner needs factor into when attracting nursing staff to rural areas.
• Consider longer-term employment contracts with key stages of development to be attained to continue employment.

Rural Retention

• There was a lack of satisfaction with support and professional development opportunities in rural practice.
• Ensure that rural graduate positions offer quality support and training.
• Rural graduate nurses feared de-skilling compared to their metropolitan counterparts.
• Provide enhanced professional development opportunities, including training for those interested in preceptorship and research the potential for implementing novel strategies used in rural areas interstate and overseas.

Limitations

• Achieving interviews with initial student participants as they moved into professional careers proved challenging; the numbers are small but have produced rich qualitative data with a variety of viewpoints from students.
• Qualitative research does not seek to be representative, and the study participants highlight the differences within the university approaches.
• Rural communities are diverse, and what works in one area may not be applicable to another.
• Further follow-up would be needed to address how the life stage of the nurses influenced the factors identified.
• Even small pieces of qualitative research can help guide policy and the development of rural workforce strategies and programs.

Conclusions

• Several factors enable nurses’ rural practice intention, employment, and retention, including a positive rural placement experience.
• However, several barriers and areas for improvement were highlighted, namely issues with obtaining rural graduate employment, employment insecurity due to short-term contracts, and the concerns of rural nurses regarding professional development opportunities.
• Understanding these factors is essential for developing strategies for attracting, recruiting, and retaining rural nurses and improving the long-term stability and sustainability of the rural nursing workforce.