Exploring Learning Engagement in Rural and Urban Nursing Placements: A Five-Year Mixed-Methods Study

TL;DR

This study explores how rural and urban nursing placements affect student learning over five years, finding rural placements and first-year experiences more positive.

Contribution

The study provides new insights into how placement location and year-level differences influence nursing students' learning engagement and satisfaction.

Findings

Rural placements were slightly more positive than urban ones for nursing students.

First-year students reported more constructive experiences than senior students.

Quality of supervision and skill development were key factors in placement satisfaction.

Abstract

Professional experience placements are a requirement for undergraduate nursing students enabling real world skill development. Barriers to meaningful and positive placements have previously been reported, however there is limited research on how the location of placement impacts the student experience and outcomes. This study investigates the placement experiences of undergraduate nursing students at the University of Tasmania (UTAS) over a five-year period, with a focus on urban versus rural settings and year-level differences. Findings reveal that over one-third of students reported constructive placement experiences, with rural placements yielding slightly more positive outcomes than urban ones. First-year students were more likely to report constructive experiences compared to their senior counterparts, suggesting that longer placement durations may contribute to increased dissatisfaction. Quality of placement—defined by supervision and skill development—emerged as the most influential factor in shaping student experiences. While most students praised the quality of supervision, third-year students expressed both the highest praise and criticism. Opportunities for clinical and interpersonal skill development were central to students’ perceptions of placement quality, with rural placements slightly outperforming urban in skill development. However, some students, particularly in later years, felt that certain venues lacked adequate opportunities for skill acquisition. The study underscores the importance of high-quality supervision and appropriate clinical settings in enhancing placement experiences and suggests that constructive placements are more conducive to learning. These insights can inform strategies to improve the educational value of nursing placements across diverse settings.

Full text

1. Introduction

Work integrated learning for undergraduate nursing students in Australia is known as professional experience placements (PEP) (‘placements’) and are a compulsory feature of undergraduate nurse educational preparation [1]. Placements enable real world learning that stimulates skills development and immerses students in the practical aspects of the profession to develop the requisite capabilities defined by the Australian Nursing and Midwifery Accreditation Council (ANMAC) Standards (2019) [1]. Nursing placement has been shown to create significant personal development opportunities with increased appreciation and sensitivity toward cultural issues and cross-cultural care [2], professional socialisation, exposure to different clinical areas [3], and clearer career planning [4]. There is enduring national and international interest examining what constitutes effective placement learning experiences. Three overarching categories define the focus of much of this research—student experience, supervision, and setting [5]. Supervision, which includes staff attitudes, and interactions between educators and students, appears to be the most reported factor when it comes to student satisfaction with their placements [5,6]. The student experience of placements has been reported as involving a wide range of emotional, professional, and interpersonal challenges that shape the overall journey. These include increased pride, self-confidence, and a desire to make a difference [7] as well as insecurity, a reality shock, and a need for support and guidance [7,8]. Furthermore, the clinical environment and the service type were also found to be fundamental influencing factors in placement satisfaction in an EU study [6], consistent with an Australian study that suggested decreased placement satisfaction when a lack of support was available [9]. It has been shown globally that overall nursing student satisfaction is strongly related to their placement experience and has a significant impact on student retention [10,11,12,13]. Previous research has identified a need to improve nursing placements, with a focus on delivering consistent, high-quality programmes, understanding barriers and enablers to student learning, and enhancing student outcomes [14]. Evidence from the United Kingdom highlights three characteristics of high-quality placements: students feeling part of the team, receiving adequate support to build confidence and competence, and having their anxiety and initial lack of preparedness acknowledged [15]. In the Australian context, three key enablers of positive placement experiences have been identified: enjoyment of place (“environment and community”), a welcoming and responsive workplace (“friendly and supportive workplace”), and diverse learning opportunities (“exposure to broad practice”) [16]. Conversely, five common barriers have been reported, including financial pressures, relocation challenges, disruption to personal routines, stress, and communication difficulties [16]. A review of student narratives on placement supervision further emphasises the importance of supportive instructors, close supervision, and a sense of belonging, while unsupportive behaviours and inadequate supervision diminish placement quality [17].

Given the ongoing challenges in nursing workforce capacity, understanding what contributes to constructive placement experiences is essential for quality assurance and reducing student attrition. This is particularly critical in rural areas, where workforce shortages significantly affect service accessibility and delivery [18]. Prior research has shown that positive rural placements can influence graduates’ decisions to remain in and work in rural settings [18,19,20]. Furthermore, Experiential Learning Theory (ELT) [21,22] emphasises the impact of cognitive, environmental, and emotional experiences in the learning process and outcomes. ELT suggests that learners develop skills more effectively when they engage with authentic, real-world contexts, such as those provided through work-integrated learning. This is particularly relevant in rural and regional settings, where learners are exposed to broader scopes of practice, closer clinician–community relationships, and the unique challenges associated with limited resources and workforce shortages. Such environments provide rich, immersive learning opportunities that can accelerate skill development and foster adaptability, resilience, and a deeper understanding of rural health contexts.

Despite sustained interest in professional experience placements (PEP), few studies have directly compared the experiences of students undertaking urban placements with those completing rural placements. Even fewer have used student-generated narratives to explore how learners themselves describe and construct effective placement experiences. We aim to answer the following research questions.

How do professional experience placement experiences differ for student nurses in urban versus rural healthcare settings?How do learning opportunities and support structures for student nurses vary between urban and rural placement settings?How do urban and rural professional experience placements shape student nurses’ perceptions of preparedness for professional practice?

2. Materials and Methods

The study involved a comprehensive mixed methods analysis of narrative feedback from nursing students at all levels of undergraduate nursing at an Australian University. The dataset consisted of reflective feedback submitted as part of routine placement evaluations, and survey responses in the form of checkbox answers, sliding scales, and Likert scale responses. A mixed-methods design was chosen to capture both the breadth and depth of students’ experiences. The decision to employ a mixed-methods design is supported by Creswell’s widely cited work on mixed-methods research [23], which emphasises the value of integrating quantitative and qualitative approaches to gain a more comprehensive understanding of complex educational and social phenomena. Creswell argues that mixed-methods designs are particularly appropriate when neither quantitative nor qualitative data alone can adequately capture the full scope of the research problem. In this study, learning engagement during professional experience placements is influenced by contextual, relational, and experiential factors that benefit from both measurable patterns and rich narrative insight. The mixed-methods approach strengthened this study by combining measurable trends with in-depth insights into students’ lived experiences.

2.1. Setting

The study explores the narrative experiences of University of Tasmania (UTAS) undergraduate nursing students. UTAS is the only university located in Tasmania (an island state of Australia). The Modified Monash Model (MMM) is a geographical location classification system used by the Australian Government to determine the rurality of a region [24]. Tasmania has two main urban centres, approximately 200 km apart. The remainder of the state is classified as regional, rural, remote and very remote. Nursing students at UTAS study across four primary campuses (Table 1). Student placements in Tasmania occur across Tasmania and include remote island regions. Student placements in New South Wales (NSW) primarily occur in Sydney (the state’s capital city), although rural placements in NSW occurred in the later years of this study. During the period of this study, UTAS nursing students undertook five placements across their pre-registration degree programme—a two-week placement in the first-year, two three-week placements in second year, and a six- and seven-week placement in third year [25]. During nursing placements, there are a variety of methods of support and supervision available to students [26], which are related to geographic location, formal placement agreement/s and health service provider requirements. Students are also supervised by staff within placement organisations, who perform this supervision as part of their clinical role. The term ‘rural’ in this paper is used to represent regional rural, remote, and very remote regions as classified by the MMM [24].

2.2. Data Collection

This study utilised secondary text data collected as part of a routine administrative survey distributed to all nursing students at the end of every nursing placement by the UTAS College of Health and Medicine—the Placement survey. This survey is accessed by students via the Placement Management System as part of their placement completion tasks and is an optional feedback mechanism. Students complete and submit the survey online.

The survey data covered the period 1 January 2017 to 31 December 2021, and the survey questions remained unchanged across the five-year data collection period. All nursing students were invited to complete the survey regardless of where placement occurred. The survey contained demographic questions about year of study, unit code, and placement facility, and three questions inviting free-text feedback on placement experiences:

1. Please list up to 3 aspects of this professional experience placement that have helped your learning.
2. Please list up to 3 aspects of this professional experience placement that have hindered your learning.
3. Are there any additional comments or suggestions you would like to make to improve your PEP learning experience?

2.3. Data Analysis

Initially, all data were descriptively coded to the demographic variables of the year of survey, student’s year of study, and placement state. All other feedback data was analysed using content analysis with an inductive approach to enable interpretation using a “systematic classification process of coding and identifying themes or patterns” [27]. Data from each feedback question was manually coded with content variables created inductively. Following the identification of the main variables, categories were identified, and comparative analyses were undertaken between sub-groups within each category. Trends and patterns were documented and quantified for reporting purposes [28]. Content analysis was an appropriate method for this research to investigate the primary categories in the data and record trends over the five-year research period.

The content analysis was guided by three questions.

What helped and what hindered nursing students’ learning during placements?Did these factors change as students progressed through their degree?Did these factors change by placement region?

Data analysis occurred using Microsoft Excel, enabling the calculation of responses for each variable and comparisons made between student sub-groups. These calculations are presented as percentages.

Several strategies were employed to minimise bias during the categorisation and interpretation of qualitative data. An inductive content-analysis approach was used to allow categories and themes to emerge from the data rather than being shaped by predetermined assumptions. To enhance the credibility of the coding process, an initial subset of responses was independently coded by two researchers. Coding decisions were then compared and discussed, with discrepancies resolved through consensus. This process supported consistency in the application of codes and reduced the influence of individual researcher perspectives. Reflexive practices were incorporated throughout the analysis, including regular team discussions to review emerging categories.

These strategies collectively strengthened the trustworthiness of the analysis and helped ensure that the categorisation of qualitative data was systematic, transparent, and as free from bias as possible.

The project received ethics approval from the UTAS Human Research Ethics Committee (H0026757) and is funded under the Rural Health Multidisciplinary Training (RHMT) project. Generative Artificial Intelligence (GenAI) was not used in any part of this study.

3. Results

3.1. Demographic Data

The research team received 3081 responses for the Placement survey for the five-year period. Responses increased each year, except in 2020, and students from 2021 were over-represented in the research results (27%). Rural NSW placements represented 1% of the overall results (Table 2).

Second year students (41%) were over-represented in the study, followed by third year students (35%), with first-year students under-represented (24%). Second- and third-year students each had two placements a year, with first-year students having one. Potentially, second- and third-year students completed the survey twice a single year, which may account for the higher response rates for these student year groups. Students with urban placements were over-represented in the results by a ratio of 3:1 (76% versus rural placements 24%). Placements in Hobart were also over-represented (34%), with Sydney placements second highest (25%), followed by rural TAS (22%). Placements in Launceston (17%) and rural NSW were under-represented (1%). Rural placements in NSW were limited during the study period accounting for this low percentage.

Placement supervision was consistent in the student narratives with praise for supervisors having the highest response rate (53%) and supervision criticism third highest (31%). Developing clinical skills was second highest (43%), and developing interpersonal skills was fourth (26%).

3.2. Categories

Three overarching categories emerged from the data: Overall placement experience, supervision during placement, and skills development. Table 3 shows the coding variables for each category. Each category is further described below.

3.2.1. Category 1: Overall Placement Experience

The results suggest most students had constructive placements during the study period (Table 4). Almost a fifth of students (19%) indicated nothing hindered their learning and 15% indicated they had constructive placements. Only 2% indicated nothing helped their learning during placement.

A higher percentage of rural placement students (17%) indicated they had constructive placements than those with urban placements (15%), and slightly more students with urban placements (20%) indicated their learning was not hindered during placement than those with rural placements (19%).

Fewer first-year students indicated nothing helped learning (1%), compared with second (2%) and third year students (3%). Fewer second-year students (17%) indicated nothing hindered learning compared with first- and third-year students (21%). More first-year students had a constructive placement experience (18%) compared with second- (15%) and third-year students (14%). Table 5 highlights student narratives about the quality of their experiences coded to these variables.

Most of the comments about ‘nothing helping learning’ came from second- and third-year students in 2017. Some students asserted a lack of learning and/or unhelpful placement experience, with claims the placement was ‘chaotic’ or caused students’ stress’. Students that had constructive and helpful learning experiences appeared to reject the notion that their learning was hindered during placement and emphasised the positive experience and learning value of the placement.

3.2.2. Category 2: Placement Supervision

Some students specified a difference between the UTAS funded supervisors, and the supervisors within the placement organisation (Table 6). When no differentiation was specified in the narrative, it was coded as supervisors within the placement organisation, although it is acknowledged this may have inflated the responses for this supervisor group. More than half (60%) of the student narratives praised their supervision during placement (some praising both groups of supervisors). Around a third criticised their supervision (37%). There were higher rates of praise (53%) and criticism (31%) for placement preceptors, supervisors, and staff (placement supervision) compared with university funded facilitators (UFFs) (20% praise and 7% criticism). Although this may be due to coding as explained above. Praise for UFFs was higher for urban placements (23%) compared to rural placements (11%). Third-year students offered more praise for UFFs (26%) than second- (19%) and first-year students (14%). Praise for placement supervisors was higher for rural placements (55%) compared to urban placements (52%), and again, third-year students offered more praise (55%), than first- (53%) and second-year students (50%).

Overall, supervision criticism for UFFs was low and first-year students had the lowest percentage of criticism (3%), and third-year students had the highest (9%). Criticism for placement supervision was lower for third-year students (30%), with rural placements the lowest (29%). First-year students had low rates of supervision criticism for UFFs, although their supervision criticisms of placement supervision were equal with second-year students, urban placements, and the combined percentage. Student narratives about supervision are shown in Table 7.

Student praise for UFFs included making time to work with students, providing support and resources. Supervision criticisms asserted a lack of support, being unapproachable, not spending enough time with students, or an absence of UFFs altogether. Some students felt disempowered by UFFs with comments that indicated this factor impacted their wellbeing.

Student praise for placement supervision indicated some staff were welcoming and supportive, available for teaching, and demonstrated patience with students. Supervision criticisms asserted placement staff sometimes did not want to teach students, did not allow students to undertake specific tasks, were rude, unsupportive, and lacked awareness of student capabilities. Some students indicated placement facilities were short-staffed or lacked registered nurses, with both impacting the quality of placement supervision available to students.

3.2.3. Category 3: Skills Development

Results indicated skills development was an important aspect for students for their placement experience (see Table 8). Students asserted that their development of clinical and interpersonal skills during placement was an important outcome of their experiences. Within this theme, developing clinical skills (43%) ranked higher than the development of interpersonal skills (26%). Student criticisms expressed a lack of opportunity to develop clinical skills (24%), with requests for more skills development opportunities during placements (8%). Some students indicated scope of practice limitations also impacted their placement experiences (7%), and some asserted acute settings were necessary for skills development during placement (4%).

Developing interpersonal skills was higher for urban placements (28%) than it was for rural placements (21%). Developing clinical skills was higher for rural areas (45%) than it was for urban placements (42%). Assertions there were limited opportunities to develop clinical skills during placement were higher for rural areas (26%) than it was for urban placements (23%). Development of clinical skills appeared to decrease as students progressed through their degree programme. First-year students had the highest rate (50%), followed by second- (44%) and third-year students (36%). First-year students also had the highest rate for developing interpersonal skills (31%), followed by third- (26%) and second-year students (24%). More second-year students asserted placements provided limited opportunities to develop clinical skills (26%) compared to first- and third-year students (22%).

More first-year students asserted scope of practice restrictions limited skills development (18%) compared to second- (4%) and third-year students (2%). Second- and third-year students asserted the need for more opportunities to develop skills (9%), and the need for acute settings for skills development (6% and 4%). Table 9 highlights student narratives about skills development during placements.

Student comments about limited opportunities to develop clinical skills often arose alongside criticisms of placement guidance, such as assertions that facility staff were too busy, did not want to teach students, lack of registered nurse (RN) supervision, or facilities being too quiet or unsuitable for the student’s learning level. Student comments about the scope of practice restrictions argued it hindered their learning opportunities, although some suggested placement supervisors expected students to undertake tasks beyond their scope of practice. Student comments that asserted the need for more opportunities to develop clinical skills also arose alongside comments about facility staff being too busy or not wanting to teach students. Student comments that argued for placements to occur in acute clinical settings were generally from second- and third-year students and often asserted the current placement facility was more suitable for earlier year students.

4. Discussion

This study aimed to explore and understand the experiences of undergraduate nursing students during placements. Overall, more than one third of nursing students in this study indicated they had constructive placement experiences with students undertaking rural placements having more constructive placements than their urban counterparts. Stratified results indicated more first-year students had constructive placements than second- and third-year students. Potentially the longer placement periods for second- and third-year students increased the opportunities for dissatisfaction with the overall experience. These findings are at odds with those from the previous rapid review [5] that found that most students in their review studies reported clinical placements as “stressful and overwhelming”, suggesting they were unhelpful experiences.

Our findings indicate that quality was the primary variable impacting students’ placement experiences, with ‘quality’ comprising supervision and skills development, irrespective of whether supervision was by placement staff or UFFs. These findings parallel other research that found “supervisory relationship(s)” to be “key to students learning” during placements [5,17]. Supervision emerged as a critical element of students’ experiences which accords with other research where Currie, Grootemaat, Samsa et al. assert multiple factors impact students’ placement experiences, with their “perception(s) of the attitude of the clinical staff they are working with” “one of the most significant” [5]. Most students praised the quality of supervision during placement, with this rate unchanged with urban or rural placements. One-third of students criticised the quality of supervision, and this rate increased slightly for urban placements, and reduced for rural placements. This suggests, contrary to other research, that UTAS students on rural placements expressed slightly more satisfaction with their supervision during placement than those with urban placements. It may be that the Whole of Community Facilitator Model of support provided by UTAS for rural placements increases this level of support [26]. The rate of praise and criticism for placement supervision also varied by students’ year of study. Third-year students were highest in both their praise and criticism of supervision during placement, followed by second-year students, with first-year students having the lowest rate for both categories.

Unsurprisingly, learning was also a significant factor in quality placements with opportunities to develop clinical and interpersonal skills during placement dominant in student narratives in this study. More students asserted they developed skills (clinical (43%) and interpersonal (26%)) than a lack of opportunities (24%). This result supports the finding that, overall, most UTAS nursing students experienced constructive placements during the five-year analysis period.

When these results were stratified by placement type there was a minimal difference between urban and rural placements. Students who felt they developed clinical skills during rural placements were slightly higher (45%) than urban placements (42%), and higher for first year (50%) than second (44%) or third-year students (36%). Students who believed they developed interpersonal skills were higher for urban placements (28%) and rural (21%). First-year students were also highest in this category (31%) compared o third (26%) and second-year students (24%).

More students with rural placements asserted a lack of opportunity to develop clinical skills (26%) than students with urban placements (23%). Given the importance students in this study placed on developing skills during placement, it is unsurprising some students stressed the importance that placements occur in acute clinical settings to develop clinical skills, particularly for later-year students. Some placement venues were considered ‘inappropriate’ for skills development for the later year students. These findings are in accordance with other studies that found students value hospital settings as critical learning spaces [17,29,30].

It is acknowledged that the research explores students’ perceptions of their experiences only, and that student enjoyment is not a measure of actual learning that may have occurred during placement.

The findings from this study indicate a constructive placement experience is more inducive to learning than a challenging one. As students’ progress through their degree programme, the findings indicate they may become more critical of their placement experiences as second- and third-year students have longer placements than first-year students. Longer placements may produce challenges due to the length of exposure to a single placement facility. In contrast to other research, the results indicate relatively little difference between students’ urban and rural placement experiences [31,32,33,34]. The results from this study add to a broader understanding of students’ placement experiences and the findings can inform quality improvement practices to enhance the learning potential of nursing student placements.

Recommendations from this study include aligning placement settings with nursing students’ year level to ensure developmental appropriateness and progressive skill acquisition. Prioritising the quality of supervision is essential, as effective clinical teaching and consistent preceptor engagement are critical determinants of students’ learning, confidence, and professional identity formation. The findings also highlight the need to identify placement environments that may be unsuitable for advanced-level students, particularly where the scope of practice, case complexity, or supervisory capacity does not support higher-level capability development.

Further recommendations include strengthening partnerships between education providers and clinical agencies to ensure shared expectations regarding student capability, supervision standards, and assessment processes. Enhanced monitoring of placement quality, including systematic feedback from students and supervisors, would support continuous improvement and early identification of environments requiring additional support or remediation. Finally, future research should explore the structural and contextual factors that influence placement suitability across different settings, with the aim of informing evidence-based placement allocation frameworks that optimise learning outcomes and workforce readiness.

Limitations

This study included experiences of students from only one university and may not be generalisable to other higher education institutions. This study also relied on self-reported data which may not accurately reflect the actual learning outcomes or clinical competence. Although this data was captured over a five-year period, there is no longitudinal follow up which may limit the insights into how placement experiences evolve over time. In addition, the survey did not assess factors such as student stress levels or the availability of social support during placements. These variables are known to influence learning engagement and overall placement experience, and their absence restricts our ability to understand how psychosocial factors may have shaped the reported outcomes.

5. Conclusions

Undergraduate nursing student placement experiences differ across geographical regions; however, the concepts that influence the constructiveness of the placement remain stable over time: quality of supervision; optimal and relevant learning opportunities; and placement allocation relevant to year level of study. This evaluation, conducted over five years, demonstrates that the factors impacting engagement with learning must be considered in the design and development of placement programmes to ensure that learning opportunities for students are maximised.