Improving the quality of allied health placements: student, educator and organisational preparedness

ABSTRACT

Work Integrated Learning is essential for healthcare degrees where students learn to become healthcare professionals. As a complex form of learning the quality of student placement experiences are variable, impacting student wellbeing and development of professional competencies. Getting it right, students enter the workforce ready to practice. Getting it wrong can have deleterious effects on all stakeholders. Although research has examined placement quality for students, less is known about the experiences of other stakeholder groups (e.g. placement educators, university academics and professional support staff). Our research addresses this gap. Using narrative interviewing methods, underpinned by social constructionism, we interviewed fifty-one participants: 19 allied healthcare students, 15 placement educators, 12 university academics and 5 professional staff from a large Australian university. We identified four preparedness themes impacting on placement quality, namely: University, Placement Site, Placement educator and Student preparedness. Within these themes, good practice is highlighted alongside examples of unsettling experiences. Curricula should be reviewed to ensure students are prepared as agentic learners for the complexities of the workplace. Furthermore, universities should co-design placements in partnership with healthcare organisations and educators to enable students to optimise their learning and contribution to patient/client care.

KEYWORDS:

• Students
• health occupations
• professional competence
• work-based placements
• education
• qualitative research

Introduction

Broadly defined, work integrated learning involves ‘authentic work-focused experiences as an intentional component of the curriculum’ (Zegwaard et al. 2023). This paper focuses on placement-based work integrated learning: ‘the teaching and learning process that occurs in real-world organisational contexts with structured supervision and as a compulsory part of an academic programme with assigned learning outcomes’ (Hay 2020, 51). Also known as work-based placements, workplace learning, internships, fieldwork, practicums or clinical education, this form of work integrated learning is a key component of healthcare professional degrees (McBride et al. 2020). For placement organisations in the healthcare context, placements often provide positive outcomes such as avenues for recruitment, strengthened university – service provider partnerships, enhanced service delivery and improved patient/client outcomes (Nisbet et al. 2021; Orrell 2018). For placement educators, positive outcomes include the satisfaction of sharing professional knowledge with students, developing the future workforce and students bringing up-to-date evidence to placement educators regarding service delivery (Nisbet et al. 2021). And for students, positive outcomes include development of knowledge, skills and capabilities (McAllister et al. 2010) and their identities as healthcare professionals as they come to feel more connected to their future work practices (Monrouxe 2016). Further, high-quality placements can also facilitate student, patient and educator wellbeing and safety (Klasen et al. 2020; Monrouxe et al. 2017). However, not all work-based placement experiences are positive. Sometimes students witness or participate in events (including incivility and professionalism lapses) that run counter to best-practice, leading to deleterious outcomes including patient harm and student distress and burnout (Babenko-Mould and Laschinger 2014; Monrouxe, Rees, and Bradley 2009; Monrouxe and Rees 2012; Monrouxe et al. 2014; Monrouxe et al. 2015; Tella et al. 2016). Furthermore, although research has examined the issue of placement quality for healthcare students, research examining the experiences of other relevant stakeholder groups (e.g. placement educators, university academics and professional placement support staff) has been lacking, or even absent. Without such work examining other stakeholders’ experiences, we risk having a relatively narrow perspective on what comprises quality in healthcare work-based placement activities, risking the omission of both positive and negative impacts for wider stakeholder groups. Our study aims to address this gap.

Quality in healthcare work-based placements

Healthcare work-based placements (henceforth, placements) offer a complex form of learning, occurring in the workplace, outside of the structured university environment. Despite the many documented benefits of placements as outlined earlier, research suggests that high-quality learning is often lacking within placement settings, in which a hidden curriculum operates (e.g. unwritten, often unspoken lessons and values running counter to those explicitly taught: Hafferty and O’Donnell 2014). Alongside the growth in placements and other work experiences in many degrees and professions outside health (Dean and Sykes 2022) and in recognition of the challenges to quality, scholars and practitioners have focused on defining and assessing placement quality. Some models of placement quality focus primarily on student experiences; for example, a national Australian project tested dimensions of quality with over 2000 students (Smith 2012; Smith, Ferns, and Russell 2016). Other frameworks recognise the need to consider the views of a broader range of stakeholders. Thus, Campbell and colleagues’ (2019) framework for quality focuses on four domains of practice: student experience, curriculum design, institutional requirements, and stakeholder engagement, emphasising the interconnectedness of these domains. More recently Campbell and Pretti (2023) have reinforced the need to consider that ‘WIL practice and pedagogy is … nested within multiple relationships and stakeholder interests’ (354).

Indeed, different stakeholders identify different factors that influence placement quality. From the educators’ perspective, a key challenge of placement quality is balancing patient care with student education (e.g. Hu, Nisbet, and Chang 2022; Nisbet et al. 2021). This balance, when disrupted, can compromise both quality of care and education alike, sometimes leading to placement educator stress and burnout (Kellish et al. 2021).

Placements can be a challenging learning environment for students, who may fail or be at risk of failure (e.g. Davenport et al. 2018), encounter racism (e.g. Gair et al. 2015), witness professionalism breaches (e.g. Monrouxe and Rees 2017), and feel psychologically or physically unsafe (e.g. Babenko-Mould and Laschinger 2014; King et al. 2021). Poor quality student placements can also compromise patient safety and dignity, especially given the complexity of student-educator-patient exchanges. For example, research with nursing students (Killam et al. 2012) identified a range of work-based placement concerns around patient care. Concerns include the endorsement of uncritical knowledge transfer (students applying their knowledge without assessing its relevance) due to hidden curricula, poor role modelling and educators being overwhelmed by role expectations. Furthermore, overt unsatisfactory clinical performance including student errors, failing to conform to clinical standards, lack of patient-centredness and poor student-patient communication were found. Finally, contravening practices (also known as professionalism lapses) were highlighted, including students practicing outside of their scope, covering up their mistakes, being given poor feedback and ignoring their educators’ guidance. Other research with medical, nursing and allied health students identified similar lapses in professionalism (Monrouxe and Rees 2017). Furthermore, students often report feeling disempowered to raise concerns about patient safety (Shaw et al. 2018), resulting in some patients experiencing adverse outcomes when students do not raise such concerns (Monrouxe and Rees 2017). Ultimately, such experiences not only threaten workplace dignity for students, staff and patients/clients (Klinner et al. 2024), but can also impact on the general quality of work-based placements.

Overall, there are ‘few systematic efforts to assess quality [of placements] in health disciplines’ (McAllister et al. 2018, 32). And despite an acknowledgement that university-industry-student interactions are central for ensuring quality outcomes for all (Henderson and Trede 2017), there is a paucity of research examining work-based placements’ quality across multiple stakeholder groups. We contribute to growing the evidence base about placement quality in allied health via this qualitative study of placement experiences of students, placement educators, university academic and professional support staff. We asked the following research question: What are university staff, placement educators’ and allied health students’ narrated experiences of work-based learning quality? From this investigation we develop recommendations for improving placement experiences for all stakeholder groups.

Methods

Study design

We undertook a narrative interview study, underpinned by a social constructionist framework (Rees, Crampton, and Monrouxe 2020). In doing so, we acknowledge the constructed nature of participants’ talk, which is not only shaped by their unique world experiences, but also by contextual constraints (e.g. power relations). The data presented in this article focuses on the narratives of participants’ personal experiences around work-based placement quality, which comes from a larger, mixed methods research project examining placement quality, safety and dignity.

Ethics

Ethics approval was granted by the University of Sydney Human Research Ethics Committee (protocol no. 2019/841).

Context

On a national level, the quality of work-based placements is under scrutiny in Australia (TEQSA 2022) and by equivalent regulatory agencies in other countries (e.g. Quality Assurance Agency 2018). Our study was conducted across a large, research-intensive Australian university and associated placement partner organisations (public and private) in which seven allied health disciplines across 13 undergraduate and graduate entry degree programmes are educated: diagnostic radiography, exercise sports science, exercise physiology, occupational therapy, physiotherapy, rehabilitation counselling and speech pathology. The placement units of study are mandatory, comprise an average of 22% of each degree programme, and are required by professional accrediting bodies to prepare students for practice upon graduation. Placement professional and academic staff work closely together in sourcing and developing around 4,500 placements per year and for preparing and supporting students and placement educators. As with all teaching academics in the School, placement academic staff receive a workload allocation largely based on the traditional teaching model of lectures and tutorials. Unlike some other universities in the Australian state of New South Wales, this university does not generally pay placement partner organisations per student for placements (although there are some exceptions). Table 1 defines the stakeholder groups in our study.

Table 1. Details of stakeholders involved in the study.

Stakeholder	Description
Students	Allied health students undertaking work-based placements
Placement educators	Allied health professionals who work at a placement organisation (e.g. hospitals, schools, residential aged care facilities, private practice), and who are responsible for supervising, mentoring and assessing students on placement
Academic staff	University staff involved in preparing students for placement, supporting students during placements, making academic decisions, and liaising with placement educators and sites
Professional staff	University staff involved in sourcing and allocating placements, ensuring students’ verification, and triaging student queries

Sampling

We adopted a stratified purposive sampling method inviting participants from three stakeholder groups (one of which has two sub-groups): students, placement educators and university staff (academic and professional placement support) from the seven allied health disciplines. Students were recruited via lecture shout-outs, announcements on learning management sites, and through snowballing. Students needed to have completed at least one placement to participate. Academic and professional staff were invited to participate via email. Both academic and support staff were asked to nominate up to 20 experienced placement educators per discipline from a range of public, non-government and private sector organisations, and nominees were invited to participate via email.

Overview of data collection

We held 33 sessions comprising 11 focus groups (between two to four participants) and 22 one-to-one interviews, totalling 51 participants (Table 2).

Table 2. Overview of participants.

Characteristic	University WIL staff		Placement educator	Student
	Academic	Professional
Age
Range	31–61	40–56	26–54	21–48
Mean	46	48	40	34.5
Gender
Female	12	5	11	17
Male	0	0	4	2
Discipline
Diagnostic radiography	3	0	0	3
Exercise sports science & exercise physiology	1	0	2	0
Occupational Therapy	1	0	5	3
Physiotherapy	3	0	4	0
Rehabilitation Counselling	0	0	1	0
Speech pathology	2	1	3	13
Cross disciplinary	2	4	0	0
First language
English	11	5	14	12
Non-English	1	0	1	7
Domestic student				14
International student				5
Totals (n = 51)	12	5	15	19

Thirty-one sessions were facilitated by CK, two were facilitated by AB: neither of whom had any prior relationship to the participants. A semi-structured interview guide, with questions and prompts, enabled participants to narrate their lived experiences where work-based placement quality was upheld and compromised. Participants were also asked for suggestions to improve placement experiences. All sessions were audio-recorded, transcribed by an external transcription service and anonymised prior to analysis.

Team reflexivity

The research team comprised work-based placement academics together with two researchers who were not placement staff, providing a mix of insider and outsider perspectives. We brought a variety of disciplinary backgrounds to the project: psychology (LVM), hospital management (CK), higher education (AB), occupational therapy (MP), public health (DS), physiotherapy (AD), and dietetics (GN), as well as a range of experience with qualitative research, from expert to novice. We drew on this range of experience as we discussed and debated interpretations of the data.

Data analysis

We used a team-based primary-level framework approach (Ritchie and Spencer 1994) to determine themes. All authors read a subset of the transcripts and collectively discussed their ideas on themes within the data. LVM and CK developed the initial framework for coding with input from the wider team. The unit of analysis comprised participants’ personal incident narratives. These were identified and coded by CK, with feedback from LVM, using the qualitative software ATLAS.ti (2021). LVM and CK collaboratively developed the final coding framework. This process and the collaborative writing up of results enabled us to further explore and develop themes.

Results

We identified four key aspects that impact placement quality, resulting in the following themes (1) University preparedness, (2) Placement Site preparedness, (3) Placement educator preparedness, and (4) Student preparedness. Each theme is further categorised into sub-themes, and these are summarised in Table 3. We present the themes and sub-themes, with relevant excerpts from participants’ narratives, using a unique identifier code denoting participant group [The two University staff groups of work-based placement Academic = WA, work-based placement Professional = WP; Placement Educator = PE; and Student = ST] alongside the participant number. As we do so, we identify which group of participants contributed to the sub-themes.

Table 3. Summary of themes and sub-themes.

Domains	Themes
University preparedness	Placement shortages Staff time Simulated placements Student learning plans
Placement site preparedness	Structured organisational processes and roles Placement educator workloads Availability of physical space Intercultural capability
Placement educator preparedness	Attitudes, motivation and competence Efforts to integrate students into the team Constructive feedback Professional learning
Student preparedness	Professional attitude and commitment Intercultural capability Communication skills Feedback literacy Mental health

Theme 1: university preparedness

This theme considers participants’ perspectives of the extent to which the university is prepared, and prepares for, work-based placements. It includes the sub-themes: placement shortages, staff time, simulated placements, and student learning plans.

Placement shortages

Focusing on structural concerns, both placement Academic and Professional staff participants described the pressures of sourcing sufficient placements:

‘We always have a shortage of placements, it is always a scramble. … We are always worried about not graduating our students … because we have such huge student numbers.’ [WA_#8]

Having insufficient placements was felt to potentially compromise quality. Participants spoke of some placements being accepted on trust due to limited time to establish a working relationship between placement organisation and university, and to ascertain the potential for quality learning experiences.

Staff time

Placement academic and professional staff participant groups, and sometimes student participants, mentioned workload concerns, asserting that university staff had insufficient time to adequately undertake their roles. Placement academic staff expressed that the workload allocation designed for a traditional teaching model (e.g. lectures, tutorials) was misaligned with their work structure, with important elements of ensuring quality placements not being well accounted for in the workload allocation. This included time to source placements, as well as providing academic support for students at risk of failing placements, placement site-specific issues and students’ mental wellbeing:

‘[An issue that has] a pretty significant impact on our time is student mental health … I spend a lot of time … supporting students … every placement block … there will be at least one or some students affected.’ [WA_#8]

Placement academic and professional staff participants reported working additional unpaid hours to manage the overwhelming workload, and narrated regularly feeling frustrated, unsupported and stressed. Student participants, in turn, narrated that university staff were often stressed and time-poor, and therefore only approachable in an emergency:

‘I know that I can talk to them via email, but they don’t typically respond quickly … they’re really stressed out and they have to organise all these placements for us, and we need to stay out of their way … ’ [ST_#17]

Simulation and placements

In terms of the university preparing students for placements, on-campus simulated clinical experiences that occur prior to external placements were discussed by all participant groups as a mostly positive way for students to prepare for placements:

‘I love the fact that the students come having done a simulation clinic now … what a great thing for the students to be able to have that ‘real life’ experience in a safe environment …  That can help the students come in with the confidence they need to be able to approach clients.’ [PE_#11]

Student participants valued interprofessional learning opportunities in the simulated environment. However, while the simulated environment was deemed technically safe, some felt it was less psychologically safe. Some student participants requested smaller, less culturally diverse learning groups, a greater number of sessions and simulation experiences dedicated to student-placement educators’ communication. A few student participants criticised the ‘undiscerning marking scheme’ of some assessments. These participants wanted more time to observe educators or undertake tasks under guidance before being assessed, and to have more time to experiment:

‘I just needed a bit more time to process … I felt I didn’t have that opportunity to make my own call rather than having the supervisor make the call for me … I didn’t feel like it was a super safe environment for me to test the things that I wanted to … that made me a little bit stressed … I know it’s supposed to be a very safe environment, but it didn’t feel very safe to me’ [ST_#14]

Student learning plans

A positive aspect of university preparedness was the placement learning plans. These were highlighted by student and placement educator participants as being a useful tool to clarify placement expectations, and goals including client contact. Learning plans were part of placement processes for some disciplines but not all. In the example below the educator is referring to a learning plan that they had personally developed:

‘I feel it’s all about setting the expectation with students … when you’ve got [a learning plan] in the beginning setting those expectations you can refer back to it, you’re not setting the expectations when something is already going wrong … it’s easier to have those discussions about how it impacts their performance across the placement’ [PE_#11]

Other in-kind resources provided by the university to placement educators were also highlighted by participants (except the student group) as positively impacting the quality of placement experiences. These included educator workshops, summarised deidentified student feedback following placements, library access and research opportunities.

Theme 2: placement site preparedness

In this theme, we report participants’ narratives around the ways that placement site preparedness impacted placement quality, covering the sub-themes: structured organisational processes and roles; placement educator workloads; availability of physical space; and intercultural capability.

Structured organisational processes and roles

Placement educator participants highlighted how organisational agendas and structures shaped rationales for hosting students. These, in turn, impacted the quality of students’ placement experiences. For example, an organisational culture of viewing student placements as a burden led to a negative learning environment, while conversely viewing student placement as a benefit led to better student learning and better patient/client care. Ideally, for a quality placement, an organisational ‘fit’ between university and workplace goals was considered necessary:

‘[we’ve] worked a lot over the last couple of years around working with departments and educators … shifting that thought process of students being a burden and it’s an obligation to take them and train them and moving towards actually the benefits of having students on placement, obviously around developing and developing the workforce, but also what the benefits they have to our patients and the services that we’re providing as well … ’ [PE_#3]

Student and placement educator participants talked about structured organisational processes that facilitated a quality experience. This included pre-placement communication between students and placement educators, student handbooks, inductions, orientations, and ‘exit’ meetings. Some organisations developed a culture of professional development around placements by encouraging educators to access training and support provided by the university, and focusing on continual improvement:

‘We always have that culture that everyone can improve at what they’re doing … as part of our performance reviews and as part of our monitoring we would have skills or tasks or areas that each of those educators needed to improve on’ [PE_#2]

Placement educators from larger sites reported employing clinical education coordinators who were either free from, or had a reduced, clinical load to focus on workplace education. Their work included training and support of early career educators and streamlining administrative aspects. Placement educator participants who had this role at their institution identified it as extremely beneficial in facilitating quality placements:

‘There would be multiple times where we have been involved as managers or senior placement educators to review placements and provide opportunities to step in and address areas where we were concerned about quality.’ [PE_#2]

Placement educator workloads

At some placement sites, student participants narrated their experiences around the construct of providing free labour, which they claimed came about due to placement educator work overload, and a mismatch between students’ and placement educators’ expectations. In such situations, participants expressed concerns about the safety of their patients/clients, their own safety (e.g., being left alone with aggressive patients/clients) and not being provided with feedback for improvement:

‘They didn’t replace the [sick] worker, they just made me do everything because it was free labour … It went on for the duration of that placement … my work wasn’t being checked … I just didn’t get the critique, the encouragement to spot out what’s wrong, what’s right and fix it so it’s better next time.’ [ST_#9]

Indeed, some placement educator participants reported difficulty finding time to supervise students alongside their usual clinical load. Further, a few student participants reported receiving little or no support or unclear instructions/feedback from their placement educator, leading to their learning progressing in a slow or uncoordinated manner:

‘My supervisor was doing shift work as well, so I found myself a lot of the time I wouldn’t have anyone to go with … I was a bit lost while I was on the whole placement … I wasn’t really learning any of those skills … I was missing out on that quality of learning.’ [ST_#5]

Placement educator participants discussed ways in which they mitigated educator availability issues. This included supervising students in groups and co-supervising with colleagues during busy periods. When educators successfully managed their workload, students saw them as positive role models regarding time management.

Availability of physical space

Placement educator and student participants also highlighted the availability of physical space as important to placement quality. This included dedicated spaces where students can work and meet other students, and spaces where placement educators and students can confidentially discuss student progress:

‘No one else can come in, so you do get that complete privacy and you can talk about pretty much anything like your challenges, your performance, your fears, what you want to do, what you want to try.’ [ST_#14]

Intercultural capability

Student and placement academic participants narrated how some students felt unwelcome or were treated differently to others, particularly culturally and linguistically diverse (CALD) students. Several explanations for this were suggested, including a lack of cultural capabilities on the part of individual educators or sites, educator frustration with students who were quiet and seemingly disengaged, and a perception that CALD students place a strain on clinicians due to extra workload:

‘One particular issue that I’m dealing with at the moment is … a site that I guess we have now identified as not being particularly culturally competent … so many Asian students that we send to that site end up failing, all of our Western students seem to be completely fine … bringing those students in and debriefing the situation … [they say] anyone who doesn’t fit into that loud, very social element just won’t be talked to and will be shunned and that they are not as interested in teaching them if they’re not fitting into the department socially.’ [WA_#7]

Theme 3: placement educator preparedness

Here we consider the preparedness of placement educators for their role of supervising students, which has some overlaps with the theme above. The sub-themes are: placement educator attitudes, motivation and competence; efforts to integrate students into the team; constructive feedback; and professional learning.

Attitudes, motivation and competence

All participant groups reported that high quality learning experiences are associated with placement educators’ attitudes and motivation towards this role as well as their competence in the role. Student participants reported enjoying their placement, and becoming clinically competent, confident and committed to the profession when they learned with well-prepared, highly competent practitioners who embraced their role as educators. Conversely, they reported poor quality learning experiences when placement educators lacked preparedness, competence or motivation for their educator role:

‘I can understand where they're coming from … they’re coming from the point of view that they don't get paid to teach students, so what's the point? … I don't think they hate students … they would prefer not to have students but, but they're just stuck in a situation where students come because the boss asked them to come … they are just handed the students.’ [ST_#18]

Efforts to integrate students into the team

All participant groups narrated how providing a supportive and professional learning environment was an active process stemming directly from placement educators’ efforts to actively integrate students into the team. This process involved educators ensuring students’ physical safety, treating them with respect, being calm, patient, caring, friendly, and empathic. It also involved educators helping students learn from their mistakes, valuing students’ opinions, setting clear expectations, scaffolding students’ learning, and providing resources to facilitate students’ self-directed learning:

‘We go to a lot of effort to include our students in meetings … in social events … in the day-to-day workings of our department … [A student] made a really big mistake with a patient … She felt comfortable enough to go to one of the other therapists that was in the room … That therapist was lovely to her and looked after her and worked through a solution which she enacted. [PE_#6]’

Constructive feedback

The ability of placement educators to provide constructive feedback was emphasised mainly by student participants, but with a few comments from placement educator and academic participant groups, as key to creating a safe and supportive learning environment. Student participants narrated the need for placement educators to ensure that feedback is confidential, clear and delivered respectfully to enable their understanding of how to improve. When feedback was delivered in this way they reported feeling valued and supported in their learning:

‘I loved my PE [placement educator], he was so supportive, he gave really honest but constructive feedback. Everything that he told me that I could improve on, I agreed with him, I thought that he could give it [feedback] to me in such a well-articulated way that I didn’t feel like I’m really struggling.’ [ST_#6]

Student participants narrated feeling negative emotions (e.g. disheartened) when they received feedback that was not constructive: ‘[the feedback] didn’t tell us what we should have done and how to improve’ [ST_#14]. This was also seen as problematic when negative feedback was delivered using snide comments, gestures – ‘clicking her fingers in my face’ [ST_#2] – or given in front of others. While there were placement educator participants who narrated situations in which they constructed students as thriving on learning by humiliation, no student participant echoed this:

‘I don’t know if they were told off, but basically told that they did the wrong thing in a public forum, in front of their patients and other students as well … My perception of that is that they’ve just become such a negative environment for the students to actually be learning and progressing and they kind of split their cohort really, so there were students who really thrive in that environment versus students who really struggle in that environment.’ [PE_#3]

Professional learning

Placement educator preparedness was considered a learned skill by all participant groups, who pointed out that skills required for good patient care do not always directly translate to facilitating student learning:

‘There’s an irony in the fact that [discipline] learn how to structure learning for their clients … in terms of ‘I’m going to pitch the session at this level, if the client can’t get it I’m going to step down and I’m going to give [them] a little bit more support … ’ It’s so ironic that … for some reason there’s a disconnect [when educating students].’ [ST_#2]

Student and placement academic participants talked about including clinical teaching and supervision skills in the university curriculum to prepare future placement educators (this links to theme one, University Preparedness). Some placement educator participants narrated how education practices had changed over time, and talked about their desire to learn about novel educational approaches for effective supervision, such as placement learning models that include group supervision and greater student responsibility for patients/clients. Conversely, others felt that supervision competence came with ‘just having more experience, more exposure’ [PE_#8]. Student participants, however, perceived their placement educators needed to learn how to be educators, rather than relying on on-the-job learning.

Theme 4: student preparedness

This theme focuses on narratives of student preparedness for placements, with sub-themes of: professional attitude and commitment; intercultural capability; communication skills; feedback literacy; and mental health.

Professional attitude and commitment

Placement educator and academic participants narrated the importance of students having a professional attitude and commitment to their placement learning. Students who demonstrated these qualities showed that they viewed their placements as a meaningful aspect of their studies, followed university, site and educator instructions, and were polite, respectful, punctual and well presented. When presenting themselves in these ways, students were highly appreciated by placement educators:

‘They were just a bit of a breath of fresh air, they were very professional, very courteous, turned up on time, they really were a breath of fresh air.’ [PE_#5]

Multiple placement educator and academics narrated students’ lack of professionalism that included students breaching patient/client confidentiality and failing to obtain consent to physically examine patients/clients:

‘What was perceived, particularly by a couple of the older patients, not to be consent taken, or ‘why does this student need to be oscillating my chest’ for one example, ‘just pulled my shirt up and oscillating my chest, didn’t talk to me about what it was’’ [PE_#2]

Intercultural capability

Problems with professional behaviour were sometimes linked with students’ cultural backgrounds in narratives by placement educators and academics, where different professional values and a more pronounced professional hierarchy may be present:

‘A lot of them come from countries where if a medical practitioner asks you to do something, then you just do it … The concept of the therapeutic relationship and building rapport with your patients is not such a big concept, whereas in Australia that’s definitely an expectation … Some students really struggle … concepts of consent are really different.’ [WA_#7]

Student participants also narrated different cultural values and professional behaviours, and called for a dialogue between themselves and their clinical educators to build shared understanding:

‘I’m an international student, I come in with different views and different perceptions of what we do in healthcare … over here they get a lot more time with each patient, but I’m brought up from, if I see a doctor … they don’t talk to me for such a long period of time. So my experiences shape how I would perform and it’s going to be different … Let us explain our side of why we perceive it this way or why we did that rather than just saying, ‘it should be done this way’.’ [ST_#14]

Communication skills

Effective communication skills were highlighted in all participant groups’ narratives as a fundamental element of student preparedness for placement learning and maintaining professional relationships with staff and patients/clients. Students with effective communication skills were considered to be better integrated into clinical teams, included in more complex therapeutic interventions, entrusted with leadership roles (under supervision), and integral to positive patient/client outcomes:

‘One of the students was actually a really high performer … excellent communication … [the team] extended them a little bit more … one particular patient was a young person with significant injuries … they [student and patient] had similar interests, they had built that connection. In a true rehab environment, you build on those connections … it was an excellent learning opportunity … [and] provided an awesome outcome for that patient.’ [PE_#2]

Placement educator and academic participants linked professional communication skills to students’ level of confidence and cultural background. This had varied impacts such as willingness to engage in therapeutic relationships with patients, verbal engagement with people of different genders, and speaking appropriately with patients/clients (e.g., not being abrupt). Students’ ineffective communication skills were attributed as contributing to negative learning outcomes, emotional distress for placement educators, academics, and professional support staff, as well as patient/client dissatisfaction.

Placement educator and academic participants narrated situations in which students who had difficulties with spoken and written communication in English also had issues in other areas relevant to learning and contributing to clinical practice. These included: fitting in with the team socially; displaying empathy with patients; asking questions; and developing confidence. Students who had difficulties with communication skills were viewed as withdrawing from engaging in placement activities. Placement educator and academic participants also narrated how such difficulties impacted on placement educator workload, and on patient/client care:

‘I had significant concerns around that [student’s] language competency … I had a whole range of different strategies to try and get them to be able to accurately interpret information from people from different cultures because their … understanding in English was not good enough to deal with the subtleties of history taking from people from other cultures who were speaking English. … they weren’t taking the right information down.’ [PE_#2]

Feedback literacy

Students’ feedback literacy was also raised by placement educator and academic participants as impacting their preparedness. They talked about the need for students to be better prepared to recognise, reflect, and act on all the types of feedback (self, peer, patient and expert) that arose in clinical settings, rather than relying solely on explicit educator feedback. A lack of feedback literacy was narrated by them as contributing to students’ perceptions that they did not receive sufficient feedback:

‘A lot of students get to the end of placement and say, ‘well I didn’t really get much feedback’ and they won’t recognise all the feedback that they've had … not just, ‘I’m sitting down, I’m giving you formal feedback’.’ [PE_#6]

Placement educator participants recounted how some students constructively engaged with feedback to improve their performance while others avoided reflexive engagement:

‘[the student] was of a Chinese background … she explained to me that in her culture you just accept everything that is told to you, you don’t question anything … she did mention that every time she thought of getting feedback or self-reflecting it was a negative thing. So it was just easier for her not to do those things, to ignore them … Anything you said just came off as, ‘you didn’t do this right’ … We got there in the end.’ [PE_#1]

Students’ poor feedback literacy was reported by placement educator and academic participants to contribute to a number of consequences, including: students failing the unit of study, placement educators’ reluctance to continue offering student placements, and patients being on the receiving end of poor treatment, poor communication and unsafe practice.

Mental health

A number of narratives from all four participant groups centred on students’ mental health and wellbeing. Placement educator, academic and professional support staff participants talked about ‘a significant increase’ [WP_#4] in recent years in the number of students with mental health issues. Students having the skills to manage their mental health was highlighted as a key requisite for their placement preparedness:

‘[students need to learn more] … about looking after yourself on a placement … work life balance [and that] ‘you’re going to experience traumatic things on a placement’ or ‘there might be something on a placement that brings up something from your personal history that might trigger you, how do you look after yourself?’.’ [PE_#14]

Pre-existing issues around students’ mental wellbeing were exacerbated by placement stressors such as challenging clinical encounters, unsupportive placement educators, feeling physically unsafe (e.g., during COVID-19), failing, or being ‘at risk’ of failing, and being on a remote placement away from usual supports. Student participants’ narratives contained a plethora of negative emotional talk about being on placement, for example: ‘very stressful … anxieties and worries and fatigue … depressed’ [ST_#8]. Student participants also discussed ways in which some placement educators supported them through their mental health issues by helping them to build uncertainty tolerance and access wellbeing strategies.

Discussion

This research contributes to understanding the importance of preparedness for healthcare work-based placements through narratives from three stakeholder groups (one with two sub-groups): students, placement educators and university staff (both academic and professional placement support staff) across seven allied health disciplines. Aligned with others, including Hains-Wesson and Ji (2024) and Jackson (2024), we identified placement preparedness as a key factor determining work-based placement quality. We strongly concur with Campbell and Pretti that each stakeholder has shared responsibility ‘in contributing towards quality WIL’ (2023, 350), with universities, placement sites, placement educators, and students being collectively responsible for ensuring preparedness.

Our findings also highlight the areas where perspectives from the four stakeholder groups converge and diverge, summarised in Table 4. Two examples of divergent perspectives include feedback literacy and intercultural capability. Students emphasised their desire for constructive feedback to support quality learning on placement, and yet according to placement educators and academics, many students did not display feedback literacy. Feedback literacy, where students recognise feedback in all forms, manage affect, and take an active role in engaging with feedback (Carless and Boud 2018), is an area of growing interest across higher education. Our findings suggest that students are not always aware of how best to make use of the various types of feedback available to them on placement. We contend that this points to a gap in preparation by universities – helping students develop feedback literacy, and more broadly, learning how to learn on placement.

Table 4. Summary of similarities and differences between stakeholder group narratives.

Themes	Key similarities and differences between stakeholder groups
University preparedness
Placement shortages	Academic and professional staff concerned
Staff time	Academic, professional staff and students concerned
Simulated placements	All agreed beneficial, students had some concerns
Student learning plans	Students and placement educators agreed these are useful
Placement site preparedness
Structured organisational processes and roles	Students and placement educators agreed these have a big impact on quality
Placement educator workloads	Students and placement educators expressed concerns and ways to mitigate
Availability of physical space	Students and placement educators discussed importance
Intercultural capability	Students and academics concerned about lack of site intercultural capability
Placement educator preparedness
Attitudes, motivation and competence	All groups discussed impact of positive and negative placement educator attitudes
Efforts to integrate students into the team	All groups discussed the importance of integrating students into the team
Constructive feedback	Students, placement educators and academics discussed the importance of constructive feedback. Students said that they value confidential, clear, respectful feedback and expressed concerns when this did not occur
Professional learning	Students, academics and placement educators discussed the importance of placement educator professional learning, with most agreeing that placement education is a learned skill
Student preparedness
Professional attitude and commitment	Placement educators and academics agreed that students’ positive professional attitudes were associated with positive placement experiences (and conversely for negative)
Intercultural capability	Some placement educators and academics linked students’ professionalism issues with their cultural backgrounds, whereas students called for dialogue to increase intercultural understanding
Communication skills	All groups agreed that communication skills are fundamental, with some placement educators and academics linking students’ cultural backgrounds to lack of confidence in communication
Feedback literacy	Placement educators and academics were concerned about lack of student feedback literacy
Mental health	All groups agreed that student mental health is of increasing concern, with students narrating stressful experiences and avenues for support

Intercultural capability was another area where stakeholder perspectives diverged, with placement educators and academics sometimes veering towards a ‘blame the student’/student deficit approach (Smit 2012), particularly with CALD students. For example, in some narratives there was a tendency for educators to view students from a Confucian education system as reticent to ask questions or to be proactive, which has also been found in other studies (e.g. Heng 2018). Educators in Asian cultures are accorded high respect, however, this is not to say that student-educator relationships foster obedience, rather that students are expected to develop warm relationships with their educators (Wang 2016) with educators being expected to become mentors, displaying harmony, closeness and empathy. Thus, students’ question-asking behaviours are likely to be entrenched with saving face considerations (i.e. to avoid public embarrassment) for their educators and themselves. Indeed, Asian students are known to report being afraid to look ignorant to their superiors (e.g. Zingoni and Byron 2017). And it is not just Asian students who fail to challenge their seniors. Recent research examining if 2,307 medical students from 16 countries contest hierarchical order (Monrouxe et al. 2022). found an interesting country-by-gender clustering suggesting an even more complex interaction of socialisation factors are at play than just Asian vs non-Asian, Eastern vs Western and so on. We therefore encourage all placement stakeholders to take a strengths-based view of diversity. CALD students are better able to understand the perspectives of CALD patients/clients and can contribute to services in ways that monolingual students cannot, for example by contributing to peer and educator learning about diverse perspectives on healthcare and social needs (Bell et al. 2022). We do not intend to dismiss the issues of communication skills and cultural understanding among CALD students that have been raised by participants in our study, which have also been found by others (e.g. Gribble, Blackmore, and Rahimi 2015; Jackson 2017). Instead, we contend that placement educators, students, and university staff need to have frank conversations about these issues. Persistent stereotyping, such as the belief that ‘all students from X background behave in Y manner,’ must be challenged. One student in our study suggested a dialogic approach between students and educators to discuss cultural differences, which can help develop mutual understanding. Placement educators and university academic staff are usually registered health professionals, and as such, guided by professional competencies and standards, they are required to provide culturally responsive client services. Therefore, it should not be a significant leap to extend this consideration to their education of students.

In some cases, divergent perspectives are due to differences in roles in, and expectations of, placement experience. Overall, we argue that it would be beneficial for each stakeholder group to gain a better understanding of each other’s perspectives to bring varying viewpoints closer together. We note that while preparedness for allied health placements is a collective endeavour, some participants tended to take an individualistic rather than systemic view, with a focus on individual educator or student behaviours rather than the systems and factors influencing such behaviours. There are systemic barriers that impact the ability of all stakeholders to fully prepare for high quality placements. As in our study, Kinsella and colleagues’ (2008) study of occupational therapy students identified systemic constraints that affect placement experiences, such as insufficient staffing and high caseloads. Everyone involved in work-based placements needs to be attuned to the contextual factors that impact placements, such as staffing cuts and restructures at placement sites and universities, and workplace cultures that tolerate overwork, sexism, and racism. Importantly, leadership of both universities and placement sites should recognise these systemic issues and actively participate as champions of change, so that such challenges are not left solely to frontline staff.

Failures in preparedness create a cyclical problem for placement quality. If the university, students, sites or educators are not well-prepared, this impacts the placement experience of all stakeholder groups: students tend to have suboptimal learning experiences, sites may be reluctant to offer placements in the future, and university staff are too occupied ‘putting out fires’ to have time to develop preparedness initiatives. We therefore present below a series of practical recommendations aimed at improving placement quality through a focus on preparedness.

Practical recommendations

We have developed four key practical recommendations based on our study findings, and with the view that placement sites, placement educators, university staff and students are collectively responsible for preparing for placements:

1. Review and further develop curricula to ensure students are prepared as agentic learners (Billett 2009) for the complexities of the workplace, with a focus on professionalism, communication, feedback literacy, and wellbeing;

2. Invest in the continuing professional development of placement educators, covering topics such as feedback literacy, understanding placement learning models, how to support agentic learning, and viewing student diversity as a strength;

3. Ensure that the range of work associated with work-based placement activities is adequately resourced so staff can allocate sufficient time developing preparedness initiatives. Also, placement experiences and supervisory arrangements should be monitored for quality assurance and risk management;

4. Harness a partnership approach where all parties work together for the benefit of allied health service users. A focus on mutual value will shift the narrative towards students as a benefit rather than a burden (Nisbet et al. 2023).

We discuss each of these in turn below.

Preparing students to be agentic learners

Placements are usually less structured and more complex than on-campus coursework units. Students may therefore experience a gap between theory and practice – ‘areas of dissonance between what [students] learn in the classroom and what they experience in clinical practice’ (Dutton and Sellheim 2017, 61). Billett (2009, 836) proposes the concept of ‘students as agentic learners’ as one way to reduce these dissonances and improve placement quality. Universities need to prepare students to be agentic learners – this includes how to deal with difficult situations, how to learn from peers and professionals, how to ask questions, how to recognise feedback and how to learn from mistakes (Nagarajan and McAllister 2015).

Professional development for placement educators

In many cases, placement educators are not required to have any prior professional development before supervising students, and ‘their ability to create [an] optimal environment for placement learning is not routinely and systemically observed, monitored or evaluated’ (Quigley et al. 2020, 508). In our own team, we have adapted the in-person workshops we offer to placement educators to an online modular programme, to allow greater flexibility and access, and provide options for both new and experienced educators. Such programmes can be a valuable investment to increase placement educators’ understanding of educational principles, develop students’ feedback literacy, and learn how to design learning activities and create environments (Burgess, van Diggele, and Mellis 2019) that support students to be agentic learners. We believe these programmes may also strengthen connections between universities, their staff, and the placement organisations and their staff.

Adequate resourcing and evaluation

Work-based placements need to be adequately resourced and evaluated for quality assurance and risk management. All stakeholders involved – academic and professional university staff, placement educators and placement sites – need adequate time and resources to focus on preparedness. Partnership initiatives, as outlined below, take time to develop, and quality evaluation requires resourcing.

A partnership approach

A deficit view of students is likely to result in viewing students as a burden, rather than as a benefit to clients/patients and the organisation. We need to ‘re-imagine the purposes and practices of clinical placements for the mutual benefit of patients, health services and students’ (Nisbet et al. 2021, 45) and use a co-design process to develop placements where ‘students … learn through enabling improvements in service delivery’ (ibid, 50) and feel ‘useful not used’ (ibid, original italics, 51). A partnership approach is our key recommendation for improving placement quality and for ensuring that any divergent perspectives/experiences are understood and addressed via collaboration and dialogue.

Strengths and limitations

The strengths of our study include the large number and variety of participants from four healthcare work-based placement stakeholder groups, rich narrative data, and our interdisciplinary, team-based approach. One limitation is that the placement experiences discussed are associated with a single university. Having said this, many of the placement organisations also host students from other universities in the vicinity and the placement educators we spoke with were not asked to focus on specific student groups, and so may have been drawing from a range of experiences of students from different universities. We therefore consider our findings may have applicability beyond a single institution. Another limitation is that we did not include patient/client perspectives which would have gleaned insights into how they perceived placement quality issues (e.g. Monrouxe, Rees, and Bradley 2009). Furthermore, our sample was almost 90% female. However, this reflects the predominance of women in many of the allied health professions (Schofield 2009). In addition, we note that while some disciplines were represented by higher participant numbers than others (e.g. speech pathology with 19 participants compared to one for rehabilitation counselling), in our experience allied health placements have many commonalities across disciplines.

Conclusion

Healthcare work-based placement quality is a concern for placement educators, students, placement organisations, professional bodies and universities. Our paper contributes to the understanding of placement quality through qualitative findings from 51 participants across four stakeholder groups. We identified placement preparedness as a key theme impacting placement quality, with universities, placement sites, placement educators, and students collectively responsible for ensuring preparedness. We highlight areas where stakeholder perspectives diverged and how these gaps might be bridged. Our practical recommendations focus on preparing students to be agentic learners, promoting placement educator professional learning, and co-designing placements that benefit both placement sites and students. We also highlight the systemic and contextual factors that impact on university, student, and organisational placement preparedness.

Acknowledgments

We thank Peter Hockey and Claire Hooker for their valuable input earlier in the study and all participants for sharing their experiences with us so candidly. We also thank the Work Integrated Learning academic team and the #thesisthinkers group for their discussion of some of the concepts in this paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This project was funded by a University of Sydney Quality Development Grant and a University of Sydney Educational Innovation Grant with financial support from the Western Sydney Local Health District Research and Education Network.