Events and experiences shaping a sense of belonging in rural and remote healthcare placements: a scoping review

Introduction

A sustainable rural workforce plays a crucial role in the healthcare system of any country where rural health access is challenging, including developed countries^1-7. However, recruiting healthcare professionals to rural and remote areas remains a persistent challenge^8,9. Factors such as the insufficient presence of healthcare professionals in rural areas, limited training prospects, concerns about social and professional isolation and restricted job opportunities for significant others impact the decision-making of current and aspiring healthcare professionals^10-15. Australia, like other countries, has undertaken proactive measures to enhance the rural healthcare workforce in response to the current crisis¹⁶. These measures include diverse career growth opportunities, financial incentives such as moving expenses and bonuses, and specialised positions aimed to bridge this workforce gap¹⁷.

In 2010, the WHO proposed a worldwide policy to improve access to health workers in remote and rural regions by enhancing retention¹⁸. The recommended strategies included educational initiatives, regulatory measures, financial incentives, and personal and professional support¹⁸. Various policies, initiatives and studies have been employed to facilitate the recruitment and retention of healthcare professionals in rural and underserved areas. These include the establishment of rural clinical schools, relocation allowances, financial bonuses, recruiting students from local rural and remote areas, creating conducive conditions for health providers, in-kind benefits (free accommodation or vehicle), relevant rural learning experiences, and incentive-based strategies with regional, state or provincial government backings^19-24.

Professional identity formation is crucial in healthcare education, shaping how students think, act and feel as professionals²⁵. It helps them find meaning in their work and supports long-term wellbeing. Professional identity formation involves developing values, attitudes and behaviours, and aligns with professional norms²⁶. In rural health care, a strong professional identity can improve retention by fostering a sense of connection and commitment²⁶. Strategies to support professional identity formation include mentorship, reflective practice and a supportive learning environment²⁵.

The Australian Government’s commitment to sustained funding in rural medical education aims to enhance the likelihood of rural area retention among medical students upon graduation^11,27,28. Rural clinical schools provide intensive clinical training to undergraduate medical students, grounded in practical experiences within hospitals and community-based settings within a rural and remote region²⁰. These schools offer high-quality medical education in rural Australia, allowing students to complete their entire medical program at rural campuses in various locations^20,29.

Extensive research associated with undergraduate medical health professionals has extended to other healthcare professionals^27,28,30,31. This has led to the introduction of the Rural Health Multidisciplinary Training Program, which aims to improve retention and recruitment of medical, nursing, allied health and dental professionals in rural and remote Australia³².

For nursing and allied health professionals, such as dentists, dieticians, physiotherapists and Aboriginal Health Workers, workforce initiatives have primarily focused on rural communities cultivating their own healthcare professionals^33,34. Research has underscored the importance of augmenting students’ clinical exposure in rural settings^13,14,16. Policymakers have recognised the need for more ‘high calibre’ extended rural placements for nursing and allied health students to bolster rural workforce recruitment and retention^35-37. Research has demonstrated that a favourable rural placement encounter enhances a student's willingness to return to practice in rural areas and influences future career intentions^35,37-39. The positivity of a rural placement experience often stems from the feeling or sense of belonging during the placement period⁴⁰. Scholarly work focusing on nursing students suggests sense of belongingness significantly impacts the learning journey of nursing and midwifery students, and a sense of belonging remains a critical factor to be considered^40-43.

Levett-Jones et al define belongingness as an intrinsically personal and contextually influenced phenomenon that develops in reaction to the extent to which an individual perceives (1) being secure, accepted, included, valued and respected by a specified group; (2) being connected with or essential to the group or community; and (3) an individual’s professional and personal values align with those of the group⁴⁰. The concept of belonging is described as an individual's engagement with a group or framework that is characterised by feelings of being appreciated, required or embraced by a group³¹. Several studies have sought to explain the relationship between positive clinical placement experiences and a sense of belonging. For example, supportive learning relationships within a clinical team are key for healthcare students to feel they have a place within that team⁴⁴.

However, limited research explores the relationship between a sense of belonging from community involvement and activities and its contribution to the future rural and remote workforce. Therefore, workplace relationships are critical both inside and outside the workplace^44,45. Developing a sense of belonging within the community environment is vital. This scoping review aims to explore what events and experiences influence medical, nursing and allied health students’ sense of belonging in rural and remote communities while on clinical placement. For this review allied healthcare professionals who undertake rural placements include nutritionists and dietitians, occupational therapists, medical radiation scientists, diagnostic radiographers, speech pathologists, physiotherapists, pharmacists, podiatrists, dentists and social workers as outlined by Allied Health Professions Australia⁴⁶. The term ‘allied health’ will be used from here on unless otherwise specified.

Methods

Study design

A scoping review was undertaken according to the Joanna Briggs Institute (JBI) scoping review methodology⁴⁷ and using the Preferred Reporting Items for Systematic Review and Meta Analysis for Scoping Reviews (PRISMA-ScR) reporting guidelines^48,49. The JBI System for the Unified Management, Assessment and Review of Information (SUMARI) is an online tool designed for a wide range of healthcare professionals, including nurses, to assist in conducting literature reviews by guiding them through each step, from planning to final report writing as methods to improve evidence-based practice and patient care⁵⁰. Overall, this approach was appropriate due to the significant body of knowledge on sense of belonging within the clinical environment, contrasted with the limited understanding of students’ sense of belonging outside the clinical environment^51,52. Therefore, the purpose of the scoping review was to broadly examine the literature to identify, map and provide key insights and potential gaps of the phenomenon^48,53.

Search strategy

A preliminary search of PROSPERO, MEDLINE, JBI Evidence Synthesis and Cochrane Database of Systematic Reviews revealed no current or in-progress scoping reviews focused on our aim. With the support of a content specialist librarian, between 1 February and 29 February 2024 we searched five electronic databases. The timeframe for published articles was set between 1995 and 2024, aligning with the introduction of the rural clinical schools through the Australian Government’s Rural Clinical Training and Support program¹⁹ and the 2010 WHO policy to enhance the rural workforce¹⁸. The databases searched were CINAHL (via EBSCOhost), APA (American Psychological Association) PsycInfo, PubMed (via Ovid), ProQuest and Informit Health Collection. We also hand-searched the reference lists of all articles extracted for full-text review.

Search terms

Key search terms included, but were not limited to, "Students, Health Occupations" OR 'Allied Health Personnel" OR 'Dentist' OR "Nurse" OR "Nutritionist" OR "Occupational Therapist" OR "Pharmacist" OR "Physical Therapist' OR "Physician" OR "speech pathologist" OR "social worker" OR "Aboriginal health practitioner' AND 'Placement' OR 'work integrated learning' AND 'Rural' OR 'Remote' AND 'Social*' OR 'Communit*' OR 'Connect*' OR 'Belong*'. Additional keyword combinations used in this review are provided in Appendix I. An exemplar of the search strategy used in PubMed is provided in Appendix II.

Eligibility criteria

We included reports on rural and remote student placement participant groups, specifically those undertaking a baccalaureate level (or higher), health professional program. We considered peer-reviewed primary research with quantitative, qualitative or mixed-methods designs. Grey literature was excluded to ensure the inclusion of rigorous and peer-reviewed evidence. Both Australian and international research written in English were included. Articles were excluded if participants were not studying at a baccalaureate level (or higher) health professional program, if placement locations were not identified as rural and remote or if sense of belonging only related to supervisor–supervisee relationships within the clinical environment. Specific inclusion criteria also encompassed key concepts and contexts outlined in detail.

Concept

We included reports on students undertaking or having completed clinical placement, classified based on the international classification of health workers by WHO⁵⁴. This included nursing, medical, dental, occupational therapy, pharmacy, physiotherapy, paramedical, dietetics and nutrition, and social work students. Publications were included if they discussed events and experiences surrounding a sense of belonging from community activities during clinical placement.

Context

Publications specific to the Australian context commonly outline the geographical location of rural and remote location based on the Modified Monash Model (MMM) classification or its precursors if written prior to the commencement of MMM⁵⁵. If the MMM was not clearly outlined, a clear definition of the study’s location was required, cross-checking against the MMM classification. As this review focused on research conducted within the rural and remote environment, the classification of ‘rural’ and ‘remote’ may differ to that of an Australian context. For this reason, this review included countries listed in the OECD that classify ‘rural’ and ‘remote’ similarly to the Australian context⁵⁶. International studies must have reported the location as being considered rural and remote, and use similar typology as defined of this geographical nature by OECD.

Source of evidence selection

All potentially relevant articles were imported into EndNote X9 for review. After removing duplicates, articles were collated and uploaded into JBI SUMARi⁵⁷. To ensure all duplicates were removed, the EndNote duplicator function was used along with the de-duplicator software due to sensitivity issues within EndNote⁵⁸. Titles and abstracts were initially reviewed by three researchers (JE, DT and LR) based on the inclusion criteria, with full text of selected articles reviewed with the JBI SUMARI platform. Two reviewers (JE and DT) then independently appraised each study, with a third reviewer (LR) consulted for any conflicts. Reasons for exclusion of articles at the full-text stage were recorded, such as ineligible population (eg not healthcare students), ineligible sense of belonging (being clinical and not community focused) and ineligible study design (eg reviews). 

Data extraction

A data extraction tool was created in JBI SUMARI and replicated into Microsoft Excel to facilitate easier manipulation and analysis of the data. Extracted data included author, publication year and location, study design, participant population, sample size, definition of ‘rural’ and ‘remote’ and of the aim of the article. Outcomes, measurement tools and data analysis methods were also extracted, along with descriptive and inferential statistics.

The results and discussions were reviewed by the authors to identify the depth of the reported events and experiences. A total of 3316 records were identified. After removal of duplicates (n=451), title and abstracts were screened, excluding 2817 records. The remaining 48 articles underwent full-text screening, resulting in 13 articles deemed eligible based on the inclusion and exclusion criteria, as detailed in Figure 1.

Quality appraisal

Two researchers independently assessed the included articles using the relevant JBI critical appraisal tools⁵⁹. These tools include the JBI Qualitative Research tool, which is designed to assess the methodological quality of qualitative studies by evaluating aspects like congruity between research methodology and objectives. Each criterion is scored as ‘yes’, ‘no’, ‘unclear’ or ‘not applicable’, helping to determine the overall trustworthiness and relevance of the study⁵⁰. The second tool used was the JBI Analytical Cross Sectional Studies tool, which evaluates the quality of cross-sectional studies by examining criteria such as the clarity of inclusion criteria and the validity of exposure measurements. Similar to the qualitative tool, each criterion is scored as yes’, ‘no’, ‘unclear’ or ‘not applicable’, providing a comprehensive assessment of the study's methodological quality⁵⁰. After each article was assessed, any disagreements were resolved through discussion with a third reviewer. The quality of each article was scored as high, moderate, low or excluded. Overall, the studies were generally of low quality, with common issues including unclear key potential confounders, lack of reference to data saturation in qualitative studies, and omission of philosophical perspectives. Quantitative studies often had small sample sizes, leading to a higher risk of biased responses. Among the included studies, five were of moderate quality and eight were of low quality. There were no high-quality studies. Table 1 and Table 2 include detailed quality criteria.

Data analysis

Researchers used tabular, descriptive and narrative approaches to present the extracted data. Due to the heterogenous nature of the studies, a narrative analysis approach was adopted to identify and synthesise themes. Following Leggo’s method⁷¹, each article was read multiple times to derive significant statements and meanings. Words and phrases were coded inductively to identify emergent themes, generating an inventory of subthemes related to participants’ experiences in community activities⁷². The research team continually refined these themes through discussion, to ensure accuracy and consistency. Leggo’s steps of thematising and expanding⁷¹ were used to assess and highlight features commonly associated with a sense of belonging from student placements. The codes were then categorised into broader domains, resulting in three main themes aligned with the review’s aim. This rigorous process ensured a comprehensive understanding of the data.

Ethics approval

This study is a review of previously published literature and did not engage any human participants or collect primary data. Accordingly, no research ethics approval was required.

Results

Among the 13 peer-reviewed articles, two were quantitative studies involving surveys and questionnaires^68,69, 10 were qualitative studies with interviews or focus groups^16,37,60-67 and one was a mixed-methods study⁷⁰. A summary of review characteristics extracted is displayed in Table 3.

All studies were conducted in Australia, with locations including Newcastle^64,65, New South Wales⁷⁰, Queensland⁶⁷, Sydney^66,69, Tasmania⁶², Victoria⁶⁰, and Western Australia^61,63. Elliott et al⁶⁸, Sutton et al³⁷ and Smith et al¹⁶ all defined their locations as being of non-specific location and were aimed at students across Australia.

Participant populations included students from various healthcare professions. Some studies focused on specific professions like nursing^62,65,69 or nursing and midwifery⁶⁷, medical students^63,68, allied health students⁷⁰ and nutrition and dietetics students⁶⁵. Five studies included a mix of professions including nursing, medical, nutrition and dietitians, occupational therapy, speech pathology, physiotherapy, pharmacy, podiatry, medical radiation science, diagnostic radiography, social work, Aboriginal health and dentistry^{16,37,60,64,66}.

Three prominent themes emerged from the literature. The three themes were rural environment and the formation of a rural identity, social isolation and community activity engagement.

Rural environment and the formation of a rural identity

Over half (n=8) of the articles examined the relationship between students’ rural and remote placement experience and the welcoming nature of community members. Bradley et al⁶⁰, Crossley et al⁶¹, McAllister et al⁶⁶, Smith et al¹⁶, Sutton et al³⁷ and Wolfgang et al⁷⁰ all noted the positive sense of belonging felt when the community appeared welcoming, positive and friendly. Simple greetings like ‘hello’ on the street was central to this sense of being welcomed. Bradley et al asserted that being recognised in town as a student further enhanced this sense of belonging⁶⁰. Fisher et al postulated the need to understand rural practice characteristics, but did not elaborate on what this entailed⁶⁴. Data provided surface-level insights into the laid-back⁶⁵ and easygoing community⁶⁶ nature of rural communities. Dalton et al’s study on nursing students in rural Tasmania found that interactions with the rural community extended beyond their professional role, integrating into their personal identities and interactions within the community⁷³. Participants emphasised the need to ‘develop a rural nurse identity’. Community interaction was also highlighted among undergraduate nutritionist and dietetic students in Newcastle⁶⁵, and various undergraduate students in Sydney⁶⁶. These interactions illustrate that the intimate nature of rural communities allows for deeper connections between healthcare professionals and community members, enabling students to experience the community’s lifestyle and values first-hand.

Social isolation

Three articles identified social isolation as an experience that inhibits a sense of belonging among healthcare students during rural placements^16,60,66. Students faced challenges related to financial stress, accommodation, travel, and the lack of familiar social and recreational activities^16,60,66. These studies highlighted the impact of being separated from family and friends, which decreased the sense of belonging to the rural and remote environment. Bradley et al identified social isolation as a critical factor negatively impacting student placement experiences and satisfaction⁶⁰. However, Smith et al indicated that if students perceived they could overcome social isolation, they found the rural placement rewarding, with a sense of belonging contributing to their personal development¹⁶.

Community activity engagement

Community activity engagement involves healthcare students participating in various community events and activities during their rural placements. Such engagement was highly valued and enhanced their sense of belonging. A significant number of studies (n=10) indicated that community activity engagement significantly contributed to a student’s sense of belonging^{16,37,61,63-65,67,68,70}. These activities helped students feel more integrated and valued as part of the community. While some publications broadly labelled these activities as ‘community activities’^69,70,74, others provided clear examples. Sporting activities, such as joining local netball and table tennis teams, were prominent^37,63,66. Other activities included bushwalking, community jogging and gym memberships^16,63,67. Walker et al described how participating in local events and activities allowed students to build relationships with community members, understand local cultures and feel more connected to their work environment⁶⁷. Fisher et al⁶⁴ and Sutton et al³⁷ outlined how community engagement bridges the gap between clinical work and community life, outlining perspectives on rural health issues and social determinants of health. By actively participating in community events, students could see first-hand the impact of health care on community members’ lives outside the clinical setting. Elliott et al noted that, despite these opportunities, students were sometimes dissatisfied with the lack of extracurricular engagement opportunities offered in the rural and remote locality compared to their home environment⁶⁸.

Discussion

Thirteen studies explored the events and experiences that influenced medical, nursing and allied health students’ sense of belonging in rural and remote communities during clinical placements. The findings highlighted three themes: rural environment and the formation of a rural identity, social isolation and community activity engagement. Understanding the possible events and experiences can help educational institutions and industry partners design and benchmark placements that positively impact students’ desire to return to rural and remote environments post-graduation.

The social aspects of rural placements for healthcare students are often overlooked, leading to significant challenges in student retention and satisfaction. Traditional emphasis on clinical training and professional development often overshadows the equally important social integration into rural communities. Social integration plays a crucial role in mitigating the risk of isolation for students separated from their usual social networks¹⁶. Previous literature underscores the significance of rural placement models that actively integrate students into rural communities to enhance their engagement and sense of belonging^34,39. For students without prior rural experience, building social connections within the community is crucial^13,34,75. Immersion in rural culture has been identified as a significant factor in encouraging individuals to stay in rural and remote areas⁷⁶.

Trede et al⁷⁷, Green et al³⁹ and Levett-Jones et al⁴¹ highlight that rural identity and a sense of belonging are closely intertwined, influenced by dynamic, relational and contextual factors. A strong sense of belonging can increase the likelihood of undergraduate students considering returning to rural areas after graduation. Opportunities to meet people and develop social networks in the rural community are fundamental for retention³⁴. Engaging with rural communities, beyond clinical exposure, helps students develop a broader rural identity and understand their role in addressing the health needs of diverse populations in rural settings^39,41. According to Levett-Jones et al, students need to be accepted as community members by both clinical and community teams⁴¹. Sedgwick and Yonge found that the quality of interpersonal interactions influences students’ sense of belonging, emphasising the need for acceptance beyond the clinical environment¹³. Healthcare policies and educational programs have predominantly focused on enhancing clinical skills and providing financial incentives to attract and retain students in rural areas. However, the holistic experience of living in these communities, which includes social engagement and forming personal connections, is critical for developing a sustainable rural workforce. Further research is needed to explore the nuanced meanings of belonging and rural identity in the context of student placements in rural health.

This scoping review identified the impact of social isolation on undergraduate students’ ability to develop a sense of belonging in the rural and remote community. Research articles highlighted that feelings of being welcomed, valued and supported by local community members during clinical placement influenced the feeling of belonging. Studies by Bradley et al⁶⁰, McAllister et al⁶⁶ and Smith et al¹⁶ examined the concern that rural placements in isolation can adversely affect students’ sense of connection, leading to loneliness and decreased overall satisfaction. To address these challenges, strategies such as sending multiple students to the same rural and remote facility or accommodating students in shared housing have been implemented⁴⁰. This concept, known as ‘ruralisation’, involves positive interactions within a friendly and supportive community^16,78. When students from various health disciplines share accommodation, it fosters valuable social network and enhances interprofessional collaboration and teamwork⁷⁹. Transportation issues can also exacerbate feelings of isolation, limiting students’ ability to engage with the community and participate in social activities^80,81. Further research is needed to identify additional strategies to decrease social isolation and its impact on students’ sense of belonging during rural placements.

The study results emphasised that participating in community activities among undergraduate students created opportunities for fostering a sense of belonging. Missing familiar social and recreational activities disconnects students from their usual support systems, leading to feelings of loneliness, and decreased overall satisfaction and wellbeing during placement. Further exploration is needed to identify which ‘community activities’ influence this feeling. Current descriptions of these activities are superficial, and more research is required to understand their relationship with students’ sense of belonging. Prior research indicates that integrating with the local community helps students gain a deeper understanding of rural practice⁶⁴. Encouraging students to engage in community activities and local events mitigates feelings of isolation, fosters a sense of belonging and aids integration into a rural lifestyle^61,69. While sports are vital for fostering social connections and a sense of community, other interests should be explored to cater to diverse student needs. Activities such as local volunteer work, participation in community projects and joining hobby groups provide alterative avenues for social engagement^82,83. Creating opportunities for students to immerse themselves in various community activities helps them form meaningful relationships and a stronger sense of belonging. Students’ professional and personal lives often overlap, reinforcing their commitment to rural settings and influencing their career choices toward rural practice. Further research is needed to identify the impact of participation in community events and activities on students’ social integration and a sense of belonging during rural placements.

Despite these efforts, there is a notable lack of research exploring the relationship between community involvement, social activities, and healthcare students’ employment intentions in rural and remote areas. Most studies have focused on clinical placement experiences and the supervisor–supervisee relationship within the workplace, neglecting the broader community socialisation context. This gap in our understanding highlights the need for comprehensive research to explore the factors that influence students’ sense of belonging in rural and remote communities. Further investigation is needed to explore how community events, social interactions and extracurricular activities impact a student’s overall placement experience and career intentions. Understanding these dynamics can inform the development of more holistic rural placement programs that address both clinical and social aspects, ultimately contributing to a more sustainable rural healthcare workforce.

Limitations

The review focused on peer-reviewed evidence, deliberately excluding grey literature, which may have limited the contextual richness of the findings. The overall quality of evidence was considered low, primarily due to small sample sizes and various biases, such as researcher bias, selection bias and information bias. These biases impacted the validity and reliability of the studies, highlighting the need for improved methodologies in future research. The review did not identify international literature, possibly due to search strategy biases and the criterion of including only English-language studies, which may have excluded relevant non-English studies and affected the global applicability of the recommendations. Excluding grey literature aimed to ensure the reliability and quality of the synthesised evidence but may have omitted relevant studies. The low quality of the studies was noted, with contributing factors including small sample sizes, biases and methodological flaws. Addressing these issues in future research is crucial to enhance the robustness and applicability of the findings.

Conclusion

It is evident that multiple events and experiences influence undergraduate healthcare students’ sense of belonging in rural and remote placements. The themes identified – rural environment and identity formation, social isolation and community engagement – highlight the complexity of this phenomenon. Positive experiences in the clinical workplace and supportive learning are crucial for fostering a sense of belonging among students; however, social integration into rural and remote communities is equally vital. The literature highlighted that a welcoming community positively affects students’ sense of belonging and can mitigate social isolation. The formation of a rural identity and the welcoming nature of the community also play significant roles. Conversely, social isolation can hinder students’ sense of belonging. Community engagement through various activities emerged as a key event/experience in enhancing students’ connections to rural and remote areas. Moreover, there are identified gaps in the existing literature, particularly in understanding the nuanced relationships between community involvement and social activities of healthcare students in rural areas. There is a need for future research to undertake a deeper exploration of the dynamics of belongingness to inform comprehensive placement programs that address both clinical training and social integration needs effectively. By addressing these factors, healthcare students’ sense of belonging during rural placements can be significantly enhanced, ultimately leading to better retention and satisfaction with rural practice.