'I can't go, I can't afford it': Financial concern amongst health students undertaking rural and remote placements during COVID-19.

INTRODUCTION: As the coronavirus pandemic unfolded during 2020, widespread financial uncertainty emerged amongst university students across the globe. What is not yet clear is how Australian health students were financially impacted during the initial stages of the pandemic and whether this influenced their ability to undertake planned rural or remote placements.
OBJECTIVE: To examine (a) financial concern amongst health students during COVID-19, (b) the financial implications of changes to planned rural or remote placements and (c) the impact of these factors on students' ability to undertake placements during the pandemic.
DESIGN: Mixed-methods design involving an online survey (n = 1210) and semi-structured interviews (n = 29). Nursing, medical and allied health students with a planned University Department of Rural Health-facilitated rural or remote placement between February and October 2020 were invited to participate.
FINDINGS: 54.6% of surveyed students reported financial concern during COVID-19. Financial concern correlated with both changes in financial position and employment, with 36.6% of students reporting a reduction in income and 43.1% of students reporting a reduction in, or cessation of regular employment. Placement changes yielded a range of financial implications. Cancelled placements saved some students travel and accommodation costs, but left others out of pocket if these expenses were prepaid. Placements that went ahead often incurred increased accommodation costs due to limited availability. Financial concern and/or financial implications of placement changes ultimately prevented some students from undertaking their rural or remote placement as planned. DISCUSSION: Many nursing, allied health and medical students expressed financial concern during COVID-19, associated with a loss of regular employment and income. Placement changes also presented unforeseen financial burden for students. These factors ultimately prevented some students from undertaking their planned rural or remote placement.
CONCLUSION: Universities need to consider how best to align financially burdensome placements with the personal circumstances of students during periods of economic uncertainty.

What is already known on this subject:

Students who undertake rural or remote placements are more likely to return to work in these contexts once graduated

Rural and remote placements can be financially burdensome, with students having to cease regular employment and pay for additional accommodation and travel costs

Employment is one of the main ways students financially support themselves, whilst studying yet COVID‐19 has impacted the employment of around 50% of university students in Australia, resulting in either reduced hours of work or loss of job

What this study adds:

Around half of all students with planned rural and remote placements reported financial concern during COVID‐19, correlated with changes in employment status and financial position

Placement changes presented further unforeseen financial impacts including students, whilst others incurred additional financial costs

Financial concern and/or the financial impact of placement changes ultimately prevented some students from undertaking their planned rural or remote placement during 2020

INTRODUCTION

In an effort to address rural and remote health workforce shortages, contribute to the health and well‐being of rural and remote communities, and foster a pipeline of graduates into rural and remote practice post‐graduation, there has been an increasing focus on ensuring students undertake placements in rural or remote locations. , , However, there are substantial barriers for students undertaking placement experiences in rural and remote locations, including social, academic and geographical isolation, travel distance and limited accommodation availability. The cost of undertaking a placement away from a usual place of residence can also present significant financial challenges. , Rural and remote placements require students to voluntarily cease paid employment for a period of time whilst simultaneously paying for accommodation and travel costs. , , , , In an effort to reduce the financial barriers, a range of scholarships are available to students undertaking placements in certain rural or remote locations. University Departments of Rural Health (UDRHs) also provide students undertaking a rural or remote placement with subsidised accommodation, travel grants and/or a weekly rural placement allowance to put towards living costs where applicable.

As the coronavirus pandemic unfolded during 2020, widespread financial uncertainty emerged amongst university students across the globe. , What is not yet clear is how Australian health students were financially impacted during the initial stages of the pandemic and whether this influenced their ability to undertake planned rural or remote placements. At the height of the initial lockdown, 30.2% of domestic students at Australian universities reported the money at their disposal to be less sufficient or not sufficient, and 20.3% of students reported accessing financial support for living costs. Changes in employment status were identified as a key driver of poor finances, with 16.5% of students experiencing reduced hours of work, 15.1% being stood down and 10% losing their job entirely. Although Dodd et al.'s study provides early insight into financial concerns among Australian university students, only 41% of their studied cohort were from medicine or health sciences, with the remaining from mixed disciplinary backgrounds. With pre‐pandemic research reporting as many as 90% of nursing students were employed during their undergraduate education, the number of health students experiencing poor financial circumstances through reduced or lost employment during COVID‐19 may be much higher.

Acknowledging the financial burden of rural and remote placements, this study aimed to understand more acutely the financial concern experienced by nursing, allied health and medical students during 2020. This included examining changes in student income and regular employment brought about by the pandemic. Lockdown measures, travel restrictions and consideration of student health and safety saw many rural and remote placements cancelled, delayed or changed to alternative locations in response to the pandemic. Placements were also adapted to online settings with a rural and remote focus, thus removing the need for students to relocate. , Therefore, an additional aim was to investigate the financial implication of placement changes enacted by universities and ultimately whether students were able to meet the fiscal demands of their placement experiences. The findings from this study will inform UDRHs, universities, health services, the Australian Rural Health Education Network (ARHEN) and governments about financial uncertainty among health students during pandemics and the fiscal implications of placement changes. Such information is critical to supporting future decision‐making during pandemics and other unforeseen events, improving student placement experiences and ultimately developing a fit for purpose rural and remote health workforce in uncertain times.

METHODS

Design

This study employed a parallel convergent mixed‐methods approach, with quantitative and qualitative data collected concurrently from nursing, allied health and medical students who had planned to undertake a UDRH‐facilitated placement in 2020 via an online questionnaire and semi‐structured interviews.

Recruitment

All students with a UDRH‐facilitated placement scheduled between February and October 2020 were invited to participate. Participants were recruited by email invitation, distributed by each of the 16 UDRHs directly to students. To maximise the response rate, two follow‐up emails were also sent to each student, one a week after the initial email and another two weeks later.

Data collection

An online survey, developed by the project team, was embedded as a link in the email invitation sent to students. The survey comprised 24 questions which elicited demographic information and asked students about the impact of COVID‐19 on their planned placement/s, their study and personal life through a mix of rating, closed and open response options. Survey data were collected and managed using REDCap (research electronic data capture) tools hosted at the University of Melbourne.

Survey respondents were invited to participate in a semi‐structured interview that sought further information on the impact of COVID‐19 on their planned placement/s, their study and personal life. From consenting survey respondents, 10 students were randomly selected at the end of June, July, August and September 2020 to be contacted for an interview. Over the study period, a total of 38 consenting survey respondents were contacted, of which six did not respond and three declined to be interviewed. The remaining 29 students were interviewed individually via Zoom Web‐conferencing by one of five trained members of the project team (BJ, BH, TP, LS and SH). Interviews were organised in such a manner that the interviewer was not affiliated with the UDRH who facilitated the student's placement. Interviews ranged from 40 to 60 min in length. All interviews were audio‐recorded via Zoom Web‐conferencing and transcribed verbatim. Transcripts were checked for accuracy by the interviewer and then deidentified by allocating a numeric code to denote participant number and removing locations and health service names.

Data analysis

Survey, then interview data, were analysed separately using SPSS (Version 27) and NVivo (Version 12) respectively. For the purposes of this study, three survey questions relating to financial concern, changes in financial position and changes in employment status were analysed. The first question asked students to rate their overall level of financial concern during COVID‐19 on a 5‐point Likert scale (strongly disagree through to strongly agree). The second question required students to indicate how their financial position had changed during the pandemic (improved, remained the same or worsened). The third question asked students to indicate changes in their employment due to COVID‐19 (no impact to employment; was not employed previously and remained so; reduced hours of work; lost job; gained employment to support COVID‐19 response). Questions relating to demographics (gender, age, health discipline, year of study, location of study and rural background) were also analysed.

Descriptive statistics were conducted to give sample characteristics and binary logistic regression was performed for predictive factors for financial concern, a worsening in financial position and a loss or reduction in employment. For all analyses, p‐values of <0.05 indicated statistical significance. Open‐ended responses were also analysed in SPSS (Version 27) after being coded by the project team (BH, RR, HH and AF) using a developed codebook. Coded data were subjected to deductive content analysis, whereby members of the project team (BJ, TP and BH) identified relevant codes relating to the predetermined categories of: (a) financial position; (b) employment stability; and (c) financial implications of placement changes. All open‐ended responses coded under relevant categories were confirmed through consensus discussion.

Interview data were also subjected to content analysis to understand more broadly student perspectives and experiences of financial and employment stability during COVID‐19 and the financial impact of placement changes. With the unit of analysis set at the whole interview, transcripts were firstly subjected to multiple readings by members of the project team (BJ, TP and BH). Deductive content analysis was then independently conducted using NVivo (Version 12), with a focus on coding data according to the same matrix of predetermined categories used for survey data analysis including: (a) financial position; (b) employment stability; and (c) financial implications of placement changes. Relevant data were coded under each category, with subcategories developed through consensus discussions between the research team. Given the same approach to coding, survey and interview data were triangulated after coding, with the convergence found between the two sets of data strengthening the breadth of student experiences. Given the agreement between findings, verbatim quotations were used from either survey and interview data to exemplify student concerns where similarity was found.

RESULTS

A total of 1505 students completed the online survey, with 295 responses excluded from analyses due to missing data. Of the 1210 included survey responses, the majority were female (n = 1023, 84.5%), under 25 years of age (n = 722, 59.7%) and were studying either nursing (n = 632, 52.2%) or allied health (n = 473, 39.1%; Table 1). Individual interviews were conducted with 29 students, with interviewees predominantly female, studying allied health or nursing and over 25 years old.

TABLE 1

Characteristics of survey respondents

Characteristics	Nursing n = 632 n (%)	Allied Health n = 473 n (%)	Medicine n = 105 n (%)	Total n = 1210 n (%)
Gender
Female	552 (87.3)	394 (83.3)	77 (73.3)	1023 (84.5)
Male	76 (12.0)	75 (15.9)	28 (26.7)	179 (14.8)
Non‐gender binary	4 (0.6)	4 (0.8)	0 (0.0)	8 (0.6)
Age
Under 25	327 (51.7)	345 (72.9)	50 (47.6)	722 (59.7)
25–34	148 (23.4)	88 (18.6)	48 (45.7)	284 (23.5)
Over 35	156 (24.7)	37 (7.8)	6 (5.7)	199 (16.4)
Missing	1 (0.2)	3 (0.6)	1 (1.0)	5 (0.04)
Course level
Undergraduate	605 (95.7)	313 (66.2)	44 (41.9)	962 (79.5)
Postgraduate	24 (3.8)	158 (33.4)	60 (57.2)	242 (20.0)
Missing	3 (0.5)	2 (0.4)	1 (1.0)	6 (0.5)
Location whilst growing up
In a capital city	187 (29.6)	195 (41.2)	47 (44.8)	429 (35.5)
In a regional or large centre	151 (23.9)	131 (27.7)	23 (21.9)	305 (25.2)
In a rural town	271 (42.9)	138 (29.2)	31 (29.5)	440 (36.4)
In a remote area	23 (3.6)	9 (1.9)	4 (3.8)	36 (3.0)
Location whilst studying
In a capital city	178 (28.2)	252 (53.3)	50 (47.6)	480 (39.7)
In a regional or large centre	227 (35.9)	184 (38.9)	43 (41.0)	454 (37.5)
In a rural town	210 (33.2)	32 (6.8)	11 (10.5)	253 (20.9)
In a remote area	17 (2.7)	5 (1.1)	1 (1.0)	23 (1.9)

Financial concern during COVID‐19

Of the 1210 students surveyed, 661 (54.6%) reported financial concern during COVID‐19, whilst 364 (30.1%) students did not. Students who expressed financial concern mirrored the sample profile, being mostly female (86.5%), under the age of 25 years (59.5%) and studying in an undergraduate course (82.6%; Table 2). Logistic regression found several predictors of financial concern including gender, discipline and course level, location whilst growing up and location whilst studying (Table 3).

TABLE 2

Student financial concerns during COVID‐19

Characteristics	Financial concerns during COVID‐19
	Agree n = 661 n (%)	Neither agree nor disagree n = 185 n (%)	Disagree n = 364 n (%)	Total n = 1210 n (%)
Gender
Female	572 (86.5)	155 (83.8)	296 (81.3)	1023 (84.5)
Male	85 (12.9)	28 (15.1)	66 (18.1)	179 (14.8)
Non‐gender binary	4 (0.6)	2 (1.1)	2 (0.6)	8 (0.7)
Age
Under 25	393 (59.5)	111 (60.0)	234 (64.3)	738 (61.0)
25 to 34	162 (24.5)	40 (21.6)	67 (18.4)	269 (22.2)
Over 35	104 (15.7)	34 (18.4)	61 (16.8)	199 (16.4)
Missing	2 (0.3)	0 (0.0)	2 (0.6)	4 (0.3)
Discipline
Nursing	397 (60.0)	93 (50.3)	142 (39.0)	632 (52.2)
Allied health	235 (35.6)	72 (38.9)	166 (45.6)	473 (39.1)
Medicine	29 (4.4)	20 (10.8)	56 (15.4)	105 (8.7)
Course level
Undergraduate	546 (82.6)	148 (80.0)	268 (73.6)	962 (79.5)
Postgraduate	111 (16.8)	37 (20.0)	94 (25.8)	242 (20.0)
Missing	4 (0.6)	0 (0.0)	2 (0.5)	6 (0.5)
Location whilst growing up
In a capital city	222 (33.6)	68 (36.8)	139 (38.2)	429 (35.4)
In a regional or large centre	160 (24.2)	45 (24.3)	100 (27.5)	305 (25.2)
In a rural town	260 (39.3)	67 (36.2)	113 (31.1)	440 (36.4)
In a remote area	19 (2.9)	5 (2.7)	12 (3.3)	36 (3.0)
Location whilst studying
In a capital city	240 (36.3)	80 (43.3)	160 (44.0)	480 (39.7)
In a regional or large centre	248 (37.5)	61 (33.0)	145 (31.9)	454 (37.5)
In a rural town	163 (24.7)	38 (20.5)	52 (14.3)	253 (20.9)
In a remote area	10 (1.5)	6 (3.3)	7 (1.9)	23 (1.9)

TABLE 3

Predictors of student financial concern, financial position and employment stability during COVID‐19

Characteristics	Financial concern		Financial position		Employment stability
	Odds ratio (95% confidence interval)	p‐value	Odds ratio (95% confidence interval)	p‐value	Odds ratio (95% confidence interval)	p‐value
Gender
Males
Females	1.40 (1.02–1.92)	0.04*	1.11 (0.79–1.54)	0.55	1.12 (0.83–1.59)	0.40
Age
Over 35 years
Under 25 years	1.04 (0.76–1.42)	0.80	1.00 (0.72–1.39)	0.99	1.34 (0.97–1.85)	0.08
25–34 years	1.38 (0.95–2.00)	0.09	1.32 (0.90–1.92)	0.15	1.34 (0.92–1.95)	0.13
Discipline
Medicine
Nursing	4.43 (2.80–6.99)	< 0.01*	3.89 (2.29–6.62)	< 0.01*	2.69 (1.65–4.40)	< 0.01*
Allied health	2.59 (1.63–4.12)	< 0.01*	2.09 (1.22–3.61)	0.01*	3.26 (1.99–5.36)	< 0.01*
Year level
Undergraduate
Postgraduate	0.65 (0.49–0.86)	<0.01*	0.53 (0.39–0.73)	<0.01*	0.89 (0.67–1.19)	0.44
Location whilst growing up
Capital city
Regional or large centre	1.03 (0.77–1.38)	0.85	1.04 (0.76–1.41)	0.82	1.06 (0.79–1.43)	0.68
Rural and remote areas	1.32 (1.02–1.72)	0.04*	1.26 (0.96–1.66)	0.09	1.10 (0.85–1.44)	0.47
Location whilst studying
Capital city
Regional or large centre	1.20 (0.93–1.56)	0.16	1.11 (0.85–1.45)	0.45	0.88 (0.68–1.14)	0.34
Rural and remote areas	1.68 (1.24–2.27)	<0.01*	1.50 (1.11–2.04)	0.01*	0.72 (0.53–0.97)	0.03*

Statistically significant p < 0.05.

Financial position during COVID‐19

During COVID‐19, 443 (36.6%) students reported that their financial position worsened, whilst 602 students (49.8%) reported no financial change (Table 4). The remaining 165 students (13.6%) indicated that their financial situation improved during the pandemic. The only predictors of poorer financial position were discipline, course level and place of residence whilst studying (Table 3).

TABLE 4

Change in student financial health during COVID‐19

Characteristics	Change in financial health
	Improved n = 165 n (%)	Stayed the Same n = 602 n (%)	Worsened n = 443 n (%)	Total n = 1210 n (%)
Gender
Female	129 (78.2)	516 (85.7)	378 (85.3)	1023 (84.5)
Male	35 (21.2)	82 (13.6)	62 (14.0)	179 (14.8)
Non‐gender binary	1 (0.6)	4 (0.7)	3 (0.7)	8 (0.7)
Age
Under 25	116 (70.3)	362 (60.1)	260 (58.7)	738 (61.0)
25–34	33 (20.0)	124 (20.6)	112 (25.3)	269 (22.2)
Over 35	14 (8.5)	115 (19.1)	70 (15.8)	199 (16.4)
Missing	2 (1.2)	1 (0.2)	1 (0.2)	4 (0.3)
Discipline
Nursing	49 (29.7)	301 (50.0)	282 (63.7)	632 (52.2)
Allied health	82 (49.7)	248 (41.2)	143 (32.3)	473 (39.1)
Medicine	34 (20.6)	53 (8.8)	18 (4.1)	105 (8.7)
Course level
Undergraduate	113 (68.5)	472 (78.4)	377 (85.1)	962 (79.5)
Postgraduate	52 (31.5)	128 (21.3)	62 (14.0)	242 (20.0)
Missing	0 (0.0)	2 (0.3)	4 (0.9)	6 (0.5)
Location whilst growing up
In a capital city	75 (45.5)	207 (34.4)	147 (33.2)	429 (35.4)
In a regional or large centre	35 (21.2)	163 (27.1)	107 (24.2)	305 (25.2)
In a rural town	51 (30.9)	214 (35.5)	175 (39.5)	440 (36.4)
In a remote area	4 (2.4)	18 (3.0)	14 (3.2)	36 (3.0)
Location whilst studying
In a capital city	81 (49.1)	238 (39.5)	161 (36.3)	480 (39.7)
In a regional or large centre	56 (33.9)	235 (39.0)	163 (36.8)	454 (37.5)
In a rural town	25 (15.2)	116 (19.3)	112 (25.3)	253 (20.9)
In a remote area	3 (1.8)	13 (2.2)	7 (1.6)	23 (1.9)

Employment stability during COVID‐19

Just over half (55.0%) of surveyed students reported no change to their pre‐pandemic employment, with 384 students (31.7%) continuing in their paid employment and 281 students (23.2%) not working by choice (Table 5). However, the remaining 521 students (43.1%) reported that their employment had either lessened or ceased during COVID‐19. Notably, few students (n = 24, 2.0%) across the three disciplines took up paid employment to assist with the pandemic response.

TABLE 5

Change in student employment status during COVID‐19

Characteristics	Change in employment status
	Continued paid employment n = 384 n (%)	Continued unemployment n = 281 n (%)	Employment reduced n = 310 n (%)	Employment ceased n = 211 n (%)	Gained employment through pandemic response n = 24 n (%)	Total n = 1210 n (%)
Gender
Female	334 (87.0)	222 (79.0)	262 (84.5)	184 (87.2)	21 (87.5)	1023 (84.5)
Male	50 (13.0)	55 (19.6)	45 (14.5)	27 (12.8)	2 (8.3)	179 (14.8)
Non‐gender binary	0 (0.0)	4 (1.4)	3 (1.0)	0 (0.0)	1 (4.2)	8 (0.7)
Age
Under 25	234 (60.9)	162 (57.7)	184 (59.4)	142 (67.3)	16 (66.7)	738 (61.0)
25–34	69 (18.0)	74 (26.3)	73 (23.5)	46 (21.8)	7 (29.2)	269 (22.2)
Over 35	80 (20.8)	44 (15.7)	53 (17.1)	21 (10.0)	1 (4.2)	199 (16.4)
Missing	1 (0.3)	1 (0.4)	0 (0.0)	2 (0.9)	0 (0.0)	4 (0.3)
Discipline
Nursing	241 (62.8)	106 (37.7)	186 (60.0)	86 (40.8)	13 (54.2)	632 (52.2)
Allied health	128 (33.3)	113 (40.2)	115 (37.1)	111 (52.6)	6 (25.0)	473 (39.1)
Medicine	15 (3.9)	62 (22.1)	9 (2.9)	14 (6.6)	5 (20.8)	105 (8.7)
Course level
Undergraduate	330 (85.9)	197 (70.1)	267 (86.1)	153 (72.5)	15 (62.5)	962 (79.5)
Postgraduate	53 (13.8)	81 (28.8)	42 (13.5)	57 (27.0)	9 (37.5)	242 (20.0)
Missing	1 (0.3)	3 (1.1)	1 (0.3)	1 (0.5)	0 (0.0)	6 (0.5)
Location whilst growing up
In a capital city	133 (34.6)	106 (37.7)	107 (34.5)	72 (34.1)	11 (45.8)	429 (35.4)
In a regional or large centre	101 (26.3)	67 (23.8)	81 (26.1)	51 (24.2)	5 (20.8)	305 (25.2)
In a rural town	135 (35.2)	102 (36.3)	112 (36.1)	83 (39.3)	8 (33.3)	440 (36.4)
In a remote area	15 (3.9)	6 (2.1)	10 (3.2)	5 (2.4)	0 (0.0)	36 (3.0)
Location whilst studying
In a capital city	125 (32.6)	121 (43.1)	117 (37.7)	104 (49.3)	13 (54.2)	480 (39.7)
In a regional or large centre	144 (37.5)	107 (38.1)	120 (38.7)	75 (35.5)	8 (33.3)	454 (37.5)
In a rural town	104 (27.1)	46 (16.4)	69 (22.3)	31 (14.7)	3 (12.5)	253 (20.9)
In a remote area	11 (2.9)	7 (2.5)	4 (1.0)	1 (0.5)	0 (0.0)	23 (1.9)

Logistic regression found allied health (OR, 3.26 [1.99–5.36, p < 0.01]) and to a lesser extent nursing students (OR, 2.69 [1.65–4.40, p < 0.01]) were more likely to report a reduction in hours or loss of employment compared to medical students (Table 3). Whilst relatively similar proportions of nursing students (n = 186, 29.4%) and allied health students (n = 115, 24.3%) experienced a reduction in hours of employment, only 13.6% of nursing students lost their job compared to 23.5% of allied health students (Table 5). Students who were studying in rural or remote areas (OR, 0.72 [0.53–0.97, p = 0.03]) were also less likely to have had their employment negatively impacted than students studying in capital cities.

Association between financial concern, financial position and employment stability

There was a moderate positive correlation between student survey scores for financial concern, financial position and employment stability (Figure 1). Students were more likely to have expressed financial concern if they had experienced a worsening in their financial position, or if their regular employment was impacted.

FIGURE 1

Correlations between study variables. **Correlation is significant at the 0.01 level (2‐tailed)

Open‐ended survey responses and interview data provided illustrative examples of the association between financial concern and changes in the financial position and employment status of students during COVID‐19. Students described financial concern due to a reduction in regular income given they or their partner had been stood down, lost their job or experienced reduced hours of employment. Some students reported voluntarily quitting a job to protect others given their exposure to health care environments and potentially, COVID‐19.

Yeah, I did lose my job in [location]. I was working for a horse riding stable and because they weren't doing any lessons anymore, I wasn't needed as like a groom and a helper. (Interviewee #24, nursing student)

… I work currently as an AIN [Assistant in Nursing] in an aged care facility … we weren't actually allowed to take on any new residents and so once beds were being emptied … we had too many staff for the patient load … so they had to cut hours … because I'm more casual… I wasn't actually able to pick up as many shifts, so it sort of impacted me a bit more financially as well. (Interviewee #3, nursing student)

Other students described how COVID‐19 had little impact on their financial situation and subsequently reported no financial concern. Some of these students were not previously working and were supported by their partner or family which did not change. Others were employed in jobs that were not affected by the pandemic, allowing for ongoing income during 2020.

…so it was good for myself, my own experience financially, I was fine. I didn't have any extra financial stress, a bit of support from my parents and some savings … (Interviewee #9, social work)

I had friends around me like losing jobs left, right and centre and yeah, I lost no hours at all, because I was going in to sit down and message on live chat rather than serve customers. So I thought that was really good. I … couldn't thank [business] enough for not dropping us. (Interviewee #28, nursing)

Some students described greater financial security during the pandemic given the increase in government student financial assistance (e.g. Austudy). Other students reported an increased income stream because they were employed in roles that were in greater demand during the pandemic. Finally, others experienced greater financial income after losing their job and receiving government payments (e.g. JobKeeper and JobSeeker) that exceeded their typical income.

… this is too much information, but …the supplement … was more … than I would have made working anyway, so like, I've actually been better off. (Interviewee #14, nursing)

And I was able to pick up more shifts with my work, which wasn't ideal with uni, but you do what you've got to do. (Interviewee #10, nursing)

Financial implications of placement changes during COVID‐19

From the open‐ended survey responses and interview data, both positive and negative financial implications were evident for changes made to rural and remote placements in response to COVID‐19, regardless of whether placements were cancelled, went ahead as planned or were changed to an alternative location.

Positive financial implications

Where rural and remote placements were cancelled or changed to a nearby metropolitan location, students described how they were better off financially because of their ability to continue in paid employment, together with saving on travel expenses and accommodation that would have been incurred by relocating for the placement.

Placement being cancelled, I'm better off because I've worked three casual jobs and I've got my money refunded from placement accommodation. (Interviewee #4, nursing)

Ironically it did reduce my financial expenditure, because obviously … it was a rural placement, so I had to pay for accommodation at [location] and … I needed to pay for my car as well for the time of being on the placement, so since I didn't go, I saved up on those finances. (Interviewee #16, social work)

Some students who went on their rural or remote placement as planned also experienced financial gains, with some placement providers fully covering travel and accommodation costs. Other students also fortuitously received additional financial assistance for accommodation from UDRHs resulting in cheaper than expected accommodation.

And I didn't have to pay a thing, it was it was all covered through [the UDRH]. (Interviewee #29, nursing)

[UDRH] waived one week of my student accommodation costs, so what was already really stupid cheap student accommodation, eighty bucks a week was actually like forty bucks a week. (Interviewee #14, nursing)

Negative financial implications

In the case of placement cancellations, students reported negative financial implications where they had prepaid accommodation and flight costs. Despite having travel insurance, students described their inability to recoup these relocation expenses that had already been paid for. Students also described how scholarships and bursaries they were initially granted to support their rural and remote experience prior to the pandemic were reneged upon in situations where placements were cancelled or cut short, leaving them out of pocket unexpectedly.

The university's insurance said they wouldn't cover it because COVID‐19 was a known event before I booked the flights and then I went through my insurance and they have said the same thing, so, it doesn't look like it will be covered. The reason I applied for the placement as well was because it was in the [location] region and students attending a placement in that region would get a grant through the government to cover accommodation and flights. So I was … counting on that money‐wise to be able to afford the placement, but then because it didn't go ahead, I was never reimbursed for it. (Interviewee #10, nursing)

In circumstances where placements went ahead as scheduled, some students reported larger than expected accommodation expenses. With COVID‐19 restrictions limiting the number of students able to reside in each accommodation facility, some students described the need to source alternative lodgings than originally booked. Further, some students whose placements went ahead also described how they were required to pay for an additional 2‐week accommodation prior to placement in order to meet quarantine requirements.

I took my placement having looked at the available accommodation on offer for students … but after I selected my placement, I was unable to get that accommodation at a great expense to myself … not working, mother of three to have to find over $3,000 for accommodation is an extremely impacting event. (Survey respondent #1420, nursing)

Where rural and remote placements were changed to a metropolitan location that still required them to relocate, students equally described the financial stress of accommodation costs. Importantly, they outlined that they were no longer eligible for bursaries or scholarships that had been made available to them as part of their planned rural or remote placement.

I originally had scholarships lined up for going to rural and remote places, organised through the university which, because all of my placements were changed to metropolitan areas, were revoked … there was just no extra sort of compensation for students … accommodation has become a lot more expensive, being in metropolitan areas versus … university organised accommodation in [location]… so I think … since March, in regards to accommodation, losing scholarships, I think I fore‐goed $5,000. So that was a big impact as well. (Interviewee #22, nursing and paramedicine)

Impact of financial concern and financial implications of placement changes on student capacity to undertake placement experiences During COVID‐19

Interview data provided illustrative examples of students who were both able and unable to undertake their planned rural or remote placement, depending on their level of financial concern and/or the negative financial implications of placement changes. Students who were financially secure or in an improved financial position reported being able to cope with the fiscal pressure of their placement. Several of these students acknowledged how government payments provided the financial stability needed to undertake their placement.

… being on Austudy, the Australian Government rolled out the coronavirus supplement, so that really aided me, especially when I was away in [location] to be able to support myself … a terrible pandemic has actually made my study a lot easier in that regard. (Interviewee #14, nursing)

Access to JobKeeper contributed to my rural placement. I would not have been able to undergo a rural placement without that financial assistance. (Survey respondent #1079, nursing)

Others who were financially concerned still chose to undertake their rural or remote placement but emphasised the financial distress in doing so.

I used up my holidays from work, I paid for all my hotels for four weeks placement ($3,500). This practically broke me, just to get this course finalised! (Survey respondent #1287, nursing)

However, other students whose financial health had worsened described how they could no longer entertain the financial demands of their placement. For students whose partners had lost their job, they highlighted the necessity of engaging in their regular employment to ensure an income stream which meant no longer entertaining a rural or remote placement that would see them unable to work.

… my partner works in hospitality, so he lost his job during COVID‐19 and I kept my part time job in pharmacy, but paying two rents and going away and working for free kind of didn't work at that time. So I ended up switching to a local placement and undertaking it later on so I could drive to and from and still be able to work in between so I could get some income. (Interviewee #12, pharmacy)

Regardless of financial situation, some students described how the financial implications of changes to their planned rural or remote placement resulted in their decision to cancel their placement. This centred mainly on the unforeseen increases in accommodation costs due to limited availability and accessibility of student accommodation together with quarantine requirements.

I did have another one that was scheduled … but I actually chose to opt out of it because this was in April and it was kind of right at the height of … the initial wave. I was very concerned and on top of that, the week I was meant to be going, my accommodation fell through because of COVID‐19, so I suddenly had nowhere to stay and … it'd be $4000 for me to stay there for the three weeks. (Interviewee #1, nursing and midwifery)

I have to cancel the placement because I cannot afford two weeks self‐isolation. (Survey respondent #928, nursing)

DISCUSSION

Over half of surveyed nursing, allied health and medicine students with planned rural or remote placements during 2020 reported financial concern as a result of the pandemic. Largely, financial concern was fuelled by a worsening of financial position associated with either a reduction or loss of regular employment. It was therefore not surprising to see financial concern more pronounced amongst allied health and nursing students given their greater participation in the labour market. However, almost twice as many allied health students were found to have lost their job than nurses in this study, emphasising the particular vulnerability of this student cohort during pandemics. This likely reflects their employment in industries vulnerable during pandemic lockdowns including retail and hospitality. , Whilst nursing students may have been somewhat safeguarded through employment in health care, students working as carers and assistants in nursing still reported losing hours. Although it seems counterintuitive that health care employment would reduce during a pandemic, this has been reported elsewhere within the literature. Similarly, very few students across all three disciplines in this study gained employment as part of the pandemic response, which conflicts with earlier suggestions that health students could be important contributors to the surge workforce.

Although students studying in rural or remote areas were also found to be more financially concerned and have experienced a worsening in their finances when compared to their metropolitan counterparts, this was not associated with underemployment or unemployment. This may reflect the notable decrease in food availability and subsequent cost increases experienced in rural and remote Australia in response to the pandemic lockdown. Whilst rural and remote areas of Australia are known to have poorer access to, and bear greater out of pocket costs for a range of healthy foods in comparison with metropolitan areas, this situation was exacerbated by the pandemic lockdown which saw the greater reliance on home cooked food and panic buying create food availability issues across rural Australia. , Additional financial support may therefore be warranted for students studying in rural and remote locations during periods of pandemic‐related lockdown to counteract the additional cost of living pressures they are likely to face. This will ensure these students continue to access their rural or remote placement experiences that may otherwise be financially prohibitive and facilitate their contribution to the future rural and remote health workforce.

Given the level of financial concern amongst the student cohort and the financial demands of planned placements, it was unsurprising that students whose rural and remote placements were cancelled or changed to a closer location expressed relief at no longer having to pay for travel and accommodation costs. However, for others whose placements were unchanged, this meant additional financial stress, which in some cases resulted in placement cancellation. This reaffirms that rural and remote placements may preclude students lacking finances. Although there are scholarship opportunities to support students undertake rural and remote placements, particularly those with extended placements and in remote areas, most students seem unaware of these opportunities. Therefore, UDRHs may need to investigate ways to disseminate information on funding support for rural or remote placements to increase student uptake, particularly amongst those lacking sufficient finances.

Even if students were to access scholarships, this study identified that during COVID‐19, some financial supports were reneged, leaving students out of pocket when placements were cancelled or cut short. This response failed to acknowledge that some relocation costs are independent of the time spent on placement and often occur before the student actually arrives on site. With students in this study detailing the precise budgeting they had done to be able to afford going on the placement, this loss of financial support was an unexpected financial burden. Positively, some students benefited from increased financial support for accommodation provided by UDRHs during the pandemic. This measure was graciously accepted by students and again highlights the value of financial assistance when undertaking a rural or remote placement.

Whilst additional financial support for accommodation was a notable bonus, this study suggests that UDRHs need to focus specifically on accommodation provision for rural and remote placements in pandemic circumstances. Limited availability of affordable, accessible accommodation has been noted in numerous studies as a placement barrier under pre‐pandemic conditions. However, this study found that further limitations were experienced during COVID‐19 as a result of the social distancing measures which saw restrictions imposed on the number of students deemed able to safely reside in UDRH‐subsidised accommodation facilities. Although students reported being able to claim an accommodation subsidy through the UDRHs when residing in alternative lodgings, it was evident that the out of pocket costs were far greater, placing additional financial pressure on students and ultimately preventing some from attending. UDRHs may need to develop strategies to ensure affordable accommodation remains accessible for students on rural and remote placement during pandemics such as increasing the value of accommodation subsidies for students forced to reside in more expensive alternative lodgings.

It is important to note that not all students were financially worse off during the pandemic, with a small proportion (13.6%) of students reporting an improved financial position. These circumstances were underscored by government assistance (e.g. Austudy or JobKeeper) exceeding regular income levels, leaving students feeling more supported and able to meet the fiscal demands of their rural or remote placement during COVID‐19 compared to normal circumstances. Further, students who had lost their job but were financially supported by government assistance described the fortuitous timing of their rural or remote placement given the lack of additional employment considerations. This reaffirms employment as a barrier to rural and remote placements and highlights the ongoing need to develop strategies to facilitate working students to access rural and remote placements. It also reiterates financial security as an enabler for a rural or remote placement experience. Universities may therefore need to reach out during times of general economic uncertainty caused by pandemics and similar adverse events to ensure better alignment between student financial capacity and the anticipated fiscal burden of placements. To this end, universities must take steps to consider the financial position of students during the placement allocation process, and ensure that students are cognisant of, and able to meet any financial demands of allocated placements.

Finally, this study was implemented rapidly to capture the perspectives and experiences of students during the pandemic and therefore is subject to limitations. Due to the timing of the study, some students were unable to complete the questionnaire until several months after the completion of their placement which may have impacted on their ability to recall information. Further, student reports of financial concern were not validated. With students self‐selecting to participate in this study, particularly in the interviews, it may be that the results reflect a bias, with students most impacted by COVID‐19 motivated to participate. However, hearing from those students most impacted by COVID‐19 may have been beneficial to understanding the breadth and depth of financial challenges students experienced during the pandemic. To this end, what may have been helpful in this study is for the industry of student employment to have been examined to understand what jobs were at risk during the pandemic. Finally, it would have been beneficial to have calculated a sample size to determine the representativeness of the questionnaire data. However, it proved difficult to determine the total number of students contacted by email to participate given the variation in student support across the 16 participating UDRHs. Based on 2019 data indicating 16 500 students had UDRH‐facilitated rural or remote placements, this study population reflects only 8% of potential students therefore limiting the generalisability of findings.

CONCLUSIONS

Many nursing, allied health and medical students at Australian universities with planned rural or remote placements during 2020 expressed financial concern because of pandemic‐related changes in their employment and financial position. This concern, together with the financial implications of placement changes, meant that some students were financially burdened by their rural or remote placement, or could not afford to go. Better alignment between student financial capacity and the fiscal demands of rural and remote placements will auger well for continued student participation in rural training during pandemics. However, targeted financial support is also needed to ensure financially challenged students can undertake placement opportunities in rural and remote communities, and ultimately develop the future rural and remote health workforce.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

Ethics approval for the study was obtained principally from the University of Melbourne (2056941.1), with ethics also sought from other participating universities if required (University of Tasmania, University of Newcastle, La Trobe University, The University of Queensland, University of Western Australia, Flinders University and James Cook University).

AUTHOR CONTRIBUTIONS

BJ: formal analysis; investigation; writing – original draft; writing – review & editing. HH: formal analysis; investigation; writing – original draft; writing – review & editing. KO: formal analysis; writing – review & editing. TP: formal analysis; investigation; writing – review & editing. LB: conceptualization; formal analysis; methodology; supervision; writing – review & editing. BH: formal analysis; investigation; project administration. SJ: investigation; writing – review & editing. SH: investigation; writing – review & editing. AF: investigation; writing – review & editing. LS: investigation; writing – review & editing. RLR: investigation; writing – review & editing.