Content area
Aim
This scoping review examines the challenges that university students face due to mandatory unpaid placements, with a focus on nursing, midwifery and healthcare programs.
BackgroundWhile these placements are essential for professional training and provide valuable real-world experience, they often impose significant financial burdens—particularly for students unable to balance paid work alongside their placement commitments.
Design and MethodsA scoping review was conducted to synthesise the literature between January 2014 and June 2024. A search was conducted in eight databases (ERIC (EBSCO), Academic Search Complete, Web of Science, MEDLINE, PubMed, Cochrane CINAHL, PsychINFO and Sportdiscus). Reports were screened by three reviewers. Data were then extracted and thematically analysed by two other authors.
ResultsNine papers met inclusion/exclusion criteria (three qualitative reports, three quantitative reports and three opinion pieces). The findings reveal that mandatory unpaid placements impose a significant financial burden on healthcare students, especially mature-aged Australian students, which can negatively contribute to their mental health and well-being and lead to student attrition.
ConclusionsFinancial hardships due to mandatory unpaid placements cause adverse effects on students’ mental health and well-being, and student retention. The review identifies key research gaps, including research on students in regional universities and the impact of healthcare student retention and the longer-term future of the healthcare workforce. Changes to policy and practice are recommended, including establishing targeted financial assistance programs, implementing flexible academic structures and comprehensive policy reforms to address the financial, emotional and professional challenges students face in mandatory unpaid placements.
In Australia, the healthcare and social assistance sector makes up the largest employing industry in the country ( Job and Skills Australia, 2024). Healthcare-related courses cover a wide range of topics, including nursing, occupational therapy, psychology, midwifery and physiology. Not surprisingly, enrolment in these healthcare-related higher education programs is incredibly popular among prospective higher education students and is a significant undertaking for prospective students. These programs often demand high academic achievements as prerequisites ( Ryan et al., 2021) and are known for their competitiveness and prestige, being considered among the noblest professions ( Dopelt et al., 2022). Further, many students are drawn to these programs because of their altruistic desire to assist others ( Allen et al., 2022; Čukljek et al., 2020). Critically, unlike non-healthcare-related courses, coursework is often combined with a clinical placement component.
Clinical placements provide authentic learning opportunities for healthcare students to bridge the gap between theoretical knowledge and practical application ( Fleming and Hay, 2021). These placements serve as platforms for on-the-job learning, fostering student competence, confidence and a deeper understanding of their chosen career paths and enhancing their professional development and employability post-graduation ( Jackson et al., 2023). There are various types of clinical placement models used in health professions including, the block placement model favoured by schools with many students, such as medicine and nursing and models with smaller student numbers that focus on more close supervision, such as occupational therapy ( Nyoni et al., 2021).
However, clinical placements can place a heavy burden on the student. Each health discipline’s accrediting body mandates the clinical hours that each student must undertake prior to graduation and these vary from 800 to 1368 hours, often equating to 30–50 % of their undergraduate program ( William et al., 2024). Students are usually assigned clinical placements in week blocks up to 12 weeks during the semester or semester breaks ( Birks et al., 2017). While these placements offer invaluable experience to apply clinical skills learnt in the classrooms in authentic settings and professional networking opportunities, participants face financial hardship since students are offered no remuneration for the work they undertake ( Zwaan, (2019)). The financial implication due to mandatory unpaid placement has been coined ‘placement poverty’ as students try to sustain their educational and living expenses ( Usher et al., 2022; William et al., 2024).
Placement poverty has significant implications for healthcare students' emotional and physical health, as well as their overall well-being ( Zwaan, (2019)). Nursing students, for example, tend to come from relatively lower household incomes compared with non-nursing students ( Cho et al., 2010) so could already be at a disadvantage before they have started placement. Midwifery students also must undertake Continuity of Care Experiences (CoCE), where students follow a minimum of 10 women from pre-natal to post-natal appointments, including attending the birth, on top of their clinical placement, increasing the financial hardships that they can encounter ( Newton et al., 2022; Moran et al., 2024). Financial hardship can adversely affect academic performance ( Moore et al., 2021) and greatly diminish the quality of placement learning experiences ( Johnstone et al., 2016). The additional expenses that students incur on placement vary, though the most common ones are accommodation if their placement is not nearby, travel costs, childcare and the inability to earn income during this time ( Usher et al., 2022). Placement poverty likewise has an impact on tertiary education. A study by Crombie et al. (2013) suggested that “clinical placements have the greatest impact on student retention” (p 1282). There has been much research on the relationship between support and student retention ( Collard et al., 2020). The demanding nature of these programs and high expectations can create a stressful environment for students, leading to attrition. In higher education, attrition refers to the number of students not completing their academic programs, which can occur for various reasons, including personal, financial, academic, or institutional factors ( Ryan et al., 2021).
The issue of high student attrition rates in healthcare programs has been a subject of research and reporting for several years ( Hamshire et al., 2017, 2019; Merkley, 2015). For instance, it is estimated that between 10 % and 40 % of nursing students leave their programs in Australia, between 30 % and 75 % in the United Kingdom and 50 % in the United States of America ( Lin, 2023; Liu et al., 2023). Physiotherapy programs report attrition rates of 11 % in Australia and 6 % in the United Kingdom ( Ryan et al., 2021). A meta-analysis exploring international medical student attrition reported ranges from 6 % to 14 % ( Maher and Macallister, 2013). The reasons for these high attrition rates are varied. Some reasons are individual student-related, such as struggling with balancing personal commitments with academic workload ( Ryan et al., 2021). Whereas other reasons are specific to healthcare programs such as financial difficulties associated with mandatory unpaid placements ( Eick et al., 2012).
Attrition is a significant concern for educational institutions because of the impact on individual students, institutional revenue, reputation and overall student success rates ( Canzan et al., 2022). However, high attrition in undergraduate healthcare programs is of even greater concern due to the current and predicted global healthcare workforce shortage ( Canzan et al., 2022; Lin, 2023). The World Health Organisation (2024) predicts a 10 million health workers shortage by 2030. These factors highlight the need to address issues having an impact on attrition in efforts to improve student retention for all students completing mandatory unpaid placements.
This scoping review seeks to consider the financial impact of mandatory unpaid placements on university health students. The rationale for focusing on mandatory unpaid placements stems from their increasing prevalence as a component of experiential learning and professional development in various disciplines. These placements offer invaluable real-world experience and professional networking opportunities, yet they also pose financial and logistical challenges that may have an impact on students' ability to sustain their educational and living expenses. These challenges may have an impact on the retention of students studying healthcare at university, which will impact the financial status of the university as well as long-term impacts on the number of students graduating from healthcare disciplines.
2 Methods2.1 Identifying the research question
A scoping review was undertaken to “identify gaps in the evidence base where no research has been conducted” ( Arksy & O’Malley, 2005, p. 7). This framework was considered appropriate given the exploratory nature of the review and its established use in similar papers examining complex, interdisciplinary issues. The Population–Concept–Context (PCC) framework is commonly used to guide the development of focused research objectives and inclusion criteria in scoping reviews ( Pollock et al., 2023). For the current study, we were guided by the following:
- • Population: Healthcare Students
- • Concept: Mandatory unpaid placements
- • Context: University Program
Based on this framework, the research question for this scoping review was: What is known from the existing literature about the financial impact of mandatory unpaid placements on healthcare students in university programs?
2.2 Identifying relevant recordsA structured literature search on the topic was conducted using the following databases: ERIC (EBSCO), Academic Search Complete, Web of Science, MEDLINE, PubMed, Cochrane CINAHL, PsychINFO and Sportdiscus. The research team devised a broad list of keywords pertinent to the topic, including retention OR attrition OR turnover AND placement* OR practicum OR “work integrated learning” OR WIL AND university or college or tertiary or “higher education” or post-secondary or postsecondary. The details about the search in each database are reported in the Appendix.
Varying combinations of the search terms were used to meet the requirements of each of the databases and to ensure a comprehensive retrieval of relevant literature (see Appendix for search details for each database). Due to language proficiency constraints, all database searches were limited to the English language. Reports were included if they discussed mandatory unpaid placements in tertiary education, including university students from health-related disciplines (i.e., Nursing, Midwifery, Occupational Therapy, Physiotherapy and Psychology), explicitly addressed student retention outcomes and were published between January 2014 and June 2024. The 10-year timeframe was selected to reflect contemporary healthcare education and policy environments, particularly considering shifting placement structures and student financial pressures. The process included journal articles, published conference papers and theses, all types of reviews, opinion pieces, editorials and case studies. Blogs, social media pages, unpublished grey literature (e.g., white papers, government reports) were not included.
2.3 Selecting ReportsThe database searches generated 4008 abstracts. The online software package Covidence (2023) was used for managing records, keeping track of papers and excluding duplicates of our study. This software also made it simple to chart our results, as seen in the following Fig. 1. Following the removal of 1625 duplicate papers, three reviewers screened 2383 records for relevance. To filter the records effectively, the inclusion and exclusion criteria for selecting publications are outlined in Table 1. Records were included if they discussed mandatory unpaid placements in tertiary education and explicitly addressed student financial concerns.
Exclusion criteria included records that focused on paid placements or those that do not directly relate to tertiary education settings. Social work was not included as a health discipline for this study. While social work can be directly involved in healthcare and work in healthcare settings, such as clinics and health agencies ( NCBI, 2019), it is an interdisciplinary and transdisciplinary subject ( IFSW, 2025) and its students are often taught outside of the health disciplines.
The 2383 records were screened by three reviewers by first using filters to remove any irrelevant records. For example, many of the papers discussed soil samples, cement resin, water retention, teeth extraction, cell placement and non-tertiary education settings. The remaining few hundred abstracts were then considered and any abstracts that contained exclusion criteria were removed from further study. After reviewing the records, a further 2218 papers were discarded, which resulted in a total of 165 papers for full-text review. A fourth reviewer who was not involved in the screening process resolved conflicts and any conflicts that they were unsure of were brought to the wider group.
The three reviewers involved in the initial screening met to have an in-depth discussion about the inclusion/exclusion criteria and appraised a few abstracts to check for ongoing agreement regarding the criterion. Two of those three reviewers went through the 165 full-text papers. Throughout the screening process, any disagreements or uncertainties were resolved through discussion with the third reviewer until consensus was reached. The reviewers noted that while a lot of papers discussed the financial implications and cost of placement, many were focused on the cost to the institution or to society (for example cost to the university if a student did not complete their degree). During the full-text review, the researchers also looked through the reference lists of the papers and found cited papers that were relevant to this study but were not included in the original search strategy. These two papers were added to the list of papers for full-text review. The full-text review resulted in an additional exclusion of 151 papers. The process concluded with a total of 16 papers that were deemed eligible for inclusion in the scoping review.
2.4 Charting the dataTo resolve any additional conflicts, two additional reviewers conducted a detailed full-text review of the 16 papers, which was then brought back to the group for a more thorough review. Disagreements were resolved through discussion or consultation with all reviewers until consensus was reached. Seven papers out of the 16 were deemed not to meet the criteria, so nine papers were extracted and included in this review. The lead data analyst extracted key information from each of the nine included reports into the structured summary Table 2, below. Extracted data included author(s), country, year of publication, discipline, study aim(s), study design, sample and key findings related to the financial impact of mandatory unpaid placements. A second analyst reviewed all extracted data to ensure completeness and accuracy. Following data extraction, both analysts independently reviewed the key findings and conducted a thematic analysis to identify recurring concepts related to financial burden, student well-being and the implications for the future healthcare workforce. As this study focused specifically on the financial implications of unpaid placements, the themes were developed in the context of unpaid placements only. Themes were developed inductively and refined through collaborative discussion to ensure consistency in interpretation.
3 ResultsNine sources were included in this review based on the eligibility criteria ( Andrew et al., 2022; Bradley et al., 2020; Fedele, 2024; Koch et al., 2014; Lloyd, 2024; Usher et al., 2022; Watson et al., 2017; Wray et al., 2014; William et al., 2024). Data from the selected sources was charted to capture essential information, such as authors, year of publication, study location, study design, population studied and key findings related to the research questions ( Table 2). The design and methodology of the sources varied - three qualitative ( Andrew et al., 2022; Bradley et al., 2020; Koch et al., 2014), three quantitative ( Watson et al., 2017; Wray et al., 2014; Usher et al., 2022) and three opinion pieces ( Fedele, 2024; Lloyd, 2024; William et al., 2024).
Although the search strategy aimed at reviewing the impact of mandatory unpaid placements for all higher education healthcare students, the focus of the sources found were mainly Nursing ( Andrew et al., 2022; Koch et al., 2014; Usher et al., 2022; Watson et al., 2017; Wray et al., 2014) or Nursing and Midwifery ( Fedele, 2024; Lloyd, 2024). Two sources incorporated multiple healthcare disciplines in their studies ( Bradley et al., 2020; William et al., 2024). Seven sources were from Australia (Andrew et al., Bradley et al., Fedele, 2024; Koch et al., 2014; Lloyd, 2024; Usher et al., 2022; William et al., 2024), one from England ( Wray et al., 2014) and one from Pakistan ( Watson et al., 2017).
3.1 ThemesThe nine sources were thematically analysed ( Braun and Clarke, 2022), guided by the following research question: What is the financial impact of mandatory unpaid placements on healthcare students in university programs? This process led to the emergence of three main themes: Financial Burden, Impact on Student Well-being and the Impact on the Future Healthcare Workforce.
3.1.1 Financial burdenIt was widely recognised that completing clinical placements is a valuable and essential component of becoming a healthcare professional. However, eight sources ( Andrew et al., 2022; Bradley et al., 2020; Fedele, 2024; Koch et al., 2014; Lloyd, 2024; Usher et al., 2022; Watson et al., 2017; William et al., 2024) highlighted that these placements incurred a significant additional financial cost to students. Students reported paying additional combined expenses of up to $9000 during their program to account for accommodation, travel, fuel, food and parking ( Bradley et al., 2020; Fedele, 2024; Lloyd, 2024; Usher et al., 2022; William et al., 2024). These costs were further compounded for students residing in regional or rural settings or students required to attend placements in regional and rural settings due to the lack of public transport, fuel and vehicle use for long-distance travel and often the necessity to pay for accommodation due to the inability to travel long distances between shift work requirements ( Bradley et al., 2020; Fedele, 2024; Koch, 2014; Lloyd, 2024; Usher et al., 2022; William et al., 2024). Placement-related costs were also problematic for international students who were required to pay $16000 per semester without financial support. These cohort of students are often not eligible for Government-subsidised Scholarships or Bursaries ( Usher et al., 2022)
Several sources highlighted that attending clinical placement costs are further compounded for healthcare students due to the loss of income during placement periods ( Andrew et al., 2022; Bradley et al., 2020; Lloyd, 2024; Usher et al., 2022). To manage some additional costs, some students moved back home to compensate for the financial pressure ( Andrew et al., 2022) or stayed and travelled with family and friends ( Usher et al., 2022).
The impact of the financial burden of mandatory unpaid placements for healthcare students was also found to differ depending on culture and individual education institutes. For example, a study from Pakistan indicated that it was culturally common practice for parents and older family members, including siblings, to support healthcare students during their study time ( Watson et al., 2017). This study also described assistance from the educational provider and associated healthcare institutes located in Pakistan. The students in this study avoided incurring additional travel or accommodation costs related to unpaid placements by having accommodation attached to their schools and hospitals. If these students were required to travel for off-site placements, this was managed by the education provider, mitigating these costs ( Watson et al., 2017). In contrast, nursing and midwifery students in Australia voiced the need for more university support to find affordable accommodation ( Fedele, 2024).
Beyond family and educational institute support, it became evident that some countries offered Government assistance to some healthcare students through scholarships and bursaries. Overseas models, like one offered in Scotland, provide students with $20,000 non-means tested annually to support placement-associated costs ( Fedele, 2024). The Council of Deans of Nursing and Midwifery (Australia and New Zealand) recommends introducing work-integrated learning bursaries/scholarships for nursing and Midwifery students, with additional support for students required to attend placements in rural and regional settings like these models ( Fedele, 2024). And while the Australian Government has committed to providing some financial support for loss of income incurred while attending mandatory unpaid placements aimed at commencing July 2025, these payments will be means-tested and limited to nursing, social work and teaching students, leaving other healthcare students unsupported ( William et al., 2024).
3.1.2 Impact on student well-beingThe negative impact of mandatory unpaid placements on healthcare students' well-being due to financial stressors was evident among eight of the sources ( Andrew et al., 2022; Bradley et al., 2020; Fedele, 2024; Koch et al., 2014; Lloyd, 2024; Usher et al., 2022; William et al., 2024; Wray et al., 2014). Financial stressors associated with unpaid placements were reported to contribute to anxiety, depression, psychological disorders and burnout among healthcare students and worsen pre-existing conditions ( William et al., 2024). Stressors for mature-aged students with dependent families were further compounded by ensuring that the children were appropriately cared for ( Andrew et al., 2022; Usher et al., 2022). Fedele (2024) reported additional childcare costs for placement periods of up to $15,000. Some students relied on family and partners to provide before and after-school care ( Usher et al., 2022). When students had no family to rely on, this compounded the stress.
To mitigate the increased financial costs of placements, some students increased their casual employment before placement ( Bradley et al., 2020; Usher et al., 2022). This was reported to contribute to students’ physical demands and inability to achieve work-life balance, such as disrupting everyday social life and not being able to participate in their usual sporting activities ( Andrew et al., 2022; Bradley et al., 2020; Wray et al., 2014). These factors had a negative impact on their well-being. In contrast, when students are supported with accommodation and placement-associated costs, students do not report financial stressors ( Watson et al., 2017).
Two sources described the additional stress for healthcare students related to the stability of ongoing employment outside their reports ( Bradley et al., 2020; Usher et al., 2022). When students were required to attend placement, especially at short notice, they were not able to work their regular allocated hours. This had an impact on employer relationships and resulted in many losing their jobs ( Bradley et al., 2020; Usher et al., 2022). Other students reported being contacted frequently by their employer to take evening or weekend shifts, feelings of guilt related to not being available and adding pressure to their co-workers to fill their shifts and having their employer decrease their regular shifts on return from placement ( Bradley et al., 2020).
Beyond the financial stressors impacting well-being, healthcare students reported additional physical impacts. Due to the added accommodation costs, many healthcare students reported stress associated with driving long distances and experiencing extreme fatigue ( Bradley et al., 2020). Other stressors were associated with driving on unfamiliar country roads, potential hazards such as animals and weather conditions and driving either late at night or early in the morning ( Bradley et al., 2020).
Unpaid clinical placements exacerbate financial stress among healthcare students, leading to negative mental and physical health outcomes, such as anxiety, depression, burnout and fatigue. Additional costs like childcare, long-distance travel and job instability during placements exacerbate these stressors, having a further impact on students’ well-being and work-life balance. In contrast, students supported with accommodation or placement cost subsidies report reduced stress and better overall experiences.
3.1.3 Impact on the future healthcare workforceSix sources indicated that unpaid clinical placements for healthcare students may have an impact on the future healthcare workforce ( Andrew et al., 2022; Fedele, 2024; Lloyd, 2024; Watson et al., 2017; William et al., 2024; Wray et al., 2014). Students reported that when they were required to increase their casual employment before placement to compensate for the loss of income during their placement period, this had a negative effect on their academic grades and course progression ( Andrew et al., 2022). Three other sources indicated that healthcare student attrition rates are directly associated with financial stressors ( Fedele, 2024; Lloyd., 2024; William et al., 2024). Another two sources indicated that when financial pressures lead to the inability to achieve a work-life study balance, leading to burnout, there is an increase in the prevalence of students wanting to leave their studies ( William et al., 2024; Wray et al., 2014).
Lloyd (2024) discussed how financial pressure can discourage students with low socio-economic and diverse backgrounds from enrolling in higher education programs. This author suggested a suitable solution for this issue would be to adopt a previously guaranteed low-wage apprenticeship model or provision of Government stipends to assist students with their associated placement costs ( Lloyd, 2024). This concept was further supported by Watson et al. (2017), reporting that student stressors were lower in students who had decreased financial stress compared with students who were required to pay for associated course costs.
Financial pressures from unpaid clinical placements can have a negative impact on healthcare students' academic performance, progression and mental health, contributing to increased attrition rates and potentially reducing diversity and participation in nursing, midwifery and healthcare programs. Addressing these issues through models like stipends or low-wage apprenticeships may alleviate financial stress and support the future healthcare workforce.
4 DiscussionThis scoping review mapped the existing literature on challenges associated with unpaid placements. Our findings reveal that mandatory unpaid placements imposed a significant financial burden on students, disproportionally having an impact on students residing in regional or rural settings and mature-aged students with children. Unpaid clinical placements intensify financial pressures on healthcare students, contributing to adverse mental and physical health outcomes, including heightened anxiety, depression, burnout and fatigue, consistent with findings from Grant-Smith and de Zwaan (2019). These challenges are compounded by additional expenses such as childcare, long-distance travel and disruptions to stable employment during placements, further straining students’ well-being and disrupting their work-life balance ( Fedele, 2024; William et al., 2024). Finally, the financial pressures resulted in student attrition, which could have an impact on the future of the healthcare workforce, as predicted by The World Health Organisation (2024).
Our findings also revealed significant differences for Australian healthcare students in terms of support. For instance, for healthcare students in Pakistan universities, culturally, it is common practice for parents and older family members to support them during their study time ( Watson et al., 2017). However, mature-aged Australian students with children of their own face unique challenges compared with their international counterparts, where these students had an additional cost associated with childcare during mandatory unpaid placement periods, contributing to their stress and mental well-being ( William et al., 2024).
Despite the breadth of research on experiential learning from placements, few reports examine the impact of financial strain, particularly for students in regional universities, on retention and the longer-term future of the healthcare workforce. Like Crombie et al. (2013) our findings highlighted that healthcare student attrition is closely linked to financial stress, with evidence suggesting that the inability to maintain a work-life-study balance due to financial pressures contributes to burnout and a higher likelihood of students considering leaving their studies. High attrition rates in undergraduate nursing, midwifery and healthcare programs are particularly concerning, given the current and projected global healthcare workforce shortages (The World Health Organisation, 2024). Addressing the financial challenges associated with placements could play a crucial role in reducing these attrition rates.
These findings highlight the pressing need for governments to reconsider how mandatory unpaid placements are supported financially, particularly regarding the financial burdens they impose on students from regional and rural settings. This study emphasises the need for broader support for healthcare students, especially nursing and midwifery students, to support placement-associated costs.
5 LimitationsThis study faced several limitations that had an impact on the scope and relevance of the literature reviewed. One significant limitation was the inconsistency in language and terminology used across reports. In some cases, the terminology deviated from the context required to align with the research topic, potentially leading to a misinterpretation of relevant data. For example, the term "clinical placement" in North American literature was often used interchangeably with "course placement," which refers to student grade assessments rather than clinical experiences. As a result, much of the literature in the initial review had to be excluded. Additionally, the term “retention” was frequently associated with soil and water conservation papers, which were irrelevant to the research topic and had to be removed, increasing the volume of articles but not the number of relevant reports.
The study was limited to undergraduate research, which meant that disciplines with unpaid mandatory placements in postgraduate studies, such as psychology, were not captured in this review. Furthermore, current placement research typically focuses on disciplines with larger student cohorts, making it difficult to capture issues in smaller cohorts like physiotherapy and occupational therapy, where relevant reports were sparse and many of the reports did not address the financial implications of unpaid placements, a key element of this research. The literature search was also constrained by a 10-year timeframe, which may have excluded reports addressing financial issues before the pandemic shifted the landscape of placement practices.
Lastly, clinical placements are not a requirement for some accrediting bodies, meaning that in certain disciplines, placements are optional rather than mandatory. As such, students who chose to engage in unpaid placements were likely doing so from a position of financial stability and their starting salaries appear to be higher ( Delis and Jones, 2023), which may limit the generalisability of findings related to students from diverse socio-economic backgrounds.
6 Implications and recommendations for practice and policyThe findings presented in this review are relevant to both national and international audiences, offering valuable insights to inform further research and policy development in higher education. Key recommendations for policy and practice include establishing targeted financial assistance programs and implementing flexible academic structures to better support students undertaking mandatory unpaid placements.
These findings can guide policy development at national and international levels. In Australia, for example, the government recently reviewed educational policies regarding mandatory unpaid placements in critical sectors such as nursing, midwifery, teaching and social work. The 2024 review recommended compensating students during their placements to reduce placement poverty. Starting July 2025, eligible students will receive $319.50 per week while undertaking their placements ( Department of Education, 2024). This initiative is expected to enhance student motivation, increase engagement and reduce attrition rates in high-demand courses. However, other fields that do not yet offer paid placements still face significant financial challenges that must be addressed.
Several studies suggest incorporating financial discussions and budgeting into student preparation for placements. It has also recommended that universities accommodate students' requests to be placed in locations closer to their homes to minimise travel and accommodation costs. Early notification of placement assignments is another common suggestion, as it would allow students to make necessary arrangements, such as organising work leave or childcare, in advance. Additionally, universities may need to collaborate with industry partners to offer shift flexibility, particularly to accommodate students’ parental care responsibilities (Grant- Smith & de-Zwaan, 2019; Andrew et al., 2022). Other studies echo these concerns, highlighting the need for collaboration between governments, universities and professional bodies to develop strategies to alleviate the financial burden of unpaid placements ( Beks et al., 2024). This could include offering small grants for nursing and allied health students and encouraging alumni to donate toward funding clinical placements at their former academic institutions.
The issue of unpaid placements has long been a source of concern, having an impact on student well-being, mental health, motivation, retention and equity. It has also raised ethical concerns, as students contribute significantly to patient care without compensation, which could be perceived as exploitation. Regarding work readiness and skills acquisition, students on unpaid placements often experience stress, particularly when they rely on part-time jobs to support themselves. This financial strain, compounded by rising living costs, can affect their academic performance and overall well-being. Unpaid placements have been linked to increased rates of burnout, depression and anxiety as students struggle to balance academic requirements with the demands of unpaid work. Furthermore, a possible implication is that students from rural or low socio-economic backgrounds may be discouraged from pursuing courses like nursing, which can undermine efforts to promote diversity and inclusion in the profession.
Despite the ongoing challenges posed by unpaid placements in various academic disciplines, it is crucial to implement policies that ensure fairness, protect student rights and establish clear mentorship guidelines. These policies should also address supervision and feedback mechanisms for students on placements. These findings underscore the need for comprehensive policy reforms to address the financial, emotional and professional challenges students face in mandatory unpaid placements.
7 Future researchGiven the scarcity of research in this area and across allied health courses like physiotherapy, occupational therapy and paramedicine, the next step could be to conduct a systematic review and a meta-analysis by evaluating domains not currently examined and extending the coverage to include postgraduate courses.
Future research should also consider cross-cultural impacts, as most of what is presently known is derived from Western, more individualistic cultures. Cross-cultural research may provide a different perspective not presently accounted for, such as the role of extended family members in childcare among more collectivistic cultures.
Given the impact of unpaid clinical placements on students’ mental health ( William et al., 2024), future studies can include perspectives of educators in clinical placements as they could provide valuable insights on student well-being and performance during clinical practice.
Finally, while this review focuses on synthesizing evidence, the findings also lay the groundwork for future policy and practice interventions. The Consolidated Framework for Implementation Research ( CFIR; CFIR Research Team – Center for Clinical Management Research, 2025), one of most highly cited frameworks in implementation science ( Damschroder et al., 2022), offers a useful lens for identifying barriers and enablers to implementing support systems for students in mandatory unpaid placements. Future studies may use CFIR to design and evaluate targeted interventions at the institutional or policy level. Further exploration of cost-of-living pressures, placement structure (e.g., block vs. integrated models) and generational attitudes toward full-time study versus work could also provide valuable context for understanding attrition trends and informing equitable placement policy reform.
8 ConclusionsThis review found that mandatory unpaid placements impose a significant financial burden on healthcare students. This, in turn, has a negative impact on students’ mental health and well-being and university retention. The review highlights the lack of research on students in regional universities and the impact on student retention and the longer-term future of the healthcare workforce. Based on these abovementioned findings, reforms in policy and practice are recommended. The present findings expand our current understanding of the intersection of experiential learning, student retention and financial equity. The review presents findings relevant to national and international audiences and provides a foundation for further research and policy development in higher education.
FundingNo external funding
CRediT authorship contribution statementRebecca Peel: Writing – review & editing. Miriam Muduwa: Writing – original draft, Data curation. Louise Allen: Writing – original draft, Formal analysis. Karen Missen: Writing – original draft, Validation, Formal analysis. Ma. Regina L. de Gracia: Writing – original draft, Methodology, Data curation. Tiffany Winchester: Writing – review & editing, Writing – original draft, Supervision, Methodology, Data curation.
Declaration of Competing InterestThe authors report there are no competing interests to declare.
AcknowledgmentsThe researchers would like to acknowledge the Liaison Librarians from Federation University, including the specialist in Review Protocols. They worked with us to identify keywords and assisted our initial search strategy.
AppendixThe full search strategies for all databases and the date the most recent search was executed.
| Database | Search Strategy |
| ERIC | (retention OR attrition OR turnover)
AND (placement* OR practicum OR “work integrated learning” OR. WIL) AND (university or college or tertiary or “higher education” or post-secondary or postsecondary) Date range: 2014–2024 Date search completed: November 1st, 2024 256 studies returned |
| Academic Search Complete | (retention OR attrition OR turnover)
AND (placement* OR practicum OR “work integrated learning” OR WIL) AND (university or college or tertiary or “higher education” or post-secondary or postsecondary) Date range: 2014–2024 Language English Date search completed: November 1st, 2024 832 studies returned |
| PsychInfo | (retention OR attrition OR turnover)
AND (placement* OR practicum OR “work integrated learning” OR WIL) AND (university or college or tertiary or “higher education” or post-secondary or postsecondary) Language: English Date range: 2014–2024 Date search completed: November 1st, 2024 335 studies returned |
| SPORTDiscus | (retention OR attrition OR turnover)
AND (placement* OR practicum OR “work integrated learning” OR WIL) AND (university or college or tertiary or “higher education” or post-secondary or postsecondary) Language: English Date range: 2014–2024 Date search completed: November 1st, 2024 17 studies returned |
| CINAHL | retention OR attrition OR turnover
AND placement* OR practicum OR “work integrated learning” AND university OR college OR tertiary OR “higher education” Limit 2014 – 2024 Limit English = 142– uploaded to covidence Date of search November 1st, 2024 |
| MEDLINE | retention OR attrition OR turnover
AND placement* OR practicum OR “work integrated learning” AND university OR college OR tertiary OR “higher education” Limit 2014 – 2024 Limit English = 1362 – uploaded to covidence Date of search November 1st, 2024 |
| Web of Science | retention OR attrition OR turnover
AND placement* OR practicum OR “work integrated learning” AND university OR college OR tertiary OR “higher education” Limit 2010–2024 Limit English = 624 uploaded to covidence Date of search November 1st, 2024 |
| Pubmed | (retention OR attrition OR turnover)
AND (placement* OR practicum OR "work integrated learning" OR WIL)) AND (university or college or tertiary or "higher education" or post-secondary or postsecondary) Language: English Date range: 2014–2024 Species: Human Age: Adolescent -> 80 + years Date search completed: November 1st, 2024 440 studies returned |
| Cochrane | retention OR attrition OR turnover
AND placement* OR practicum OR “work integrated learning” AND university OR college OR tertiary OR “higher education” All year's number returned (full text) = 597 all irrelevant articles Searched title and abstract = 1 irrelevant article on dental There was a tab on trials and clicked out of curiosity returned = 121 quite irrelevant articles. Conclusion= nothing from Cochrane Date search completed: November 1st, 2024 |
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| Journal articles, published conference papers and theses, all types of reviews, opinion pieces, editorials, and case studies | Blogs, social media pages, unpublished grey literature such as white papers, government reports |
| Higher education, undergraduate, university students | Post-graduates, TAFE (Diploma or Certificate level), Registered Training Organisations (RTOs) |
| Mandatory placements, placement poverty | Optional placements, employment, internships or cadetships |
| Published within the last 10 years (2014–2024) | Publications before 2014 |
| Due to language proficiency constraints, the review might limit sources to those available in English. | Not in English |
| Health related disciplines | Education, Social Work, other subjects outside health disciplines |
| Financial challenges in placement, including costs, expenses, income support, lost wages | Non-financial challenges such as mentorship, bullying, peer support, general stresses |
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Andrew et al. (2022)
Australia | Nursing | To report on the practicum experience of women nurse students with family responsibility in an Australian School of Nursing. | Qualitative | 23 Women nurse students in their final semester of study. | Two themes:
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Bradley et al. (2020)
Australia | Nursing, Occupational Therapy, Social work, Medical imaging, physiotherapy | To identify the enablers and barriers most strongly affecting placement satisfaction and personal wellbeing. | Qualitative | Nursing (6), Occupational Therapy (6), Social work (10), Medical imaging (2), physiotherapy (1) | Three themes:
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Fedele, (2024)
Australia | Nursing & Midwifery | Opinion pieces
| 2 BNBM students, Executive Dean of Nursing | Key notes:
Costs to complete clinical placement hours about $9000 each year include: fuel, parking, uniforms, clinical tools & food expenses, and $15,000 for childcare. Attrition is directly associated to expenses. Poverty on Placement refers to Usher et al.’s 2022 article. An Academic recommends introduction of WIL bursaries is similar to international models (Scotland). Two student survey are also referred to from La Trobe University & Griffith University | |
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Koch et al. (2014)
Australia | Nursing | To describe the clinical experiences of nursing students and the diversity characteristics that affect this learning experience | Qualitative
Open-ended responses from surveys | 704 nursing students & 165 academic staff | Three themes and their subthemes:
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Lloyd, (2024)
Australia | Nursing/midwifery | Opinion Piece | ANMF (Nursing & Midwifery Union vice president. | Key notes:
Clinical placements are valuable but come at a high financial cost. These include travel, accommodation, food expenses and loss of income. This financial pressure affects student well-being and academic grades. Financial pressure can discourage students with low socio-economic backgrounds & diverse backgrounds from enrolling. Previous apprenticeship models did offer low wage guaranteed wages. Proposed means-tested Government stipends may assist in addressing some of the associated placement financial costs. | |
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Watson et al. (2017)
Pakistan | Nursing | To determine factors contributing to stress experienced by preregistration nursing students in Pakistan, using the stressors in Nursing Students scale. | Quantitative
Cross-sectional survey (Stressors in Nursing students scale) | 726 nursing (Diploma and BN) students from 11 schools | Key findings:
Pakistani nursing programs have 50 % theory and 50 % practical element, allowing more integration and accounting for the reduced issues. Parents and older family members often cover the costs associated with education, suggesting that students do not see finances as a cause of stress. The hospital met all accommodation needs and travelled to off-site placements. Male students reported higher stress than females. |
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William et al. (2024)
Australia | Nursing, Para medicine, Physiotherapy, Paramedicine, Medicine, Occupational Therapy, Clinical Psychology, Speech-language Pathology | Editorial | Key notes:
Financial stressors of unpaid placements, such as additional costs of housing and transport, contribute to Anxiety, Depression, psychological disorders and Burnout. Additional stress occurs for mature-aged students from regional and rural areas with extra costs such as childcare and travel. These stressors impact the future health workforce shortfall. Although the Australian Government has committed to providing some financial support for nursing students in 2025, it will be means-tested (not available for all students), not available for other health disciplines, and will not support current students. | ||
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Wray et al. (2014)
England | Nursing | To explore the characteristics, views & experiences of continuing students on factors that facilitated continuation | Quantitative
Cross sectional survey design | 195 nursing students | Key findings:
Results are divided into pull & push factors in decisions to stay. Pull factors (to stay enrolled) included career opportunities, ability to continue in the course, personal attributes such as determination or fear to leave, and support from the university and others. Push factors (to leave) included: financial, life-work-study balance, placement and lack of support. |
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Usher et al. (2022)
Australia | Nursing | To quantify the financial challenges faced by Australian preregistration nursing students associate with mandatory practice-base WIL placements | Quantitative
Cross sectional Online survey (28-items) | 2359 Nursing students from 9 universities who have attended at least one WIL placement | Ten themes:
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