A realist exploration of co-designed practice-placement models that ‘worked’ in shifting contexts of allied health industry, workforce and policy

A realist exploration of co-designed practice-placement models that ‘worked’ in shifting contexts of allied health industry, workforce and policy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A realist exploration of co-designed practice-placement models that ‘worked’ in shifting contexts of allied health industry, workforce and policy Stacie Attrill, Kristen Foley, Chris Brebner This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7266234/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Dec, 2025 Read the published version in BMC Health Services Research → Version 1 posted 12 You are reading this latest preprint version Abstract Practice placements are a substantive component of allied health student curriculum that are critical for developing allied health professional competence. Students are situated in practice settings during placement, where their learning opportunities are opportunistic, and shaped according to population, industry, and policy needs: which change over time and in relation to each other as well as external forces. Allied health practice-placements must respond and adapt to the complex and evolving landscapes of practice; and evidence about the processes and products of such innovation is critical. Realist exploration of practice placements as open systems that occur within broader open systems, helps to expose and explore the changing factors that enfold practice placements and render them workable for service providers who manage competing priorities. We contribute a realist exploration of placement models developed for allied health learning during a profound transition of the Australian disability sector: from centrally- to recipient-controlled funding. In the context of declining placement offerings and reports of practitioner fatigue and administrative load, we facilitated an action-research workforce project with university and placement providers of allied health services to develop and trial quality placement education amidst transitional policy implementation. Our investigation seeks to understand the context-mechanism-outcome-configurations of innovative placement models that ‘worked’ for placement providers and students during a time of policy and industry turbulence. We apply layered realist inference to explore qualitative data collection with 40 students, practitioners, educators and placement facilitators about the process/es of innovating student placements (n = 50 instances); novel placement features co-designed during the project; and the role of placement facilitation within processes of co-design. Our key findings show that a collaborative approach to practice-placement education supports reflection about novel models and helps the needs of students and service recipients to become more visible in the relevant context/s of service provision. We further show the importance of developing reciprocity and partnerships for quality placement outcomes, without the need for resource-intensive placement facilitation approaches. This evidence is useful for promoting quality allied health education as the profession continues to expand and evolve, amidst open systems of policy and industry that influence practice and education. student placement/WIL service provision allied health realist synthesis clinical placement practice education Figures Figure 1 Figure 2 Background Allied health placements are situated within a patchwork of health and community service provision that respond to diverse individual and community needs; divested through heterogenous policy, sectoral, and funding models. In allied health, placements form a critical component of pre-qualification curricula, facilitating students’ development of the knowledge, skills and attributes of practice, and providing exposure to a range of organisational cultures, settings and practice populations that underpin professional socialisation and the shaping of practice ( 1 , 2 ). Students are typically supervised by allied health practitioners employed within ‘host’ organisations, who engage students in learning activities informed and shaped by practice germane to the setting ( 3 , 4 ). The structure of placements, student supervision, and understandings of the role of students in practice settings and how they are afforded learning opportunities is relatively consistent across allied health professions and settings ( 5 ), often grounded in historical conceptions of practice and pedagogy ( 6 ), yet may not necessarily ‘work’ for all providers and settings. Different dimensions of placement education are explored within the literature. A recent review explored the ratio of supervisor to students, and the nature of supervision type (e.g. in-person supervision, long-arm supervision, interprofessional supervision) ( 4 ). Temporal dimensions inform how placements might fit for university and practice stakeholders, with options for placements in ‘block’ or ‘sessional’ formats, reflecting a commitment of time in placement that students attend each week ( 3 , 7 ). Recent research has explored peer-learning placements, identifying students’ role in supporting their own and others’ learning ( 8 ). The research literature on allied health professional education suggests that placement design is prominently university-led, and adapted according to student or supervisor factors ( 6 ); while contextual features like service provision, organisational design, funding or models of care receive less attention despite their salient impact on placement outcomes. Placement design, relating to how students interact with activities of practice and are positioned within and contribute to dynamic workplace environments as learners, remains relatively unchanged since early conceptions of practice-based learning. Close individual or paired student supervision remains dominant in allied health ( 3 , 9 ), providing oversight that reduces perceived risk of students practicing with the public, but producing resource-intensive supervision structures that are burdensome for practitioners who concurrently manage complex clinical caseloads and broader organisational demands ( 10 , 11 ). Increasing population complexity, and the broadening scope and demand on allied health services ( 12 ), in addition to the cost burden for service providers and universities and administering quality placement experiences ( 13 ) further constrain capacity to produce quality learning outcomes. Novel placement design that is fit-for-purpose for contemporary practice settings is needed in the face of these competing factors. Allied health practice is influenced by surrounding policy climates ( 14 ), cultural values ( 15 ) and diverse views of what health is and to whom ( 16 , 17 ). Global shifts in health, disability and education policy frameworks towards individualised or activity-led funding schemes have produced a marketisation of allied health that focusses funding on service activity and empowers consumers to make service choices that best meet their needs and goals ( 18 ). Allied health placements, situated in these global phenomena of change, are increasingly pressured ( 6 , 19 ). Amidst this context, it remains critical to optimise the transformational learning and competency outcomes that placements provide to allied health students ( 20 ). This manuscript uses data-driven realist analysis to describe collaborative design, development, enactment and revision of innovative allied health placement models in novel and transitional industry settings. We delineate three research questions for investigation: RQ1: What novel placement education models ‘worked’ amidst transitional contexts of allied health service provision? Fee-for-service practice, developed to respond to the introduction of individualised disability funding in Australia provides a useful theoretical window, as findings transfer to broader individualised and/or activity funded settings that represent the cross-sectoral work of allied health professionals. This context enables a granular realist exploration of the interrelationships within context-mechanism-outcome-configurations (CMOCs) that enable or constrain placement education: RQ2: What are common elements, features and factors that enabled the development, implementation and revision of these placement models? To facilitate quality outcomes, placement facilitators liaised with service providers while developing the models. As placement facilitators were an interim project mechanism, we sought to understand: RQ3: How can placement models be made sustainable? We seek to contribute pragmatic resources and reflections that guide the development of placement models that can ‘work’ in emergent industry and policy landscapes. Methods Realist thinking and paradigms Realist exploration recognises that social life is a complex open system where multiple systems interrelate to produce certain phenomena ( 21 ). Placement education can be considered as an emergent system which co-occurs with other complex, open and emergent systems, such as university education and allied health service delivery systems, with the focus of realist analyses emphasising practicality and real-world problem-solving (Bhaskar & Hartwig, 2010; Price & Martin, 2018). A cohering question of realist methods is: ‘what works, for whom, under what circumstances?’ ( 22 ), described via a Context-Mechanism-Outcome-Configuration (CMOC) that can be interrogated through logic such as, ‘if’ this is present, then ‘ this’ happens ( 21 ). Certain ‘mechanisms’ that work in some contexts, cannot be assumed to produce the same ‘outcomes’ in another context – the elements are evaluated together as systems ( 23 )). For this study, realist thinking is helpful to ( 1 ) position placement models as ‘outcomes’ that emerge in particular contexts (i.e. RQ1); to ( 2 ) use data to identify which mechanisms were useful for their development, enactment and revision (i.e. RQ2); and to ( 3 ) hypothesise how these processes could be made sustainable within other contexts (i.e. RQ3). Materials We draw on multiple perspectives derived from the activities of a large-scale allied health workforce project ( 19 ) to explore the different features and elements within the CMOCs. This includes qualitative interviews with stakeholders and case study evidence of how placements were developed, implemented and revised. Overarching Project Context The workforce project addressed declining placement numbers during Australian disability sector transition from government-led to individualised funding (the National Disability Insurance Scheme (NDIS)). In Australia, disability services are fairly distinct from health services in their provision and both sectors are key employers of allied health practitioners. Allied health placements occur across both settings, however this project focussed on increasing placements within disability settings because of a decline amidst the transition to the NDIS. The project was overseen by a Project Advisory Group (PAG), comprised of invited experts from multiple sectors relevant to the NDIS and allied health services, who provided input on the project methods, interpretations and recommendations. Of relevance to this study, the PAG oversaw development of the initial principles to guide placement model development with service providers; reported in detail elsewhere ( 19 ). Participants from disability, policy, higher education and service provision sectors were then involved in iterative knowledge-action cycles to co-develop and refine placement models that would ‘work’ in diverse contexts of service provision. Placement facilitators were allied health practitioners who were funded within the project, in capacity-focussed roles to support service providers to develop and implement placement models for the changing NDIS context (see position description in Supplementary File 1). As the placement models were designed to be sustained, it was planned that the facilitators would be withdrawn following their implementation and refinement. During their collaborations with service providers in the project, they recorded field notes and reflections to document the reasoning and processes associated with developing and revising student placements. These reasoning elements are valuable for evidential critique to unpack how the presence and actions of placement facilitators were productive in the ways they nuanced CMOCs ( 24 ). Realist/retroductive approach to understanding the workings of placement models This manuscript synthesises evidence developed about the context and mechanisms of placement education to understand why certain placement models ‘worked’ (represented in Fig. 1 below). We use retroduction to guide understanding of if, or to what extent, casual chains of influence predicted during the development of placement models (i.e. our ‘program theories’) unfolded in the real world ( 25 ). We integrated prior evidence developed within the project activities ( 6 , 14 , 18 , 19 ) from a realist frame, to inform our understanding of the contexts, and subsequently collated and analysed the CMOCs in which the models increased placement availability. Data Collection, Collation and Considerations Eight service providers were recruited by university placement education staff through existing relationships as project partners. Discussion prior to each provider consenting included: confidentiality, the integrity of their relationship with the university auspicing the project, and future use of their data to translate project learnings. As placement facilitators liaised with service providers and provided a bridge to the university research team, they did not access raw project data, instead, accessing synthesised, de-identified data to assist in developing and refining iterative placement models. This distinction supported appropriate boundaries and feedback transparency, which was established in the ethics approval, provided by XXXX (project number 7551). Placement facilitators were also approved to be interviewed as project participants to contribute their first-hand perspectives on mechanisms (and limitations) of the novel models. We draw on primary data analysis via qualitative data collection with placement facilitators (n = 4), service providers (n = 24), placement coordinators (n = 3), peak body representatives (n = 4), chief financial officers (n = 3) and students (n = 12); summarised in Table 1 in relation to the ‘stage’ of data collection. Table 1: Stage of data collection in relation to practice-placement planning, trial, and refinement Develop Trial Refine Total Service providers 6 8* 10* 24 Peak body representatives (disability and profession-specific) 2 2* 4 Placement facilitators 2 2* 4 Placement coordinators 3 3 Chief financial officers 3 3 Students (focus groups and individual interviews) 12 12 8 13 29 50 *Ten participants were interviewed twice to capture depth and change through the project stages (placement facilitators, peak body representatives, and six service providers). Researchers were Speech-Language Pathology and Occupational Therapy practitioners trained in qualitative research. Interviews were conducted at places convenient to participants or via phone or Zoom, and ranged between 30–60 minutes. At least one practitioner from each service provider was interviewed, however interviews were completed with two or three practitioners for providers with larger operations. Interviews took place pre-, mid-, and post-trial of newly-developed placement models with iteratively developed interview guides reported elsewhere ( 6 ). Allied health students who had completed at least one placement in a model developed through the project were invited to interview with peers or individually if preferred. Prior to consenting, students were provided information which noted their participation would not affect their learning or assessment. Five students participated in two group interviews, and seven students completed a phone interview. Refer to Supplementary File 2 for student interview guide. Interviews followed a semi-structured guide that was iteratively adjusted to respond to early themes, reflecting a responsive qualitative approach ( 26 ) and our action-research approach to the project (i.e. 19, 27). Different stakeholder groups were asked different questions, as related to their positioned experience and engagement with placements developed during the project. Data Analysis and Reflexive Posturing Interviews audio-recorded and transcribed, and then coded inductively by author XX, with fortnightly research team meetings to cross-check and explore the findings. Author XX subsequently coded the project data deductively to explore features of developing and enacting placements for this study. This round of coding was cross-checked by the first and fourth authors. Abductive examination ( 24 ) was developed by authors XX and XX regarding the role and impacts of particular elements in the CMOCs in which placement education is an outcome. Further retroductive theorization ( 28 ) was undertaken – looking across placement models, the broader workforce project, the industry landscape, and determining the relevance of various service provision elements to how particular CMOCs unfold. The output of this collaborative work forms the Results and Discussion. Results We have organized our analyses to directly respond to the three research questions. We use participant quotes, denoted by a pseudonym, their role in relation to placement education, and the timing of the interview (pre-, mid- or post-trial of placement models). RQ1: Innovative Placement Education Models that ‘Worked’ Contextual factors enfolding placement models The iterative co-development and refinement of placement models revealed the importance of tailoring placement design according to the service provider’s context, including organisational approaches, objectives and goals, and practice context including the population/s served and type/s of practice provided. Identifying how student placement activity could contribute within these contexts was key to stakeholder buy-in, with goals often related to: increasing operational capacity or service throughput via student activity; or addressing funding-related service gaps or reduced clinical staffing availability or capacity. developing future disability workforce capabilities or facilitating recruitment of future practitioners to the organisation. facilitating outcomes for specific client or community needs (e.g. opportunities for clients with communication difficulties to engage with new people) providing supervision opportunities for staff or new practice areas that result from increased service capacity. As service provider contexts were mapped, mechanisms that may afford successful placements within each organisation were identified and modelled. Model features that enabled placement capacity related to how student activities were coordinated within service provision or supervision functions, and were categorised as: Increasing student volume (e.g. groups of students placed together), frequency or continuity of placement/s to give rise to new or increased service capacity. Utilising peer learning and mentoring approaches between students to open up supervision capacity, foster student learning, orientation and continuity of client care. Prioritising placement scheduling and timings according to peak service provision periods and organisational drivers, to optimise supervision capacity and workforce availability. Mapping student activities to best meet specific needs of clients engaged in each organisation, enhancing service delivery. Optimising usual organisational functions to support student experience (e.g. students working across clinic and school settings to optimise funding availabilities of each setting). Promoting proactive, early supports for placement design, student performance and learning outcomes via early regular communication with the university provider. An analytical approach to the placement dimensions (19) was used to develop and revise the placement models. The dimensions outline how placement features may interact through the contexts of service provision, and can be tailored and further iterated for individual organisations. These dimensions focussed initial discussions with service providers, who then collaborated with a placement facilitator using reflection tools that were developed to support the conceptualisation of model features (see Supplementary File 3) to adapt ideas that were fit for their setting. Two exemplars that illustrate how novel placement models were designed to ‘work’ in particular settings, using the placement dimensions, are provided in Boxes 1 & 2. Box 1 Context: A private practice situated in an urban, metropolitan area providing paediatric allied health services in a community experiencing socio-economic disadvantage. The practice had traditionally struggled to recruit allied health practitioners, and prospective clients experienced lengthy waiting periods, with few alternative services available. The practice location had poor public transport access, and previous students had experienced difficulties travelling to placement. The practice had hosted incidental placements of individual or paired students, but reported challenges in providing the support time for student learning without affecting their usual business functions, or impacting their capacity to see clients. Entirely reliant on fee-for-service income, the practice needed solutions to a) manage implications related to cost and b) ensure positive student learning experiences that would promote future recruitment; while c) retaining supportive and authentic placement experiences. Model: Cross-over continuous placements, utilising group supervision and peer transition A continuous, year-round placement model was designed to ensure consistency and reliability of client services. Placements were three days/week for 13 weeks, to cohere with service provider and university needs. A placement cross-over was designed, whereby the final week of a placement was also timetabled as the first week of the next placement, enabling a system of placements to be scheduled continuously across the year. Completing students were paired with commencing students, who provided mentoring for placement orientation, client hand-over, and opportunities for the commencing students to observe their practice during the ‘cross-over week’. This critical education design feature, provided all students with peer learning, orientation and models of relevant practice knowledge and skills, while also reducing the supervision load. The continuous presence of students across the year was critical for the business needs of the service provider, as it supported consistent planning and service capacity for clients, and reduced the necessity to increase or decrease client activity to accommodate student needs. In each placement, four students were placed together, supervised by a single or pair of practitioners, depending on the time of year and availability; and enabling students to arrange shared travel to the setting. Opportunities for practitioners to supervise students together developed supervision capacity across the service, and ensured regular supervision breaks for team members across the year. This also enabled capacity to increase supervision input for students needing additional support to develop competency. Placements were carefully mapped against typical service performance measures to ensure that average expected client activity and income was maintained. To achieve this, the client activity affordances of four students were accounted for across the placement, with the model designed to progressively reduce supervision scaffolding according to students’ developing competency and increasing capacity for client load. Students were initially paired, and peer-learning principles were used to guide student-led client planning, paired session procedures, feedback and group reflection. The supervision model was designed to ensure the practitioner oversaw student activities with clients, meeting the funding requirements and supporting student-led sessions. Recognising opportunities to address thin service availability in the region, the service provider negotiated a student-led screening and early intervention clinic in a local school as a community value-add. This addition meant that each 3 day/week placement was comprised of two clinic days and a third day in the school. Whilst this required the service to provide student supervision at the school, the provider benefitted through increased referrals and community awareness. For students, placement across the school and clinic enabled opportunities to work with clients across contexts, and as school services were not fee-for-service, to enact more autonomous practice in alignment with their developing competency. We now present a second placement model that responds to different contextual drivers of a community service provider, with placement capacity afforded through mechanisms that focussed on student collaboration and client needs. Box 2 Context: A not-for-profit, community-based disability service providing allied health services for an under-served, adult population that had not previously hosted student placements. The service provider identified a need to increase cross-sectoral awareness and continuity of care for the complex population it serves. Opportunities to enhance the continuity of support for clients transitioning from inpatient rehabilitation services to their community-based program were identified as important, and funding gaps that often occurred during this transition were reported to exacerbate challenges for commencing clients. The service prioritised interdisciplinary care that supports clients to meet community participation and vocational goals. Whilst good practice, the service reported that interdisciplinary care models were difficult to achieve as clients were typically funded for sessions with a single practitioner. The service provider identified opportunities for students to lead work in client advocacy and community-awareness which is critical for this population, but these indirect client activities were under-funded in individualised NDIS plans. As such, placement outcome goals were prioritised to a) support cost-effective interdisciplinary client services; b) develop a tangible interface between health and community services to support continuity of care and service; and c) to conduct advocacy and community-awareness activities. Model: Interprofessional paired placement model using peer mentoring An interprofessional model with four students allocated to each placement was designed to enable two pairs of speech pathology and occupational therapy students learning and practicing together to provide integrated, goal-oriented client services. The placement was designed as two days/week for 20 weeks to accord with the organisation’s service provision patterns, supervision capacity and space availability; and aligned with university semesters. The service provider allocated a speech pathologist and occupational therapist as student supervisors who split supervision time and processes to facilitate interprofessional and profession-specific learning. Students interacted with clients in a specifically designed student-led service, and were supported to understand the client group, placement objectives and the nature of interprofessional learning via a prescribed orientation completed prior to the placement. The student-led service was designed to supplement existing services and expand on and practice client’s participation goals. A peer-mentoring model of learning was enacted using a supported learning structure that enabled final year students who were experienced in placement learning to provide structured supervision, feedback and modelling to novice students of their own profession who were commencing their placement program, under the overarching guidance of the practitioner supervisors. This developed student skills in supervision and mentoring, a critical graduate competency, whilst also reducing the supervision load. This mix of student experience enabled clients to be stratified according to complexity and the students’ placement learning requirements, with senior students completing case management and more complex clinical work, while their less experienced peer mentees worked in parallel on progressing clients’ therapeutic and participatory goals. In this model, senior students completed 2 days/week and mentee novice students completed 1 day/week to align with the organisation’s capacity and client program availability. This also enabled senior students to use the second day to progress interprofessional goals and implement advocacy and community awareness activities. To support the organisation’s goals to reduce the continuity gap experienced when clients commenced with the organisation, cross-sectoral activities were designed to enable collaboration between the senior students and the referring healthcare team in discharge planning and client goal setting, and to commence early practice with prospective clients during the transition period to their community service. Several innovative practice-placement models were implemented during the project, each producing increased placement capacity, yet individually designed to respond to particular practice settings. Discussions with the placement facilitators enabled service providers to reflect about previous students’ placement experiences, opening metacognitive considerations of how their settings might best afford student learning outcomes and build towards organisational goals – this reflective process of mapping between contextual settings of placement and a range of desired outcomes, seemed to act as a mechanism that helped to optimise the ‘workability’ of the model: We've modified the locations that we offer the placements in to try and get a client load that’s going to better fit with the student experience. We've done a bit of work around trying to set up good induction processes and good information provision to the students to try and help them prepare to come in, be ready a little bit quicker to understand what their placement's going to look like and what their responsibilities in that will be and what our role will be and what things we'll do to try and support them with being successful with that. (Practice manager 2, pre-trial) Such reflections examined historical assumptions and restrictions that had constrained placement design (14): Ultimately I'd like to have them all the time, I would like to have at least one to two students that can have a placement here year-round, so that one is finishing and another one is starting. But it just is a bit dependent on the capacity of the staff member to be able to take that on… At the moment we've got four students on placement and it's worked quite well in the way that I've been able to have two directly with me… I guess in the past then, mostly what we've had is one student to one clinical educator, that's mostly how it's worked. (Provider 4, post-trial) Placement facilitators identified that the process of placement design and discussion opened opportunities to consider how traditional placement structures could be refined to situate placement activities effectively within the service context: The [particular] proposal is that it doesn’t sit within traditional placements at all. It is very much around community access and functional communication and generalisation and basically everything we aspire to as speech pathologists and clinicians… what’s going to happen is once it’s up and running you have a couple of senior students and four junior students, in a mentoring style. The placement will run across about six to nine months of the year, and it will be looking at taking the clients… in to the community to learn to interact and use communication functionally. (Facilitator 1, mid-trial) Students highlighted that learning grounded in the disability service contexts during these placements linked with their future plans and capacity to engage with the workforce: I want to work in disability. It's - well one of the areas I've always wanted to go down that track. I was a bit hesitant to have a placement in a private practice because you do hear… like the prime example of what I wouldn't want to work in. But I think I've had time to think about it and realise that you have to do your investigating and find out what a practice is like. Because …I want to make really informed decisions around moving into private practice. (Student group 2, post-trial) Students articulated struggles with placement models that moved away from individual supervision, however, they reported these as also enabling new and mutual ways to learn and connect with others: I think the mentoring system was really, really good on the placement. When I first started I wasn't very sure, only… because we were the mentors… our mentees were in their third year of the degree and some of them… seemed to have just as much, if not a bit more knowledge than we did initially. I'm still in touch with most of the mentees as well, there were only four of them but it was nice to get to know [them] and hear all their knowledge as well…They were also our mentors in a way. (Student 5, post-trial) Peer mentoring, paired supervision, supporting community engagement objectives that were elsewise underfunded, and cross-over placement models that involved a handover period between groups of students were therefore some of the features of placement models that ‘worked’ with the support of placement facilitation. RQ2: Common elements, features and factors that enabled development, enactment and revision of placement models Our data identify the importance of guiding principles to enable placement model development that fosters innovation. The principles below, reported in detail elsewhere (19), reflected collaborative input on the overarching purpose of placements, which within our project were considered as the ‘outcomes’ which demonstrated that placements were working: Pedagogically sound Quality for all Person (family) -centred NDIS compliant Informed by evidence. The principles guide mapping of student education and service provider goals and activities; and how collaborative relationships involving service provider and practitioners, clients, students and the university may integrate. Model design also situated individual ‘placements’ within an overall program of placements tailored for each service provider, then also using the context-mechanism relationships explicated in the ‘placement dimensions’ with the placement principles to co-develop setting responsive placement systems (RQ1, Fig 2). Placement design commonly prioritised quality services oriented to client goals and needs. Opportunities for innovation included recognising what clients valued about services – and working backwards from this logic to develop new ways to enact placements. The following provider prioritised person-centredness, prompting a placement design in which students complete placement one or two days each week over a longer timespan to facilitate continuity of service and relationship development: I think for families what I was finding was - that relationship was really important to them and having students come in and cycle through was not at all what they wanted. (Provider 3, post-trial) Another provider reflected on the importance of ensuring that a student placement came at the ‘right time’ within a client’s developmental or service trajectory to ensure quality outcomes: … that's the kind of thing that we need to start thinking about is, when a kid's ready maybe for a student placement - some of our clients like maybe we need to get you started… (Provider 6, pre-trial) Several providers identified how using the dimension of placement timing to support their thinking opened opportunities to test traditional temporal structures that had constrained placements in their setting: I think, for us, in terms of looking at offering placements at the same time as other disciplines, so specifically looking at [OT] to then to be able to provide more of a [multi D] clinic, which then, will actually set the students up in a better place to actually come and work… …we're hoping to look at having a more ongoing clinic for service. (Provider 3, mid-trial) Some providers examined how placement models might enhance service delivery. For example, service gaps created by funding rules created opportunities for placements to respond in ways that added value to clients: I feel that the clients have been able to get more of a holistic service. Meaning that what we've been able to do in [student] sessions, we've also been able to target things outside of sessions a little bit more in terms of providing resource development or additional take-home things, out of therapy sessions, those sorts of things. (Provider 4, post-trial) Mutuality of learning and benefit for the provider, clients and students was an important design input: To build [student] skills in evidence-based practice and presenting to team members, while students are with us they run a tute for our team.... It has to be important for the practice, and they need to… make sure that we don't already have key information around that. (Provider 1, mid-trial) The placement dimensions prompted service providers to reflect about implementing placement models for particular communities and areas of need, creating space to enhance service equity and accessibility: I think having more student clinics out maybe in some of the more disadvantaged, socially-economically disadvantaged areas might be really good… If there was a way to try and take the clinics to those locations and make it even easier for families to be able to access that would be, potentially, a useful thing to do. (Practice manager 2, pre-trial) Placement modelling enabled expansion from and improvement of existing service capabilities, that were sometimes reported as limited by NDIS operational or workforce constraints: If I am at a school… I don’t have time to speak to all of the teachers every time I'm there. But when the students are there, not seeing as many clients as I would… they've got the opportunity to go and observe at recess and lunchtime; they've got the opportunity to go and speak to the teachers. So we're getting more information from the teachers... We're getting more options for observations, which is feeding into our therapy. (Provider 1, mid-trial) Such expansion enabled interprofessional service provision, that had been difficult to implement via NDIS funding. For example, Occupational Therapy and Speech-Language Pathology placement models offered social and skills-building services for clients, and also facilitated students’ interprofessional learning in a peer-supported environment: We've also more recently been doing… more group therapy sessions where perhaps the students have taken out a group of participants to the markets or [shopping] mall and then each participant is working on perhaps a slightly different [disciplinary] goal. (Provider 2, mid-trial) The ‘impact’ of placement models cohered strongly when benefits were realised for both clients and the service provider, underpinned by a salient student education approach. Peer mentoring models were often used as a dual mechanism to benefit clients and effectively utilise the provider’s supervision resource: It's been really helpful when there's been two [students] so that they can support each other because… we have to meet our KPIs now and we don’t have that time to spend with them all the time. Having the two of them - I think that mentoring role that they can have with each other - they can chat… and nut some things out before they bring it to you has been really helpful... We have actually been able to set up some groups… that we feel like the students can run and are really beneficial for the students, and then give our participants the extra stuff that they wouldn’t have had. (Provider 11, mid-trial) Structuring in handover between students was positively reported because it supported learning outcomes for incoming and outgoing students, optimised supervisory resources, and enhanced continuity of client service: So there's a two week period where you have the exiting students and the incoming students working together... It's been really great to support us in terms of the time that it takes to get students set up and ready to go, but also… for the exiting student reinforcing the knowledge and the growth that they've made over their placement. (Provider 1, mid-trial) Clear expectations about roles and responsibilities were a mechanism for peer-learning models to be effective and safe for clients and students: I do think mentors can definitely be useful in a placement, just in terms of helping guide the earlier students around… where they can actually look for information. I made it fairly clear to the students that the mentors aren't the ones providing the clinical justification that they're not at that level that, that's my role. So I think there needs to be really clear roles and responsibilities of what each person is doing in that relationship. (Provider 3, mid-trial) This reinforces the necessity to ensure students are well prepared to move from traditional to peer placement models; which is also a supervision mechanism: A partner is good as well, just to jump ideas back and forth. On my previous placement, my partner might have thought of a goal that maybe I might not have thought of. So, that sort of thing and working - learning from each other. (Student 4, post-trial) Open, ongoing and flexible communication between universities and service providers was important for effective implementation amidst the changing service environment: So we found it really helpful… when we moved from single student placement to having groups. We found the collaboration and support from the uni really supportive in assuring us that having a large number of students was okay, and that now I'm so grateful for that, because I would never have a single placement again. (Provider 1, pre-trial) With shifting service environments, the dimensions used in placement models, and they way these interact together also change over time. This is a useful juncture to consider our third research question: the extent to which placement models can be made usual and sustainable in services. RQ3: Reflection on how to make placement models sustained Though resource intense, this project conceptualised placements through investing in placement facilitator roles. This additional resource is justified in some cases – for example in innovating new placement models for specific contexts (29, 30), but permanent implementation lacks sustainability and risks becoming a redundant crutch that inhibits innovation (31). To understand how such resource might transfer to future placement development, we reflect on useful placement facilitation within this project. Placement facilitators explained their role (see Supplementary File 1) to providers as the following: Extra staffing time to resource placement Bridge between university and provider Help providers recognise where/how students might fit into the organisation Provide specific ideas of how to re-think traditional placement processes and what operations could look like. Give voice to the client and student experience. Build trust and confidence with providers – implement recommendations slowly and evaluate each small step rather than the whole change process. The following data describe positive functions of the placement facilitation resource. A key benefit was in developing resources to reduce administration for service providers who were concurrently managing new NDIS organisational processes: [Facilitators enable] the development of resources that could be used by private practitioners…a guideline or how-to books, practice manuals, whatever. …They're resources that could be… tailored by individual practitioners and targeted at different groupings… So the development of resources that could be shared, perhaps in conjunction with the professional organisations… I think could be very valuable. (Advocate 2, pre-trial) This extended to producing client education materials about the presence and purpose of placements, in particular, information about how student supervision assures quality services delivered via students, and informing clients about their service choices: Having some of those fact sheets to give to families to promote their understanding of the student and how they're involved with the NDIS and how that all works. (Provider 16, mid-trial) The placement facilitators enabled a systems-located approach that integrated placement activities with key service functions that were a previous disincentive for placements. Our data point to the importance of space to critically explore what, who and how placements could be conceptualised for each service: I think it was really just… opening up the discussion about what is it that could make this work, when maybe there wasn’t that much that couldn’t make it work. Some of the agencies that had thought that student placements were off the cards, then actually thought, well there isn’t really a reason we can't try it. (University Coordinator 1, post-trial) This reflective space facilitated placement design elements to be refined; with potentially only minor adjustments needed to facilitate new placements: I think [placement facilitators] have been able to provide an outside view on what other places are doing… They're able to problem solve around - some organisations are trying this, some are trying this, just giving us some of those extra ideas of what to do. So that helped with how to put business plans together, proposals and orientation manuals together… The really practical stuff. (Provider 3, post-trial) In addition to problem solving, providers identified that placement facilitators ‘opened up’ capacity for a collaborative approach to developing placements between providers and universities. Just to keep those communications open and lines of communication, who to communicate with about what, is really important, [so] that we don't have these… fragmented reactive scenarios, rather than ongoing partnerships. (University Coordinator 3, post-trial) Placement facilitators liaised between service providers and universities to provide relevant contextual information about services, that re-dressed historical university-directed approaches to managing placements: It's allowed easy communication backwards and forwards. It kind of opens the door, opens the relationship, sets out what you… can and can't really ask for help with… (Provider 9, post-trial) This liaison space also enabled the student to become more visible within placement models: [Placement facilitators] were really helpful in helping us develop a business plan and a model to take to management, and how we could see students working within that and how we could package it to management of what's beneficial for the business, but also for us to maintain our professional integrity and also what's really beneficial for the student. (Provider 11, mid-trial) Sustainability for placements that work, in this way, appears to be enveloped within mechanisms that respond to the dynamic complexity of service provision settings and priorities, student learning needs, and client goals and requirements, that potentially change over time. The partnership between universities and providers is therefore a contextual factor conducive to practice placement innovation and supportive of placement models generally. Discussion This project was designed to increase placement capacity within the turbulent context of emergent individualised funding of disability services that replaced traditional government-led funding and reduced resources available for allied health student placements. Our analysis uses realist thinking to unpack how allied health placements can ‘work’ within new workplace structures for disability service providers, which were reforming for individualised funding and related practice. As service provision captures a great variety of practices, populations, settings, workforces and knowledges, this range of contexts potentially gives rise to a range of mechanisms that might facilitate placements to ‘work’ for each setting. As service models shifted iteratively in response to changed funding and practice, so too placement models developed through the project were evolved to ‘work’ responsively with new ways of providing services. Indeed, this was a key function of the placement facilitators, who analysed and adjusted the placement models according to these changing contexts. Demonstrated through the placement model exemplars, our analysis showcases particular CMOCs which are likely to be useful for other university and service providers seeking to innovate placement models. The multiple configurations in operation during the project (interfacing between placements, providers, facilitation, and education) explains why there lacks a single, closed solution or causal claim that solves how placements can ‘work’ as services continue to adapt for such contexts as funding opportunities, evidence and practice change, population shifts and workforce develops ( 32 ). Analysis demonstrated that whilst successful placement models were individualised to the values, goals and affordances of each setting, each model cohered with the Placement Dimensions that were co-developed with policy, service provider and university partners to delineate the key minimum features of placement design ( 19 ). These various configurations are coalesced to an overarching program theory below that situates these CMOCs (placement models as ‘open systems’) within a broader open system that has increased placement availability as an outcome: If allied health providers that are grounded in varying values, service priorities, client populations and motivations for hosting student placements (C) are to increase placements (O), then placement models must be co-developed with all stakeholders (M1), individualised for the needs and priorities of the service (M2), and incorporate organisational affordances for student learning (M3) Whilst the placement dimensions situated the contextual factors of the practice setting, population and supervision capacity as critical design elements, so too were dimensions related to the nature and experience of students completing placement, the placement timing, and the interfacing university. These educational design elements interacted with practice setting elements, including the operational approach, client priorities, and values and goals to guide placement design. For example, an organisation may prioritise students’ practise towards co-developing client goals or providing individual therapeutic services; but an alternative service provider may prioritise students from different professions providing group-based services to clients with interprofessional goals. Service providers co-developed individualised placement models in which the dimensions exerted varying influence, according to ‘what worked’ for each setting and the nature of students learning within them. For universities, who have historically directed the design, purpose and educational intent of placements, and imposed constraints around the timing, duration and type of students coordinated into placements, the shifts in service provision that prompted this project provide impetus to change this position and develop collaborative practices in designing contemporary, fit-for-purpose placement learning experiences ( 6 ). Such shifts have influenced how students, practitioners and consumers interact within placements ( 6 ). In particular, as funding has shifted to concentrate on direct activities with clients/patients, service administration and how practitioners operate has also changed. This project demonstrates that student placements can be successfully designed for individualised funding contexts and contexts that are shifting across multiple axes. However, as individualised or activity-led funding intentionally focus service activities on the recipient, there is a need ensure that student learning outcomes are intentionally and visibly embedded in placement design. Ensuring that service provider and recipient outcomes are balanced with student learning underpin the purpose of co-developing placement models across stakeholders. The use of placement facilitators as a bridge between universities and service providers was a novel mechanism to develop, trial and evaluate placement models in this project to address an immediate gap in placement availability resulting from the NDIS transition. The different ways that placement facilitator resources were directed to supporting service providers gave visibility to the frictions in the service provision context that require addressing across student placement ‘systems’. Whilst placement facilitators were a mechanism to increase placement availability, this was intended as a temporary project resource. As shifting funding contexts become typical, we anticipate that developing placement models will become recursive, reducing the necessity for this resource. However, it was apparent in our data that placement facilitators afforded exploration of how placements could ‘work’ in individual service contexts, resources that may not typically be available for university staff. Our data exposes how universities could invest to incentivise placements with service providers who operate within such emergent contexts; and further, opens space for critique of how such systems can develop future workforces to sustain quality population outcomes. Limitations While data were collected in 2017–2019; the findings we present here are not time-bound, because they retain conceptual value to examining the process of developing and implementing placement models during times of industry shift. Data were collected in one geographical region during the transition to the NDIS, which may limit generalisability; yet the mechanisms through which change happens are critical tools for reflection about how particular program elements might unfold within diverse contexts and systems. In considering which data to present we have made decisions that will inevitably result in decompositions and reductions of reality, however, we aimed to retain coherence so that the findings remain complex enough to be transferable to other contexts ( 32 ) That these models may not directly transfer across service providers, reinforces that placement design should be individualised for specific contexts – as our evidence showcases this as a feature of practice placements that ‘work’. Whilst this project focussed on ‘what worked’ for placements within a co-evolving industry and policy shift, evaluation and follow-up of whether placement models reverted, retained or further developed following the end of the project was out of scope. It is possible that the placement models could not adapt to further adjustments in service provision as the policy and service landscape consolidated. Further work is needed to identify and evaluate allied health placement models that respond to shifting funding and service provision contexts, yet provide quality student learning outcomes amidst the shift/s. This will be critical for facilitating a contemporary, fit-for-purpose allied health workforce system that can interact amidst co-evolving open systems of policy, industry and regulatory environments. Conclusion This project used a realist analysis to identify ‘what works’ for allied health service providers and students to increase student placement availability in a turbulent period of policy and funding disruption in the Australian disability sector, that had reduced placement numbers. Placement models were co-developed with service providers, attending to individualised contexts and responding to how student activities could interface with unique service operations and goals. This interface between the context, including the service providers’ values, types of services and nature of clients and workforce priorities – revealed a range of supervision, student and placement design mechanisms that may afford placement capacity. This project identified individualised placement models, co-developed with and responsive to service providers are critical to facilitate placements, revealing key mechanisms and contexts that can support provide a useful future resource to guide future allied health placements. Declarations Ethics approval and consent to participate This research was approved by the Flinders University Human Research Ethics Committee (Reference number: 7551). Five modifications were approved by the same Committee to adjust interview procedures and the purposive sampling of new stakeholder groups across the action cycles. All research participants provided informed, written consent of their participation. The research was carried out in accordance with relevant guidelines and regulations of the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding The research on which this manuscript reports was funded by the South Australian Department of State Development. They had no role in the analysis nor interpretation of the data. Authors' contributions Stacie conceptualised the design of the manuscript, wrote the main manuscript text and contributed to data collection and analysis. Kristen collected and analysed the research data, developed the figures, and reviewed the manuscript. Chris led the project, contributed to data analysis and reviewed the manuscript. Stacie was a co-investigator of the research project which was project-managed by Kristen. The author(s) read and approved the final manuscript. Acknowledgements We would like to thank those that contributed their time and knowledge to this project. Specific acknowledgements go to Nicole Baldwin and Kendall Stone, who worked in placement facilitation roles during the project, and the service providers and students for their generous contributions. We would also like to recognise the input of Dr Angela Lawless, Lilienne Coles, and Professor Sue McAllister on the project team. References Billett S. Integrating learning experiences across tertiary education and practice settings: A socio-personal account. Educational Research Review. 2014;12(0):1-13. Billett S. Learning through health care work: premises, contributions and practices. Medical Education. 2016;50(1):124-31. Sheepway L, Lincoln M, Togher L. An international study of clinical education practice in speech-language pathology. International Journal of Speech-Language Pathology. 2011;13(2):174-85. Pope K, Barclay L, Dixon K, Kent F. Models of pre-registration student supervision in allied health: a scoping review. Focus on Health Professional Education: A Multi-Professional Journal. 2023;24(2):27-62. Gibson SJ, Porter J, Anderson A, Bryce A, Dart J, Kellow N, et al. Clinical educators’ skills and qualities in allied health: a systematic review. Medical Education. 2019;53(5):432-42. Attrill S, Foley K, Gesesew HA, Brebner C. Allied health workforce development for participant-led services: structures for student placements in the National Disability Insurance Scheme. BMC Medical Education. 2023;23(1):95. Dalton M, Davidson M, Keating JL. The Assessment of Physiotherapy Practice (APP) is a reliable measure of professional competence of physiotherapy students: a reliability study. Journal of Physiotherapy. 2012;58(1):49-56. Sevenhuysen S, Thorpe J, Molloy E, Keating J, Haines T. Peer-Assisted Learning in Education of Allied Health Professional Students in the Clinical Setting: A Systematic Review. J Allied Health. 2017;46(1):26-35. Beveridge J, Pentland D. A mapping review of models of practice education in allied health and social care professions. British Journal of Occupational Therapy. 2020;83(8):488-513. Rodger S, Webb G, Devitt L, Gilbert J, Wrightson P, McMeeken J. Clinical education and practice placements in the allied health professions: an international perspective. Journal of Allied Health. 2008;37(1):53-62. Wray A, Lewis LK, Yaxley A, Attrill S. Underperformance and failure in allied health practice placements: a scoping review of student performance experiences. Teaching in Higher Education.1-28. Department of Health and Aged Care. Unleashing the potential of our health workforce: Scope of practice review - Final report. Australian Government; 2024. Foo J, Rivers G, Ilic D, Evans DJR, Walsh K, Haines T, et al. The economic cost of failure in clinical education: a multi-perspective analysis. Medical Education. 2017;51(7):740-54. Foley K, Attrill S, Brebner C. 'Hearts' and 'minds': Illustrating identity tensions of people living and working through marketising policy change of allied health disability services in Australia. Health (London). 2025;29(1):39-61. Reid H, Hocking C, Smythe E. Occupational therapy's oversight: How science veiled our humanity. Scandinavian journal of occupational therapy. 2024;31(1):2306585. Baum F, Freeman T, Lawless A, Labonte R, Sanders D. What is the difference between comprehensive and selective primary health care? Evidence from a five-year longitudinal realist case study in South Australia. BMJ Open. 2017;7(4):e015271. Foley K, Freeman T, Wood L, Flavel J, Parry Y, Baum F. Logic modelling as hermeneutic praxis: Bringing knowledge systems into view during comprehensive primary health care planning for homelessness in Australia. Health (London). 2024;28(5):673-97. Foley K, Attrill S, McAllister S, Brebner C. Impact of transition to an individualised funding model on allied health support of participation opportunities. Disability and Rehabilitation. 2020:1-10. Foley K, Attrill S, Brebner C. Co-designing a methodology for workforce development during the personalisation of allied health service funding for people with disability in Australia. BMC Health Services Research. 2021;21(1):680. Sheepway L, Lincoln M, McAllister S. Impact of placement type on the development of clinical competency in speech–language pathology students. International Journal of Language & Communication Disorders. 2014;49(2):189-203. Pawson R. Evidence-Based Policy: A Realist Perspective: SAGE Publications; 2006. Pawson R, Tilley N. Realistic evaluation. Thousand Oaks, CA, US: Sage Publications, Inc; 1997. xvii, 235-xvii, p. Rhodes T, Lancaster K. Evidence-making interventions in health: A conceptual framing. Social science & medicine (1982). 2019;238:112488. Meyer SB, Lunnay B. The Application of Abductive and Retroductive Inference for the Design and Analysis of Theory-Driven Sociological Research. Sociological Research Online. 2013;18(1):86-96. Funnell SC, Rogers PJ. Purposeful Program Theory: Effective Use of Theories of Change and Logic Models: Wiley; 2011. Popay J, Rogers A, Williams G. Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res. 1998;8(3):341-51. Baum F, MacDougall C, Smith D. Participatory action research. Journal of Epidemiology and Community Health. 2006;60(10):854-7. Mukumbang FC, Kabongo EM, Eastwood JG. Examining the Application of Retroductive Theorizing in Realist-Informed Studies. International Journal of Qualitative Methods. 2021;20:16094069211053516. Jones D, Haddadan G, Dunsmore M, Williams A, White D, Hanniver J, et al. Reframing Nurse Education in Rural Australia: Implications for Advancing Longitudinal Integrated Placements. Aust J Rural Health. 2025;33(2):e70041. Moran A, Nancarrow S, Cosgrave C, Griffith A, Memery R. What works, why and how? A scoping review and logic model of rural clinical placements for allied health students. BMC Health Services Research. 2020;20(1):866. van Merrienboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ. 2010;44(1):85-93. Gerrits L, Verweij S. Critical Realism as a Meta-Framework for Understanding the Relationships between Complexity and Qualitative Comparative Analysis. Journal of Critical Realism. 2013;12(2):166-82. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1.docx SupplementaryFile2.docx SupplementaryFile3.docx Cite Share Download PDF Status: Published Journal Publication published 29 Dec, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 28 Aug, 2025 Reviews received at journal 27 Aug, 2025 Reviews received at journal 26 Aug, 2025 Reviews received at journal 18 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers invited by journal 11 Aug, 2025 Editor assigned by journal 11 Aug, 2025 Submission checks completed at journal 11 Aug, 2025 First submitted to journal 11 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7266234","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502075280,"identity":"5ce9a75d-cb8e-418f-90c6-1761e51a8a74","order_by":0,"name":"Stacie Attrill","email":"data:image/png;base64,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","orcid":"","institution":"University of Adelaide","correspondingAuthor":true,"prefix":"","firstName":"Stacie","middleName":"","lastName":"Attrill","suffix":""},{"id":502075281,"identity":"3ba23d5f-bbcf-4627-8723-d181050de87b","order_by":1,"name":"Kristen Foley","email":"","orcid":"","institution":"Torrens University Australia","correspondingAuthor":false,"prefix":"","firstName":"Kristen","middleName":"","lastName":"Foley","suffix":""},{"id":502075282,"identity":"108563ac-e182-44a0-b23e-1f4ee31e36a9","order_by":2,"name":"Chris Brebner","email":"","orcid":"","institution":"Flinders University","correspondingAuthor":false,"prefix":"","firstName":"Chris","middleName":"","lastName":"Brebner","suffix":""}],"badges":[],"createdAt":"2025-08-01 01:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7266234/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7266234/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13758-7","type":"published","date":"2025-12-29T15:57:22+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89419741,"identity":"3b8f4aa3-8501-470a-afa3-508efd801e6e","added_by":"auto","created_at":"2025-08-19 18:15:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":103127,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eA realist exploration of practice-placement education models as outcome(s) within multiple CMOCs\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7266234/v1/df0d4cafa1fa26ea466f59bf.jpg"},{"id":89419732,"identity":"67d44a68-cda4-440a-a79f-a5bb60b588e7","added_by":"auto","created_at":"2025-08-19 18:15:29","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":37094,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDimensions of Placement Education\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7266234/v1/112037b6fae8dc29dd0f43c1.jpg"},{"id":99546150,"identity":"5d5d1c81-9a34-4b63-9818-eb2c97fa4132","added_by":"auto","created_at":"2026-01-05 16:10:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":709979,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7266234/v1/3851f306-64b9-4ff1-b43a-299710c2b790.pdf"},{"id":89419733,"identity":"bfc71781-3ab3-4296-9106-bab8e767c600","added_by":"auto","created_at":"2025-08-19 18:15:29","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17382,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7266234/v1/dd128253c874e73fc69dc4a0.docx"},{"id":89419739,"identity":"6a88d569-3bc5-42c4-9d8b-006fd0d65347","added_by":"auto","created_at":"2025-08-19 18:15:29","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20557,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7266234/v1/70f51236dc381509f7c94189.docx"},{"id":89420644,"identity":"87ba1b9c-b169-4c14-9c2d-75d97758cb18","added_by":"auto","created_at":"2025-08-19 18:31:29","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":21146,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7266234/v1/dc65be614beb77a9342cc1b8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A realist exploration of co-designed practice-placement models that ‘worked’ in shifting contexts of allied health industry, workforce and policy","fulltext":[{"header":"Background","content":"\u003cp\u003eAllied health placements are situated within a patchwork of health and community service provision that respond to diverse individual and community needs; divested through heterogenous policy, sectoral, and funding models. In allied health, placements form a critical component of pre-qualification curricula, facilitating students’ development of the knowledge, skills and attributes of practice, and providing exposure to a range of organisational cultures, settings and practice populations that underpin professional socialisation and the shaping of practice (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Students are typically supervised by allied health practitioners employed within ‘host’ organisations, who engage students in learning activities informed and shaped by practice germane to the setting (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The structure of placements, student supervision, and understandings of the role of students in practice settings and how they are afforded learning opportunities is relatively consistent across allied health professions and settings (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), often grounded in historical conceptions of practice and pedagogy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), yet may not necessarily ‘work’ for all providers and settings.\u003c/p\u003e\u003cp\u003eDifferent dimensions of placement education are explored within the literature. A recent review explored the ratio of supervisor to students, and the nature of supervision type (e.g. in-person supervision, long-arm supervision, interprofessional supervision) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Temporal dimensions inform how placements might fit for university and practice stakeholders, with options for placements in ‘block’ or ‘sessional’ formats, reflecting a commitment of time in placement that students attend each week (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Recent research has explored peer-learning placements, identifying students’ role in supporting their own and others’ learning (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The research literature on allied health professional education suggests that placement design is prominently university-led, and adapted according to student or supervisor factors (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e); while contextual features like service provision, organisational design, funding or models of care receive less attention despite their salient impact on placement outcomes.\u003c/p\u003e\u003cp\u003ePlacement design, relating to how students interact with activities of practice and are positioned within and contribute to dynamic workplace environments as learners, remains relatively unchanged since early conceptions of practice-based learning. Close individual or paired student supervision remains dominant in allied health (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), providing oversight that reduces perceived risk of students practicing with the public, but producing resource-intensive supervision structures that are burdensome for practitioners who concurrently manage complex clinical caseloads and broader organisational demands (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Increasing population complexity, and the broadening scope and demand on allied health services (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), in addition to the cost burden for service providers and universities and administering quality placement experiences (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) further constrain capacity to produce quality learning outcomes.\u003c/p\u003e\u003cp\u003eNovel placement design that is fit-for-purpose for contemporary practice settings is needed in the face of these competing factors. Allied health practice is influenced by surrounding policy climates (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), cultural values (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and diverse views of what health is and to whom (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Global shifts in health, disability and education policy frameworks towards individualised or activity-led funding schemes have produced a marketisation of allied health that focusses funding on service activity and empowers consumers to make service choices that best meet their needs and goals (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Allied health placements, situated in these global phenomena of change, are increasingly pressured (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAmidst this context, it remains critical to optimise the transformational learning and competency outcomes that placements provide to allied health students (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This manuscript uses data-driven realist analysis to describe collaborative design, development, enactment and revision of innovative allied health placement models in novel and transitional industry settings.\u003c/p\u003e\u003cp\u003eWe delineate three research questions for investigation:\u003c/p\u003e\n\u003ch3\u003eRQ1: What novel placement education models ‘worked’ amidst transitional contexts of allied health service provision?\u003c/h3\u003e\n\u003cp\u003eFee-for-service practice, developed to respond to the introduction of individualised disability funding in Australia provides a useful theoretical window, as findings transfer to broader individualised and/or activity funded settings that represent the cross-sectoral work of allied health professionals. This context enables a granular realist exploration of the interrelationships within context-mechanism-outcome-configurations (CMOCs) that enable or constrain placement education:\u003c/p\u003e\u003cp\u003e\u003cem\u003eRQ2: What are common elements, features and factors that enabled the development, implementation and revision of these placement models?\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTo facilitate quality outcomes, placement facilitators liaised with service providers while developing the models. As placement facilitators were an interim project mechanism, we sought to understand:\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eRQ3: How can placement models be made sustainable?\u003c/h2\u003e\u003cp\u003eWe seek to contribute pragmatic resources and reflections that guide the development of placement models that can ‘work’ in emergent industry and policy landscapes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eRealist thinking and paradigms\u003c/p\u003e\n\u003cp\u003eRealist exploration recognises that social life is a complex open system where multiple systems interrelate to produce certain phenomena (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Placement education can be considered as an emergent system which co-occurs with other complex, open and emergent systems, such as university education and allied health service delivery systems, with the focus of realist analyses emphasising practicality and real-world problem-solving (Bhaskar \u0026amp; Hartwig, 2010; Price \u0026amp; Martin, 2018). A cohering question of realist methods is: \u0026lsquo;what works, for whom, under what circumstances?\u0026rsquo; (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e), described via a Context-Mechanism-Outcome-Configuration (CMOC) that can be interrogated through logic such as, \u003cem\u003e\u0026lsquo;if\u0026rsquo;\u003c/em\u003e this is present, then \u0026lsquo;\u003cem\u003ethis\u0026rsquo;\u003c/em\u003e happens (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Certain \u0026lsquo;mechanisms\u0026rsquo; that work in some contexts, cannot be assumed to produce the same \u0026lsquo;outcomes\u0026rsquo; in another context \u0026ndash; the elements are evaluated together as systems (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e)). For this study, realist thinking is helpful to (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) position placement models as \u0026lsquo;outcomes\u0026rsquo; that emerge in particular contexts (i.e. RQ1); to (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) use data to identify which mechanisms were useful for their development, enactment and revision (i.e. RQ2); and to (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) hypothesise how these processes could be made sustainable within other contexts (i.e. RQ3).\u003c/p\u003e\n\u003cp\u003eMaterials\u003c/p\u003e\n\u003cp\u003eWe draw on multiple perspectives derived from the activities of a large-scale allied health workforce project (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) to explore the different features and elements within the CMOCs. This includes qualitative interviews with stakeholders and case study evidence of how placements were developed, implemented and revised.\u003c/p\u003e\n\u003cp\u003eOverarching Project Context\u003c/p\u003e\n\u003cp\u003eThe workforce project addressed declining placement numbers during Australian disability sector transition from government-led to individualised funding (the National Disability Insurance Scheme (NDIS)). In Australia, disability services are fairly distinct from health services in their provision and both sectors are key employers of allied health practitioners. Allied health placements occur across both settings, however this project focussed on increasing placements within disability settings because of a decline amidst the transition to the NDIS. The project was overseen by a Project Advisory Group (PAG), comprised of invited experts from multiple sectors relevant to the NDIS and allied health services, who provided input on the project methods, interpretations and recommendations. Of relevance to this study, the PAG oversaw development of the initial principles to guide placement model development with service providers; reported in detail elsewhere (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). Participants from disability, policy, higher education and service provision sectors were then involved in iterative knowledge-action cycles to co-develop and refine placement models that would \u0026lsquo;work\u0026rsquo; in diverse contexts of service provision.\u003c/p\u003e\n\u003cp\u003ePlacement facilitators were allied health practitioners who were funded within the project, in capacity-focussed roles to support service providers to develop and implement placement models for the changing NDIS context (see position description in Supplementary File 1). As the placement models were designed to be sustained, it was planned that the facilitators would be withdrawn following their implementation and refinement. During their collaborations with service providers in the project, they recorded field notes and reflections to document the reasoning and processes associated with developing and revising student placements. These reasoning elements are valuable for evidential critique to unpack how the presence and actions of placement facilitators were productive in the ways they nuanced CMOCs (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eRealist/retroductive approach to understanding the workings of placement models\u003c/p\u003e\n\u003cp\u003eThis manuscript synthesises evidence developed about the context and mechanisms of placement education to understand why certain placement models \u0026lsquo;worked\u0026rsquo; (represented in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e below). We use retroduction to guide understanding of if, or to what extent, casual chains of influence predicted during the development of placement models (i.e. our \u0026lsquo;program theories\u0026rsquo;) unfolded in the real world (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). We integrated prior evidence developed within the project activities (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) from a realist frame, to inform our understanding of the contexts, and subsequently collated and analysed the CMOCs in which the models increased placement availability.\u003c/p\u003e\n\u003cp\u003eData Collection, Collation and Considerations\u003c/p\u003e\n\u003cp\u003eEight service providers were recruited by university placement education staff through existing relationships as project partners. Discussion prior to each provider consenting included: confidentiality, the integrity of their relationship with the university auspicing the project, and future use of their data to translate project learnings. As placement facilitators liaised with service providers \u003cem\u003eand\u003c/em\u003e provided a bridge to the university research team, they did not access raw project data, instead, accessing synthesised, de-identified data to assist in developing and refining iterative placement models.\u003c/p\u003e\n\u003cp\u003eThis distinction supported appropriate boundaries and feedback transparency, which was established in the ethics approval, provided by XXXX (project number 7551). Placement facilitators were also approved to be interviewed as project participants to contribute their first-hand perspectives on mechanisms (and limitations) of the novel models. We draw on primary data analysis via qualitative data collection with placement facilitators (n\u0026thinsp;=\u0026thinsp;4), service providers (n\u0026thinsp;=\u0026thinsp;24), placement coordinators (n\u0026thinsp;=\u0026thinsp;3), peak body representatives (n\u0026thinsp;=\u0026thinsp;4), chief financial officers (n\u0026thinsp;=\u0026thinsp;3) and students (n\u0026thinsp;=\u0026thinsp;12); summarised in Table 1 in relation to the \u0026lsquo;stage\u0026rsquo; of data collection.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cem\u003eTable 1: Stage of data collection in relation to practice-placement planning, trial, and refinement\u003c/em\u003e\u003c/div\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Taba\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDevelop\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTrial\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRefine\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eService providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeak body representatives\u003c/p\u003e\n \u003cp\u003e(disability and profession-specific)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlacement facilitators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlacement coordinators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChief financial officers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents\u003c/p\u003e\n \u003cp\u003e(focus groups and individual interviews)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e29\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e50\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*Ten participants were interviewed twice to capture depth and change through the project stages (placement facilitators, peak body representatives, and six service providers).\u003c/p\u003e\n\u003cp\u003eResearchers were Speech-Language Pathology and Occupational Therapy practitioners trained in qualitative research. Interviews were conducted at places convenient to participants or via phone or Zoom, and ranged between 30\u0026ndash;60 minutes. At least one practitioner from each service provider was interviewed, however interviews were completed with two or three practitioners for providers with larger operations. Interviews took place pre-, mid-, and post-trial of newly-developed placement models with iteratively developed interview guides reported elsewhere (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). Allied health students who had completed at least one placement in a model developed through the project were invited to interview with peers or individually if preferred. Prior to consenting, students were provided information which noted their participation would not affect their learning or assessment. Five students participated in two group interviews, and seven students completed a phone interview. Refer to Supplementary File 2 for student interview guide.\u003c/p\u003e\n\u003cp\u003eInterviews followed a semi-structured guide that was iteratively adjusted to respond to early themes, reflecting a responsive qualitative approach (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) and our action-research approach to the project (i.e. 19, 27). Different stakeholder groups were asked different questions, as related to their positioned experience and engagement with placements developed during the project.\u003c/p\u003e\n\u003cp\u003eData Analysis and Reflexive Posturing\u003c/p\u003e\n\u003cp\u003eInterviews audio-recorded and transcribed, and then coded inductively by author XX, with fortnightly research team meetings to cross-check and explore the findings. Author XX subsequently coded the project data deductively to explore features of developing and enacting placements for this study. This round of coding was cross-checked by the first and fourth authors. Abductive examination (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) was developed by authors XX and XX regarding the role and impacts of particular elements in the CMOCs in which placement education is an outcome. Further retroductive theorization (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) was undertaken \u0026ndash; looking across placement models, the broader workforce project, the industry landscape, and determining the relevance of various service provision elements to how particular CMOCs unfold. The output of this collaborative work forms the Results and Discussion.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe have organized our analyses to directly respond to the three research questions. We use participant quotes, denoted by a pseudonym, their role in relation to placement education, and the timing of the interview (pre-, mid- or post-trial of placement models).\u003c/p\u003e\n\u003cp\u003eRQ1: Innovative Placement Education Models that \u0026lsquo;Worked\u0026rsquo;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eContextual factors enfolding placement models\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe iterative co-development and refinement of placement models revealed the importance of tailoring placement design according to the service provider\u0026rsquo;s context, including organisational approaches, objectives and goals, and practice context including the population/s served and type/s of practice provided. Identifying how student placement activity could contribute within these contexts was key to stakeholder buy-in, with goals often related to:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eincreasing operational capacity or service throughput via student activity; or addressing funding-related service gaps or reduced clinical staffing availability or capacity.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003edeveloping future disability workforce capabilities or facilitating recruitment of future practitioners to the organisation.\u003c/li\u003e\n \u003cli\u003efacilitating outcomes for specific client or community needs (e.g. opportunities for clients with communication difficulties to engage with new people)\u003c/li\u003e\n \u003cli\u003eproviding supervision opportunities for staff or new practice areas that result from increased service capacity.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAs service provider contexts were mapped, mechanisms that may afford successful placements within each organisation were identified and modelled. Model features that enabled placement capacity related to how student activities were coordinated within service provision or supervision functions, and were categorised as:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eIncreasing student volume (e.g. groups of students placed together), frequency or continuity of placement/s to give rise to new or increased service capacity.\u003c/li\u003e\n \u003cli\u003eUtilising peer learning and mentoring approaches between students to open up supervision capacity, foster student learning, orientation and continuity of client care.\u003c/li\u003e\n \u003cli\u003ePrioritising placement scheduling and timings according to peak service provision periods and organisational drivers, to optimise supervision capacity and workforce availability. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMapping student activities to best meet specific needs of clients engaged in each organisation, enhancing service delivery.\u003c/li\u003e\n \u003cli\u003eOptimising usual organisational functions to support student experience (e.g. students working across clinic and school settings to optimise funding availabilities of each setting).\u003c/li\u003e\n \u003cli\u003ePromoting proactive, early supports for placement design, student performance and learning outcomes via early regular communication with the university provider.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAn analytical approach to the placement dimensions (19) was used to develop and revise the placement models. The dimensions outline how placement features may interact through the contexts of service provision, and can be tailored and further iterated for individual organisations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese dimensions focussed initial discussions with service providers, who then collaborated with a placement facilitator using reflection tools that were developed to support the conceptualisation of model features (see Supplementary File 3) to adapt ideas that were fit for their setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo exemplars that illustrate how novel placement models were designed to \u0026lsquo;work\u0026rsquo; in particular settings, using the placement dimensions, are provided in Boxes 1 \u0026amp; 2.\u003c/p\u003e\n\u003cp\u003eBox 1\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eContext:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA private practice situated in an urban, metropolitan area providing paediatric allied health services in a community experiencing socio-economic disadvantage. The practice had traditionally struggled to recruit allied health practitioners, and prospective clients experienced lengthy waiting periods, with few alternative services available. The practice location had poor public transport access, and previous students had experienced difficulties travelling to placement. The practice had hosted incidental placements of individual or paired students, but reported challenges in providing the support time for student learning without affecting their usual business functions, or impacting their capacity to see clients. Entirely reliant on fee-for-service income, the practice needed solutions to a) manage implications related to cost and b) ensure positive student learning experiences that would promote future recruitment; while c) retaining supportive and authentic placement experiences.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eModel: Cross-over continuous placements, utilising group supervision and peer transition\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA continuous, year-round placement model was designed to ensure consistency and reliability of client services. Placements were three days/week for 13 weeks, to cohere with service provider and university needs. A placement cross-over was designed, whereby the final week of a placement was also timetabled as the first week of the next placement, enabling a system of placements to be scheduled continuously across the year. Completing students were paired with commencing students, who provided mentoring for placement orientation, client hand-over, and opportunities for the commencing students to observe their practice during the \u0026lsquo;cross-over week\u0026rsquo;. This critical education design feature, provided all students with peer learning, orientation and models of relevant practice knowledge and skills, while also reducing the supervision load.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe continuous presence of students across the year was critical for the business needs of the service provider, as it supported consistent planning and service capacity for clients, and reduced the necessity to increase or decrease client activity to accommodate student needs. In each placement, four students were placed together, supervised by a single or pair of practitioners, depending on the time of year and availability; and enabling students to arrange shared travel to the setting. Opportunities for practitioners to supervise students together developed supervision capacity across the service, and ensured regular supervision breaks for team members across the year. This also enabled capacity to increase supervision input for students needing additional support to develop competency.\u003c/p\u003e\n\u003cp\u003ePlacements were carefully mapped against typical service performance measures to ensure that average expected client activity and income was maintained. To achieve this, the client activity affordances of four students were accounted for across the placement, with the model designed to progressively reduce supervision scaffolding according to students\u0026rsquo; developing competency and increasing capacity for client load. Students were initially paired, and peer-learning principles were used to guide student-led client planning, paired session procedures, feedback and group reflection. The supervision model was designed to ensure the practitioner oversaw student activities with clients, meeting the funding requirements and supporting student-led sessions. Recognising opportunities to address thin service availability in the region, the service provider negotiated a student-led screening and early intervention clinic in a local school as a community value-add. This addition meant that each 3 day/week placement was comprised of two clinic days and a third day in the school. Whilst this required the service to provide student supervision at the school, the provider benefitted through increased referrals and community awareness. For students, placement across the school and clinic enabled opportunities to work with clients across contexts, and as school services were not fee-for-service, to enact more autonomous practice in alignment with their developing competency.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe now present a second placement model that responds to different contextual drivers of a community service provider, with placement capacity afforded through mechanisms that focussed on student collaboration and client needs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBox 2\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eContext:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA not-for-profit, community-based disability service providing allied health services for an under-served, adult population that had not previously hosted student placements. The service provider identified a need to increase cross-sectoral awareness and continuity of care for the complex population it serves. Opportunities to enhance the continuity of support for clients transitioning from inpatient rehabilitation services to their community-based program were identified as important, and funding gaps that often occurred during this transition were reported to exacerbate challenges for commencing clients. The service prioritised interdisciplinary care that supports clients to meet community participation and vocational goals. Whilst good practice, the service reported that interdisciplinary care models were difficult to achieve as clients were typically funded for sessions with a single practitioner. The service provider identified opportunities for students to lead work in client advocacy and community-awareness which is critical for this population, but these indirect client activities were under-funded in individualised NDIS plans. As such, placement outcome goals were prioritised to a) support cost-effective interdisciplinary client services; b) develop a tangible interface between health and community services to support continuity of care and service; and c) to conduct advocacy and community-awareness activities.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eModel: Interprofessional paired placement model using peer mentoring\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAn interprofessional model with four students allocated to each placement was designed to enable two pairs of speech pathology and occupational therapy students learning and practicing together to provide integrated, goal-oriented client services. The placement was designed as two days/week for 20 weeks to accord with the organisation\u0026rsquo;s service provision patterns, supervision capacity and space availability; and aligned with university semesters. The service provider allocated a speech pathologist and occupational therapist as student supervisors who split supervision time and processes to facilitate interprofessional and profession-specific learning. Students interacted with clients in a specifically designed student-led service, and were supported to understand the client group, placement objectives and the nature of interprofessional learning via a prescribed orientation completed prior to the placement. The student-led service was designed to supplement existing services and expand on and practice client\u0026rsquo;s participation goals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA peer-mentoring model of learning was enacted using a supported learning structure that enabled final year students who were experienced in placement learning to provide structured supervision, feedback and modelling to novice students of their own profession who were commencing their placement program, under the overarching guidance of the practitioner supervisors. This developed student skills in supervision and mentoring, a critical graduate competency, whilst also reducing the supervision load. This mix of student experience enabled clients to be stratified according to complexity and the students\u0026rsquo; placement learning requirements, with senior students completing case management and more complex clinical work, while their less experienced peer mentees worked in parallel on progressing clients\u0026rsquo; therapeutic and participatory goals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this model, senior students completed 2 days/week and mentee novice students completed 1 day/week to align with the organisation\u0026rsquo;s capacity and client program availability. This also enabled senior students to use the second day to progress interprofessional goals and implement advocacy and community awareness activities. To support the organisation\u0026rsquo;s goals to reduce the continuity gap experienced when clients commenced with the organisation, cross-sectoral activities were designed to enable collaboration between the senior students and the referring healthcare team in discharge planning and client goal setting, and to commence early practice with prospective clients during the transition period to their community service.\u003c/p\u003e\n\u003cp\u003eSeveral innovative practice-placement models were implemented during the project, each producing increased placement capacity, yet individually designed to respond to particular practice settings. Discussions with the placement facilitators enabled service providers to reflect about previous students\u0026rsquo; placement experiences, opening metacognitive considerations of how their settings might best afford student learning outcomes and build towards organisational goals \u0026ndash; this reflective process of mapping between contextual settings of placement and a range of desired outcomes, seemed to act as a mechanism that helped to optimise the \u0026lsquo;workability\u0026rsquo; of the model:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe\u0026apos;ve modified the locations that we offer the placements in to try and get a client load that\u0026rsquo;s going to better fit with the student experience. We\u0026apos;ve done a bit of work around trying to set up good induction processes and good information provision to the students to try and help them prepare to come in, be ready a little bit quicker to understand what their placement\u0026apos;s going to look like and what their responsibilities in that will be and what our role will be and what things we\u0026apos;ll do to try and support them with being successful with that. (Practice manager 2, pre-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSuch reflections examined historical assumptions and restrictions that had constrained placement design (14):\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUltimately I\u0026apos;d like to have them all the time, I would like to have at least one to two students that can have a placement here year-round, so that one is finishing and another one is starting. But it just is a bit dependent on the capacity of the staff member to be able to take that on\u0026hellip; At the moment we\u0026apos;ve got four students on placement and it\u0026apos;s worked quite well in the way that I\u0026apos;ve been able to have two directly with me\u0026hellip; I guess in the past then, mostly what we\u0026apos;ve had is one student to one clinical educator, that\u0026apos;s mostly how it\u0026apos;s worked. (Provider 4, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePlacement facilitators identified that the process of placement design and discussion opened opportunities to consider how traditional placement structures could be refined to situate placement activities effectively within the service context:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe [particular] proposal is that it doesn\u0026rsquo;t sit within traditional placements at all. \u0026nbsp;It is very much around community access and functional communication and generalisation and basically everything we aspire to as speech pathologists and clinicians\u0026hellip; what\u0026rsquo;s going to happen is once it\u0026rsquo;s up and running you have a couple of senior students and four junior students, in a mentoring style. The placement will run across about six to nine months of the year, and it will be looking at taking the clients\u0026hellip; in to the community to learn to interact and use communication functionally. (Facilitator 1, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudents highlighted that learning grounded in the disability service contexts during these placements\u0026nbsp;linked with their future plans and capacity to engage with the workforce:\u003c/p\u003e\n\u003cp\u003eI want to work in disability. It\u0026apos;s - well one of the areas I\u0026apos;ve always wanted to go down that track. I was a bit hesitant to have a placement in a private practice because you do hear\u0026hellip; like the prime example of what I wouldn\u0026apos;t want to work in. But I think I\u0026apos;ve had time to think about it and realise that you have to do your investigating and find out what a practice is like. Because \u0026hellip;I want to make really informed decisions around moving into private practice. (Student group 2, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudents articulated struggles with placement models that moved away from individual supervision, however, they reported these as also\u003cem\u003e\u0026nbsp;\u003c/em\u003eenabling new and mutual ways to learn and connect with others:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI think the mentoring system was really, really good on the placement. When I first started I wasn\u0026apos;t very sure, only\u0026hellip; because we were the mentors\u0026hellip; our mentees were in their third year of the degree and some of them\u0026hellip; seemed to have just as much, if not a bit more knowledge than we did initially. I\u0026apos;m still in touch with most of the mentees as well, there were only four of them but it was nice to get to know [them] and hear all their knowledge as well\u0026hellip;They were also our mentors in a way. (Student 5, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePeer mentoring, paired supervision, supporting community engagement objectives that were elsewise underfunded, and cross-over placement models that involved a handover period between groups of students were therefore some of the features of placement models that \u0026lsquo;worked\u0026rsquo; with the support of placement facilitation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRQ2: Common elements, features and factors that enabled development, enactment and revision of placement models\u003c/p\u003e\n\u003cp\u003eOur data identify the importance of guiding principles to enable placement model development that fosters innovation. The principles below, reported in detail elsewhere (19), reflected collaborative input on the overarching purpose of placements, which within our project were considered as the \u0026lsquo;outcomes\u0026rsquo; which demonstrated that placements were working:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003ePedagogically sound\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eQuality for all\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePerson (family) -centred\u003c/li\u003e\n \u003cli\u003eNDIS compliant\u003c/li\u003e\n \u003cli\u003eInformed by evidence.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe principles guide mapping of student education and service provider goals and activities; and how collaborative relationships involving service provider and practitioners, clients, students and the university may integrate. Model design also situated individual \u0026lsquo;placements\u0026rsquo; within an overall program of placements tailored for each service provider, then also using the context-mechanism relationships explicated in the \u0026lsquo;placement dimensions\u0026rsquo; with the placement principles to co-develop setting responsive placement systems (RQ1, Fig 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePlacement design commonly prioritised quality services oriented to client goals and needs. Opportunities for innovation included recognising what clients valued about services \u0026ndash; and working backwards from this logic to develop new ways to enact placements. The following provider prioritised person-centredness, prompting a placement design in which students complete placement one or two days each week over a longer timespan to facilitate continuity of service and relationship development: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI think for families what I was finding was - that relationship was really important to them and having students come in and cycle through was not at all what they wanted. (Provider 3, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother provider reflected on the importance of ensuring that a student placement came at the \u0026lsquo;right time\u0026rsquo; within a client\u0026rsquo;s developmental or service trajectory to ensure quality outcomes:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026hellip; that\u0026apos;s the kind of thing that we need to start thinking about is, when a kid\u0026apos;s ready maybe for a student placement - some of our clients like maybe we need to get you started\u0026hellip; (Provider 6, pre-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral providers identified how using the dimension of placement timing to support their thinking opened opportunities to test traditional temporal structures that had constrained placements in their setting: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI think, for us, in terms of looking at offering placements at the same time as other disciplines, so specifically looking at [OT] to then to be able to provide more of a [multi D] clinic, which then, will actually set the students up in a better place to actually come and work\u0026hellip; \u0026hellip;we\u0026apos;re hoping to look at having a more ongoing clinic for service. (Provider 3, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome providers examined how placement models might enhance service delivery. For example, service gaps created by funding rules created opportunities for placements to respond in ways that added value to clients:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI feel that the clients have been able to get more of a holistic service. Meaning that what we\u0026apos;ve been able to do in [student] sessions, we\u0026apos;ve also been able to target things outside of sessions a little bit more in terms of providing resource development or additional take-home things, out of therapy sessions, those sorts of things. (Provider 4, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMutuality of learning and benefit for the provider, clients and students was an important design input:\u003c/p\u003e\n\u003cp\u003eTo build [student] skills in evidence-based practice and presenting to team members, while students are with us they run a tute for our team.... \u0026nbsp;It has to be important for the practice, and they need to\u0026hellip; make sure that we don\u0026apos;t already have key information around that. (Provider 1, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe placement dimensions prompted service providers to reflect about implementing placement models for particular communities and areas of need, creating space to enhance service equity and accessibility:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI think having more student clinics out maybe in some of the more disadvantaged, socially-economically disadvantaged areas might be really good\u0026hellip; If there was a way to try and take the clinics to those locations and make it even easier for families to be able to access that would be, potentially, a useful thing to do. (Practice manager 2, pre-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePlacement modelling enabled expansion from and improvement of existing service capabilities, that were sometimes reported as limited by NDIS operational or workforce constraints:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIf I am at a school\u0026hellip; I don\u0026rsquo;t have time to speak to all of the teachers every time I\u0026apos;m there. \u0026nbsp;But when the students are there, not seeing as many clients as I would\u0026hellip; they\u0026apos;ve got the opportunity to go and observe at recess and lunchtime; they\u0026apos;ve got the opportunity to go and speak to the teachers. So we\u0026apos;re getting more information from the teachers... \u0026nbsp;We\u0026apos;re getting more options for observations, which is feeding into our therapy. (Provider 1, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSuch expansion enabled interprofessional service provision, that had been difficult to implement via NDIS funding. \u0026nbsp;For example, Occupational Therapy and Speech-Language Pathology placement models offered social and skills-building services for clients, and also facilitated students\u0026rsquo; interprofessional learning in a peer-supported environment:\u003c/p\u003e\n\u003cp\u003eWe\u0026apos;ve also more recently been doing\u0026hellip; more group therapy sessions where perhaps the students have taken out a group of participants to the markets or [shopping] mall and then each participant is working on perhaps a slightly different [disciplinary] goal. (Provider 2, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe \u0026lsquo;impact\u0026rsquo; of placement models cohered strongly when benefits were realised for both clients and the service provider, underpinned by a salient student education approach. Peer mentoring models were often used as a dual mechanism to benefit clients and effectively utilise the provider\u0026rsquo;s supervision resource:\u003c/p\u003e\n\u003cp\u003eIt\u0026apos;s been really helpful when there\u0026apos;s been two [students] so that they can support each other because\u0026hellip; we have to meet our KPIs now and we don\u0026rsquo;t have that time to spend with them all the time. Having the two of them - I think that mentoring role that they can have with each other - they can chat\u0026hellip; and nut some things out before they bring it to you has been really helpful... We have actually been able to set up some groups\u0026hellip; that we feel like the students can run and are really beneficial for the students, and then give our participants the extra stuff that they wouldn\u0026rsquo;t have had. (Provider 11, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStructuring in handover between students was positively reported because it supported learning outcomes for incoming and outgoing students, optimised supervisory resources, and enhanced continuity of client service:\u003c/p\u003e\n\u003cp\u003eSo there\u0026apos;s a two week period where you have the exiting students and the incoming students working together... It\u0026apos;s been really great to support us in terms of the time that it takes to get students set up and ready to go, but also\u0026hellip; for the exiting student reinforcing the knowledge and the growth that they\u0026apos;ve made over their placement. (Provider 1, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClear expectations about roles and responsibilities were a mechanism for peer-learning models to be effective and safe for clients and students:\u003c/p\u003e\n\u003cp\u003eI do think mentors can definitely be useful in a placement, just in terms of helping guide the earlier students around\u0026hellip; where they can actually look for information. I made it fairly clear to the students that the mentors aren\u0026apos;t the ones providing the clinical justification that they\u0026apos;re not at that level that, that\u0026apos;s my role. So I think there needs to be really clear roles and responsibilities of what each person is doing in that relationship. (Provider 3, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis reinforces the necessity to ensure students are well prepared to move from traditional to peer placement models; which is also a supervision mechanism:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA partner is good as well, just to jump ideas back and forth. On my previous placement, my partner might have thought of a goal that maybe I might not have thought of. So, that sort of thing and working - learning from each other. (Student 4, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOpen, ongoing and flexible communication between universities and service providers was important for effective implementation amidst the changing service environment:\u003c/p\u003e\n\u003cp\u003eSo we found it really helpful\u0026hellip; when we moved from single student placement to having groups. \u0026nbsp;We found the collaboration and support from the uni really supportive in assuring us that having a large number of students was okay, and that now I\u0026apos;m so grateful for that, because I would never have a single placement again. (Provider 1, pre-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith shifting service environments, the dimensions used in placement models, and they way these interact together also change over time. This is a useful juncture to consider our third research question: the extent to which placement models can be made usual and sustainable in services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRQ3: Reflection on how to make placement models sustained\u003c/p\u003e\n\u003cp\u003eThough resource intense, this project conceptualised placements through investing in placement facilitator roles. This additional resource is justified in some cases \u0026ndash; for example in innovating new placement models for specific contexts (29, 30), but permanent implementation lacks sustainability and risks becoming a redundant crutch that inhibits innovation (31). To understand how such resource might transfer to future placement development, we reflect on useful placement facilitation within this project. Placement facilitators explained their role (see Supplementary File 1) to providers as the following:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eExtra staffing time to resource placement\u003c/li\u003e\n \u003cli\u003eBridge between university and provider\u003c/li\u003e\n \u003cli\u003eHelp providers recognise where/how students might fit into the organisation\u003c/li\u003e\n \u003cli\u003eProvide specific ideas of how to re-think traditional placement processes and what operations could look like.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGive voice to the client and student experience.\u003c/li\u003e\n \u003cli\u003eBuild trust and confidence with providers \u0026ndash; implement recommendations slowly and evaluate each small step rather than the whole change process.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe following data describe positive functions of the placement facilitation resource. A key benefit was in developing resources to reduce administration for service providers who were concurrently managing new NDIS organisational processes:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Facilitators enable] the development of resources that could be used by private practitioners\u0026hellip;a guideline or how-to books, practice manuals, whatever. \u0026nbsp;\u0026hellip;They\u0026apos;re resources that could be\u0026hellip; tailored by individual practitioners and targeted at different groupings\u0026hellip; So the development of resources that could be shared, perhaps in conjunction with the professional organisations\u0026hellip; I think could be very valuable. (Advocate 2, pre-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis extended to producing client education materials about the presence and purpose of placements, in particular, information about how student supervision assures quality services delivered via students, and informing clients about their service choices:\u003c/p\u003e\n\u003cp\u003eHaving some of those fact sheets to give to families to promote their understanding of the student and how they\u0026apos;re involved with the NDIS and how that all works. (Provider 16, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe placement facilitators enabled a systems-located approach that integrated placement activities with key service functions that were a previous disincentive for placements. Our data point to the importance of space to critically explore what, who and how placements could be conceptualised for each service:\u003c/p\u003e\n\u003cp\u003eI think it was really just\u0026hellip; opening up the discussion about what is it that could make this work, when maybe there wasn\u0026rsquo;t that much that couldn\u0026rsquo;t make it work. Some of the agencies that had thought that student placements were off the cards, then actually thought, well there isn\u0026rsquo;t really a reason we can\u0026apos;t try it. (University Coordinator 1, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis reflective space facilitated placement design elements to be refined; with potentially only minor adjustments needed to facilitate new placements:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI think [placement facilitators] have been able to provide an outside view on what other places are doing\u0026hellip; They\u0026apos;re able to problem solve around - some organisations are trying this, some are trying this, just giving us some of those extra ideas of what to do. So that helped with how to put business plans together, proposals and orientation manuals together\u0026hellip; The really practical stuff. (Provider 3, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to problem solving, providers identified that placement facilitators \u0026lsquo;opened up\u0026rsquo; capacity for a collaborative approach to developing placements between providers and universities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJust to keep those communications open and lines of communication, who to communicate with about what, is really important, [so] that we don\u0026apos;t have these\u0026hellip; fragmented reactive scenarios, rather than ongoing partnerships. (University Coordinator 3, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePlacement facilitators liaised between service providers and universities to provide relevant contextual information about services, that re-dressed historical university-directed approaches to managing placements:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt\u0026apos;s allowed easy communication backwards and forwards. It kind of opens the door, opens the relationship, sets out what you\u0026hellip; can and can\u0026apos;t really ask for help with\u0026hellip; (Provider 9, post-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis liaison space also enabled the student to become more visible within placement models:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Placement facilitators] were really helpful in helping us develop a business plan and a model to take to management, and how we could see students working within that and how we could package it to management of what\u0026apos;s beneficial for the business, but also for us to maintain our professional integrity and also what\u0026apos;s really beneficial for the student. (Provider 11, mid-trial)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSustainability for placements that work, in this way, appears to be enveloped within mechanisms that respond to the dynamic complexity of service provision settings and priorities, student learning needs, and client goals and requirements, that potentially change over time. The partnership between universities and providers is therefore a contextual factor conducive to practice placement innovation and supportive of placement models generally.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis project was designed to increase placement capacity within the turbulent context of emergent individualised funding of disability services that replaced traditional government-led funding and reduced resources available for allied health student placements. Our analysis uses realist thinking to unpack how allied health placements can \u0026lsquo;work\u0026rsquo; within new workplace structures for disability service providers, which were reforming for individualised funding and related practice. As service provision captures a great variety of practices, populations, settings, workforces and knowledges, this range of contexts potentially gives rise to a range of mechanisms that might facilitate placements to \u0026lsquo;work\u0026rsquo; for each setting.\u003c/p\u003e\u003cp\u003eAs service models shifted iteratively in response to changed funding and practice, so too placement models developed through the project were evolved to \u0026lsquo;work\u0026rsquo; responsively with new ways of providing services. Indeed, this was a key function of the placement facilitators, who analysed and adjusted the placement models according to these changing contexts. Demonstrated through the placement model exemplars, our analysis showcases particular CMOCs which are likely to be useful for other university and service providers seeking to innovate placement models. The multiple configurations in operation during the project (interfacing between placements, providers, facilitation, and education) explains why there lacks a single, closed solution or causal claim that solves how placements can \u0026lsquo;work\u0026rsquo; as services continue to adapt for such contexts as funding opportunities, evidence and practice change, population shifts and workforce develops (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Analysis demonstrated that whilst successful placement models were individualised to the values, goals and affordances of each setting, each model cohered with the Placement Dimensions that were co-developed with policy, service provider and university partners to delineate the key minimum features of placement design (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). These various configurations are coalesced to an overarching program theory below that situates these CMOCs (placement models as \u0026lsquo;open systems\u0026rsquo;) within a broader open system that has increased placement availability as an outcome:\u003c/p\u003e\u003cp\u003e\u003cem\u003eIf allied health providers that are grounded in varying values, service priorities, client populations and motivations for hosting student placements (C) are to increase placements (O), then placement models must be co-developed with all stakeholders (M1), individualised for the needs and priorities of the service (M2), and incorporate organisational affordances for student learning (M3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhilst the placement dimensions situated the contextual factors of the practice setting, population and supervision capacity as critical design elements, so too were dimensions related to the nature and experience of students completing placement, the placement timing, and the interfacing university. These educational design elements interacted with practice setting elements, including the operational approach, client priorities, and values and goals to guide placement design. For example, an organisation may prioritise students\u0026rsquo; practise towards co-developing client goals or providing individual therapeutic services; but an alternative service provider may prioritise students from different professions providing group-based services to clients with interprofessional goals. Service providers co-developed individualised placement models in which the dimensions exerted varying influence, according to \u0026lsquo;what worked\u0026rsquo; for each setting and the nature of students learning within them. For universities, who have historically directed the design, purpose and educational intent of placements, and imposed constraints around the timing, duration and type of students coordinated into placements, the shifts in service provision that prompted this project provide impetus to change this position and develop collaborative practices in designing contemporary, fit-for-purpose placement learning experiences (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSuch shifts have influenced how students, practitioners and consumers interact within placements (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In particular, as funding has shifted to concentrate on direct activities with clients/patients, service administration and how practitioners operate has also changed. This project demonstrates that student placements can be successfully designed for individualised funding contexts and contexts that are shifting across multiple axes. However, as individualised or activity-led funding intentionally focus service activities on the recipient, there is a need ensure that student learning outcomes are intentionally and visibly embedded in placement design. Ensuring that service provider and recipient outcomes are balanced with student learning underpin the purpose of co-developing placement models across stakeholders.\u003c/p\u003e\u003cp\u003eThe use of placement facilitators as a bridge between universities and service providers was a novel mechanism to develop, trial and evaluate placement models in this project to address an immediate gap in placement availability resulting from the NDIS transition. The different ways that placement facilitator resources were directed to supporting service providers gave visibility to the frictions in the service provision context that require addressing across student placement \u0026lsquo;systems\u0026rsquo;. Whilst placement facilitators were a mechanism to increase placement availability, this was intended as a temporary project resource. As shifting funding contexts become typical, we anticipate that developing placement models will become recursive, reducing the necessity for this resource. However, it was apparent in our data that placement facilitators afforded exploration of how placements could \u0026lsquo;work\u0026rsquo; in individual service contexts, resources that may not typically be available for university staff. Our data exposes how universities could invest to incentivise placements with service providers who operate within such emergent contexts; and further, opens space for critique of how such systems can develop future workforces to sustain quality population outcomes.\u003c/p\u003e\u003cp\u003eLimitations\u003c/p\u003e\u003cp\u003eWhile data were collected in 2017\u0026ndash;2019; the findings we present here are not time-bound, because they retain conceptual value to examining the process of developing and implementing placement models during times of industry shift. Data were collected in one geographical region during the transition to the NDIS, which may limit generalisability; yet the mechanisms through which change happens are critical tools for reflection about how particular program elements might unfold within diverse contexts and systems. In considering which data to present we have made decisions that will inevitably result in decompositions and reductions of reality, however, we aimed to retain coherence so that the findings remain \u003cem\u003ecomplex enough\u003c/em\u003e to be transferable to other contexts (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) That these models may not directly transfer across service providers, reinforces that placement design should be individualised for specific contexts \u0026ndash; as our evidence showcases this as a feature of practice placements that \u0026lsquo;work\u0026rsquo;.\u003c/p\u003e\u003cp\u003eWhilst this project focussed on \u0026lsquo;what worked\u0026rsquo; for placements within a co-evolving industry and policy shift, evaluation and follow-up of whether placement models reverted, retained or further developed following the end of the project was out of scope. It is possible that the placement models could not adapt to further adjustments in service provision as the policy and service landscape consolidated. Further work is needed to identify and evaluate allied health placement models that respond to shifting funding and service provision contexts, yet provide quality student learning outcomes amidst the shift/s. This will be critical for facilitating a contemporary, fit-for-purpose allied health workforce system that can interact amidst co-evolving open systems of policy, industry and regulatory environments.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis project used a realist analysis to identify \u0026lsquo;what works\u0026rsquo; for allied health service providers and students to increase student placement availability in a turbulent period of policy and funding disruption in the Australian disability sector, that had reduced placement numbers. Placement models were co-developed with service providers, attending to individualised contexts and responding to how student activities could interface with unique service operations and goals. This interface between the context, including the service providers\u0026rsquo; values, types of services and nature of clients and workforce priorities \u0026ndash; revealed a range of supervision, student and placement design mechanisms that may afford placement capacity. This project identified individualised placement models, co-developed with and responsive to service providers are critical to facilitate placements, revealing key mechanisms and contexts that can support provide a useful future resource to guide future allied health placements.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis research was approved by the Flinders University Human Research Ethics Committee (Reference number: 7551). Five modifications were approved by the same Committee to adjust interview procedures and the purposive sampling of new stakeholder groups across the action cycles. All research participants provided informed, written consent of their participation. The research was carried out in accordance with relevant guidelines and regulations of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe research on which this manuscript reports was funded by the South Australian Department of State Development. They had no role in the analysis nor interpretation of the data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors' contributions\u003c/p\u003e\n\u003cp\u003eStacie conceptualised the design of the manuscript, wrote the main manuscript text and contributed to data collection and analysis. Kristen collected and analysed the research data, developed the figures, and reviewed the manuscript. Chris led the project, contributed to data analysis and reviewed the manuscript. Stacie was a co-investigator of the research project which was project-managed by Kristen. The author(s) read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to thank those that contributed their time and knowledge to this project. Specific acknowledgements go to Nicole Baldwin and Kendall Stone, who worked in placement facilitation roles during the project, and the service providers and students for their generous contributions. We would also like to recognise the input of Dr Angela Lawless, Lilienne Coles, and Professor Sue McAllister on the project team.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBillett S. Integrating learning experiences across tertiary education and practice settings: A socio-personal account. Educational Research Review. 2014;12(0):1-13.\u003c/li\u003e\n\u003cli\u003eBillett S. Learning through health care work: premises, contributions and practices. Medical Education. 2016;50(1):124-31.\u003c/li\u003e\n\u003cli\u003eSheepway L, Lincoln M, Togher L. An international study of clinical education practice in speech-language pathology. International Journal of Speech-Language Pathology. 2011;13(2):174-85.\u003c/li\u003e\n\u003cli\u003ePope K, Barclay L, Dixon K, Kent F. Models of pre-registration student supervision in allied health: a scoping review. Focus on Health Professional Education: A Multi-Professional Journal. 2023;24(2):27-62.\u003c/li\u003e\n\u003cli\u003eGibson SJ, Porter J, Anderson A, Bryce A, Dart J, Kellow N, et al. Clinical educators\u0026rsquo; skills and qualities in allied health: a systematic review. Medical Education. 2019;53(5):432-42.\u003c/li\u003e\n\u003cli\u003eAttrill S, Foley K, Gesesew HA, Brebner C. Allied health workforce development for participant-led services: structures for student placements in the National Disability Insurance Scheme. BMC Medical Education. 2023;23(1):95.\u003c/li\u003e\n\u003cli\u003eDalton M, Davidson M, Keating JL. The Assessment of Physiotherapy Practice (APP) is a reliable measure of professional competence of physiotherapy students: a reliability study. Journal of Physiotherapy. 2012;58(1):49-56.\u003c/li\u003e\n\u003cli\u003eSevenhuysen S, Thorpe J, Molloy E, Keating J, Haines T. Peer-Assisted Learning in Education of Allied Health Professional Students in the Clinical Setting: A Systematic Review. J Allied Health. 2017;46(1):26-35.\u003c/li\u003e\n\u003cli\u003eBeveridge J, Pentland D. A mapping review of models of practice education in allied health and social care professions. British Journal of Occupational Therapy. 2020;83(8):488-513.\u003c/li\u003e\n\u003cli\u003eRodger S, Webb G, Devitt L, Gilbert J, Wrightson P, McMeeken J. Clinical education and practice placements in the allied health professions: an international perspective. Journal of Allied Health. 2008;37(1):53-62.\u003c/li\u003e\n\u003cli\u003eWray A, Lewis LK, Yaxley A, Attrill S. Underperformance and failure in allied health practice placements: a scoping review of student performance experiences. Teaching in Higher Education.1-28.\u003c/li\u003e\n\u003cli\u003eDepartment of Health and Aged Care. Unleashing the potential of our health workforce: Scope of practice review - Final report. Australian Government; 2024.\u003c/li\u003e\n\u003cli\u003eFoo J, Rivers G, Ilic D, Evans DJR, Walsh K, Haines T, et al. The economic cost of failure in clinical education: a multi-perspective analysis. Medical Education. 2017;51(7):740-54.\u003c/li\u003e\n\u003cli\u003eFoley K, Attrill S, Brebner C. \u0026apos;Hearts\u0026apos; and \u0026apos;minds\u0026apos;: Illustrating identity tensions of people living and working through marketising policy change of allied health disability services in Australia. Health (London). 2025;29(1):39-61.\u003c/li\u003e\n\u003cli\u003eReid H, Hocking C, Smythe E. Occupational therapy\u0026apos;s oversight: How science veiled our humanity. Scandinavian journal of occupational therapy. 2024;31(1):2306585.\u003c/li\u003e\n\u003cli\u003eBaum F, Freeman T, Lawless A, Labonte R, Sanders D. What is the difference between comprehensive and selective primary health care? Evidence from a five-year longitudinal realist case study in South Australia. BMJ Open. 2017;7(4):e015271.\u003c/li\u003e\n\u003cli\u003eFoley K, Freeman T, Wood L, Flavel J, Parry Y, Baum F. Logic modelling as hermeneutic praxis: Bringing knowledge systems into view during comprehensive primary health care planning for homelessness in Australia. Health (London). 2024;28(5):673-97.\u003c/li\u003e\n\u003cli\u003eFoley K, Attrill S, McAllister S, Brebner C. Impact of transition to an individualised funding model on allied health support of participation opportunities. Disability and Rehabilitation. 2020:1-10.\u003c/li\u003e\n\u003cli\u003eFoley K, Attrill S, Brebner C. Co-designing a methodology for workforce development during the personalisation of allied health service funding for people with disability in Australia. BMC Health Services Research. 2021;21(1):680.\u003c/li\u003e\n\u003cli\u003eSheepway L, Lincoln M, McAllister S. Impact of placement type on the development of clinical competency in speech\u0026ndash;language pathology students. International Journal of Language \u0026amp; Communication Disorders. 2014;49(2):189-203.\u003c/li\u003e\n\u003cli\u003ePawson R. Evidence-Based Policy: A Realist Perspective: SAGE Publications; 2006.\u003c/li\u003e\n\u003cli\u003ePawson R, Tilley N. Realistic evaluation. Thousand Oaks, CA, US: Sage Publications, Inc; 1997. xvii, 235-xvii, p.\u003c/li\u003e\n\u003cli\u003eRhodes T, Lancaster K. Evidence-making interventions in health: A conceptual framing. Social science \u0026amp; medicine (1982). 2019;238:112488.\u003c/li\u003e\n\u003cli\u003eMeyer SB, Lunnay B. The Application of Abductive and Retroductive Inference for the Design and Analysis of Theory-Driven Sociological Research. Sociological Research Online. 2013;18(1):86-96.\u003c/li\u003e\n\u003cli\u003eFunnell SC, Rogers PJ. Purposeful Program Theory: Effective Use of Theories of Change and Logic Models: Wiley; 2011.\u003c/li\u003e\n\u003cli\u003ePopay J, Rogers A, Williams G. Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res. 1998;8(3):341-51.\u003c/li\u003e\n\u003cli\u003eBaum F, MacDougall C, Smith D. Participatory action research. Journal of Epidemiology and Community Health. 2006;60(10):854-7.\u003c/li\u003e\n\u003cli\u003eMukumbang FC, Kabongo EM, Eastwood JG. Examining the Application of Retroductive Theorizing in Realist-Informed Studies. International Journal of Qualitative Methods. 2021;20:16094069211053516.\u003c/li\u003e\n\u003cli\u003eJones D, Haddadan G, Dunsmore M, Williams A, White D, Hanniver J, et al. Reframing Nurse Education in Rural Australia: Implications for Advancing Longitudinal Integrated Placements. Aust J Rural Health. 2025;33(2):e70041.\u003c/li\u003e\n\u003cli\u003eMoran A, Nancarrow S, Cosgrave C, Griffith A, Memery R. What works, why and how? A scoping review and logic model of rural clinical placements for allied health students. BMC Health Services Research. 2020;20(1):866.\u003c/li\u003e\n\u003cli\u003evan Merrienboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ. 2010;44(1):85-93.\u003c/li\u003e\n\u003cli\u003eGerrits L, Verweij S. Critical Realism as a Meta-Framework for Understanding the Relationships between Complexity and Qualitative Comparative Analysis. Journal of Critical Realism. 2013;12(2):166-82.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"student placement/WIL, service provision, allied health, realist synthesis, clinical placement; practice education","lastPublishedDoi":"10.21203/rs.3.rs-7266234/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7266234/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePractice placements are a substantive component of allied health student curriculum that are critical for developing allied health professional competence. Students are situated in practice settings during placement, where their learning opportunities are opportunistic, and shaped according to population, industry, and policy needs: which change over time and in relation to each other as well as external forces. Allied health practice-placements must respond and adapt to the complex and evolving landscapes of practice; and evidence about the processes and products of such innovation is critical. Realist exploration of practice placements as open systems that occur within broader open systems, helps to expose and explore the changing factors that enfold practice placements and render them workable for service providers who manage competing priorities.\u003c/p\u003e\u003cp\u003eWe contribute a realist exploration of placement models developed for allied health learning during a profound transition of the Australian disability sector: from centrally- to recipient-controlled funding. In the context of declining placement offerings and reports of practitioner fatigue and administrative load, we facilitated an action-research workforce project with university and placement providers of allied health services to develop and trial quality placement education amidst transitional policy implementation. Our investigation seeks to understand the context-mechanism-outcome-configurations of innovative placement models that \u0026lsquo;worked\u0026rsquo; for placement providers and students during a time of policy and industry turbulence. We apply layered realist inference to explore qualitative data collection with 40 students, practitioners, educators and placement facilitators about the process/es of innovating student placements (n\u0026thinsp;=\u0026thinsp;50 instances); novel placement features co-designed during the project; and the role of placement facilitation within processes of co-design.\u003c/p\u003e\u003cp\u003eOur key findings show that a collaborative approach to practice-placement education supports reflection about novel models and helps the needs of students and service recipients to become more visible in the relevant context/s of service provision. We further show the importance of developing reciprocity and partnerships for quality placement outcomes, without the need for resource-intensive placement facilitation approaches. This evidence is useful for promoting quality allied health education as the profession continues to expand and evolve, amidst open systems of policy and industry that influence practice and education.\u003c/p\u003e","manuscriptTitle":"A realist exploration of co-designed practice-placement models that ‘worked’ in shifting contexts of allied health industry, workforce and policy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 18:15:24","doi":"10.21203/rs.3.rs-7266234/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-28T17:39:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-27T04:50:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T12:06:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T15:26:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214794496640120240855888998386473925619","date":"2025-08-15T13:37:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92274849542331493772532702391378744055","date":"2025-08-14T10:31:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92919177569010071552459399585095765121","date":"2025-08-14T04:08:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152974209820937602694307926650593154749","date":"2025-08-14T00:23:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-12T00:26:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-11T18:37:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-11T10:26:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-11T10:22:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c9be95b4-b1ab-4772-bcec-f6753cb45aa1","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:08:35+00:00","versionOfRecord":{"articleIdentity":"rs-7266234","link":"https://doi.org/10.1186/s12913-025-13758-7","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-12-29 15:57:22","publishedOnDateReadable":"December 29th, 2025"},"versionCreatedAt":"2025-08-19 18:15:24","video":"","vorDoi":"10.1186/s12913-025-13758-7","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13758-7","workflowStages":[]},"version":"v1","identity":"rs-7266234","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7266234","identity":"rs-7266234","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}