The midwifery undergraduate programme is challenging; to be successful, student midwives are required to navigate both academic and clinical practice demands. To date, little is known about the experiences of student midwives and the factors that support their successful completion of the programme. The concept of resilience is now being considered as a potential trait that is required to be an effective health care practitioner. The literature reviewed to date reveals that there appears to have been no research that has studied resilience in student midwives. This paper will detail a pilot study that took place in December 2015, as part of a Doctorate of Education programme, and examined the role resilience might play for student midwives. This pilot was in preparation for the main study that will follow a cohort of student midwives during the first 18 months of their undergraduate programme.
Context for the study
The term ‘resilience’ is not consistently defined across the literature, although it is in common use. Some authors have suggested that an individual may have a genetic disposition to being resilient (Muller et al, 2009) whereas it is also described as something that may be developed as a result of some significant childhood experiences (Pooley and Cohen, 2010). There is, therefore, dispute as to whether resilience is an inherited personal characteristic or a trait that develops as a result of external stressors (Ahern et al, 2006). Masten et al's (2010: 214) review of resilience research considered that it has moved through four phases; they suggested that current resilience study is focused around ‘integrative ways to better understand the complex processes that lead to resilience’.
Resilience is now being considered as a key characteristic that health professionals need to be able to cope with the demands of their chosen profession (Grant and Kinman, 2014). There is an increasing amount of literature suggesting that if students could be equipped to be resilient they would be better able to cope with their undergraduate programmes (McGillivray and Pidgeon, 2015).
Students who are not coping on their programmes have expressed feeling burnt out, overloaded and depressed (Enoch et al, 2013). McGillivray and Pidgeon (2015) supported the promotion of protective resilience interventions in undergraduate programmes. The idea that some sessions on resilience will satisfactorily prepare students for the work of being a health professional is appealing, albeit somewhat simplistic. It could also be argued that such research assumes that resilience is a tangible trait that can be definitively measured through specifically designed tools.
Student midwives face many issues while undertaking the pre-registration midwifery course. Anecdotally, midwifery lecturers have observed how students arrive on the programme feeling enthusiastic and motivated to be a midwife, having secured their place through a very competitive selection process. They have been briefed at various stages during the process that the programme is a challenging one, not least because they have to succeed both academically and in clinical practice. Once on the programme, students face an array of challenges and some report that midwifery does not meet their expectations and is not the right career choice. Others may have personal issues that necessitate an interruption from the programme, and some then do not return.
The midwifery profession is currently facing many challenges following failings in maternity services reported in the Kirkup report (2015). As a result, the profession is undergoing unpre cedented change in both regulation and delivery of maternity care (Nursing and Midwifery Council (NMC), 2015; National Maternity Review, 2016). Student midwives will inevitably be affected by the changes occurring and will potentially need to develop skills to be able to cope.
The rationale for this study is that there is a paucity of research that has considered resilience in midwifery. Hunter and Warren's (2013) research was key to increasing our understanding about resilience in registered midwives currently working in the NHS. However, to date there has been no research that has investigated resilience in student midwives while on their undergraduate programme, and its potential to help ensure they remain within the midwifery profession. Additionally, it is questioned whether the definitions of resilience found in the literature can be applied to what is being experienced by student midwives. Therefore, a definition of resilience was not assumed at the commencement of the research but explored in the study, to develop a definition of how student midwives view the term and its relevance for midwifery practice.
Aims
The theoretical underpinning of this pilot study had the features of a single case study design method. Denscombe (2010: 52) proposed that case studies focus on:
‘…a particular phenomenon with a view to providing an in-depth account of events, relationships, experiences or processes occurring in that particular instance.’
Case studies are suggested to be holistic, occurring in the natural setting, and can reveal how different processes may be interconnected and interrelated. One strength of the case study approach is that a number of methods can be used within it. Stake (2005) identified intrinsic and instrumental case studies. An instrumental case study is relevant for this study, as it provides insight into an issue with the purpose of the findings being able to go beyond the case itself (Silverman, 2013). For the purpose of the pilot study an instrumental case study seems relevant i.e. the case is examined because it provides insight into an issue.
The aim of the pilot study in December 2015 was to trial the True Resilience Scale (Wagnild and Young, 1993) and explore the definition of resilience to determine its significance for the midwifery undergraduate programme (Box 1). Research questions and sub-questions were formulated (Table 1).
| 1. How do student midwives recount their understanding of resilience in relation to the midwifery undergraduate programme? |
| 2. To what extent is the development of resilience in the first 18 months of a 3-year undergraduate midwifery programme a factor in a students' ability to cope with the undergraduate midwifery programme? |
| Sub-questions: What characteristics are evident in student midwives who describe themselves as resilient? What coping strategies do students adopt who describe themselves as resilient? |
Methodology
Four activities were completed by five student midwives:
An NMC-approved higher education institution, which delivers the 3-year undergraduate midwifery programme and where the researcher is employed, was used for the case study. It is recognised that this is ‘intimate’ insider research (Burgess et al, 2006) as the researcher was known to the student midwives and had a key role in their midwifery programme as their programme leader. However, the researcher was not the personal tutor of any of the study participants. All participants were invited to raise any questions that they might have immediately before commencement of the study.
Convenience sampling was used to select the sample for the initial study (Braun and Clarke, 2013). The participants were accessible to the researcher as they were all current student midwives on the undergraduate programme and they responded to an email inviting them to participate. Four participants had commenced the midwifery programme in September 2014 and one had commenced in March 2014 but had been back-grouped to this cohort. All five focus group participants were invited and agreed to participate in a one-to-one interview with the researcher.
Ethical considerations
Ethical approval to conduct the initial study was sought from the ethics committees and obtained from both the university where the researcher is registered for the doctoral programme and the host university. All participants were provided with a participant information sheet describing the initial study, and they signed and returned a consent form. By agreeing to take part in the study, confidentiality and anonymity were assured. Each student midwife was allocated a code so that all names were anonymised. In the event of any one of the four NHS Trusts where the students undertake practice being commented on during the research, they were each given a pseudonym.
Administration of the True Resilience Scale
Braun and Clarke (2013) stated that the use of a quantitative survey was a quick and inexpensive way of collecting a lot of data. They also proposed that surveys are suited to sensitive topics as they can offer ‘privacy’ and ‘anonymity’ to the participants (Braun and Clarke 2013: 137). The scale was self-administered and the researcher remained in the room while it was completed by hand to ensure there was no conferring among participants (Wagnild, 2014).
The focus groups and one-to-one interviews were all recorded and field notes completed. The recordings of the focus group and the one-to-one interviews were transcribed verbatim. On completion of the transcription, a process of thematic analysis was conducted across the dataset. First, complete coding was used with the aim of identifying everything of relevance to the study's research questions; this enabled identification of a feature in the data and then a label was applied. Braun and Clarke (2013: 211) state that coding is an ‘organic and evolving process’; therefore, once the first coding of the dataset was complete, the whole dataset was systematically revisited looking for chunks of data that could be re-coded.
Findings
Demographic data
Five participants completed the demographic data form (Table 2) and the True Resilience Scale. All participants were female, with a mean age of 31.2 years. All had passed their first-year assessments at the first attempt with grades above 60%. Two students were course and education representatives and three were actively involved in the university's student midwife society.
| Sample size | n = 5 | % |
|---|---|---|
| Gender | ||
| Female |
5 |
100 |
| Placement | ||
| Home |
1 |
20 |
| Age (mean 31.2 years, range 24–49 years) | ||
| 20–29 years | 3 | 60 |
| 30–39 years | 1 | 20 |
| 40–49 years | 1 | 20 |
| Marital status | ||
| Single | 2 | 40 |
| Married | 2 | 40 |
| Living with partner | 1 | 20 |
| Entry qualifications | ||
| Access course | 2 | 40 |
| Undergraduate degree | 2 | 40 |
| Master's degree | 1 | 20 |
True Resilience Scale
One participant scored ‘moderate’ on the scale, three ‘moderately high’ and one ‘high’. The oldest participant had the highest resilience score and had the highest entry qualifications. The highest mean item score was 5.8, for two items: ‘My deeply held values guide my choices’ and ‘I am excited about the plans I have’. The lowest mean item score was 4, for the item: ‘I can say what I am good at’.
Focus group and one-to-one interviews
A list of questions had been pre-prepared and was used as a guide (Table 3), but additional probing questions were asked to gain more detail and explanation from the participants in the focus group and the one-to-one interviews.
| Focus group questions | What is your understanding of the term ‘resilience’? |
| How do you recognise resilience in midwifery practice? | |
| How does resilience feature in the midwifery undergraduate programme? | |
| What professional factors would you identify as contributing to resilience? | |
| What personal attributes would you identify in someone who describes themselves as resilient? | |
| What would you say are the barriers to someone being resilient? | |
| How could resilience be enhanced in student midwives to prepare them for becoming registered midwives? | |
| One-one interview questions | What do you understand by the term ‘resilience’? |
| Would you describe yourself as resilient? | |
| If yes: What personal attributes would you say you have by describing yourself as resilient? What has an impact on you so that you can describe yourself as resilient? If no: What personal attributes would you say you lack by describing yourself as not resilient? What would you say are the barriers to you being resilient while on the midwifery programme? | |
| How could resilience be enhanced generally in student midwives for the midwifery programme and to prepare them for becoming registered midwives? |
The participants seemed very familiar with the term ‘resilience’, and described many examples of what they did to preserve their own resilience and how it was being challenged during the pre-registration midwifery programme. Four participants defined themselves as resilient. The participant who had scored highest on the True Resilience Scale reported that she was resilient only some of the time. The examples she used illustrated how her resilience had been affected.
Enthusiasm and passion were observed when the participants were talking about midwifery experiences. They all spoke confidently about their resilience and how it was built through the many experiences, both positive and negative, that student midwives encountered as the programme progressed. Rather than negative encounters being a deterrent, the group members con firmed that they had found such experiences to be motivational and something that strengthened their personal resilience. Participants gave examples that illustrated their clear identities as student midwives and they spoke confidently about their experiences, even where these had been negative. None of them expressed any indication that they had doubts about being on the programme or becoming a midwife at the end of the course.
Themes
Six main themes emerged from the focus group and interviews:
1. Defining and recognising resilience
The focus group participants readily defined the term resilience. Four of the five participants used positive language to describe their resilience, such as ‘carrying on’, ‘ability to cope’, ‘juggling’, ‘picking yourself up’, ‘move forward and build’. Phrases such as ‘being positive, being challenged’, ‘having broad shoulders’ and being able to ‘power through’ were used. The participants raised the issue of ‘getting it right for women’ and being resilient for them.
‘To pick yourself up when something goes wrong and all goes right and to acknowledge that you can move forward.’ Student midwife ISFG3
However, the participants were clear that resilience could not be seen or observed per se in a student midwife; it was more about how an individual behaved in response to what they experienced while being on the programme:
‘…but you showed resilience because you challenged that when you got that opportunity, you did challenge that situation.’ Student midwife ISFG5
Additionally, this participant thought that resilience was something that was required to be a midwife:
‘It's for the rest of your career pathway that you need to keep this resilience so it's not just seeing it [as] a student but also seeing it as a qualified midwife.’ Student midwife ISFG5
2. Building and developing resilience through reflection
The term ‘reflection’ was used repeatedly throughout the focus group and the participants expressed strongly that they felt this was an integral part of resilience. They described how an individual could not build resilience if they were not prepared to reflect. Participants were clear that the process of reflection was key for knowing how to react in future situations.
‘I think resilience is something you gain with experience ’cause of the reflection… you can look back and say, “oh well, this happened before and worked for me, this didn't work…”’ Student midwife ISFG4
It was suggested that an individual could not make the transitions required as they moved through the programme without reflecting, and that this would result in lower resilience.
‘So you can't be resilient on something you haven't experienced yourself, until you've tested that situation you don't know where your resilience is, so the reflection kinda helps you for future situations and your resilience comes hand in hand.’ Student midwife ISFG3
3. Developing resilience through positive and negative encounters on the midwifery programme
The participants spoke about how the programme personally challenged and tested them, and they were expected to do many new things. They spoke about how they were emotionally tested in theory and on placement, and how they had to learn to cope with ‘everything that was thrown at’ them. It was felt that practice mentors had particular expectations of midwifery students, and this instilled fear in the participants about doing something wrong; they found this stressful and often described taking things personally. They recalled how, at times, they made mistakes:
‘We are all human and we are going to make mistakes and nobody’ s perfect, but it is what you do with those mistakes, how you, erm, take them forward which is what is going to help your resilience in the future.’ Student midwife ISFG5
The participants recounted a number of examples of positive and negative events that they and their peers had encountered while being on the programme, and the effect these had on their resilience. Some of the examples cited included difficult clinical situations—such as third-degree tears, fetal loss and difficult exchanges with other professionals—and failing theoretical assessments.
The participants used the term ‘build’ on many occasions as they engaged in both theory and practice activities. They were candid in their descriptions of scenarios and what they had learnt, needing to assemble all the pieces of learning to make sense of them. Some of the practice scenarios had clearly affected the individuals personally at the time, but they recognised that they had learnt a valuable lesson as a result:
‘Because it's not just about building on the positives. One of my old lecturers used to say that feedback is a gift, good or bad, but it's about recognising when something has gone good how you can still improve it when things are not going so well, what you could have done differently, what will you do next time, who else can you get to help and support you though that.’ Student midwife ISFG1
The term ‘midwifery toolbox’ was discussed, with each participant giving examples including: being on top of work, the importance of mental health, using exercise, being proactive, the importance of knowing when to access help and support, and the need to be prepared.
Students are in the same NHS Trust placement for the first and third year of the programme, and a different Trust for the second year. The change to their base site this academic year had resulted in the participants experiencing particular challenges. Although the move was seen as positive in terms of the benefits it afforded, it was found to be difficult. The students had been required to get used to new ways of working, but their practice mentors still had certain expectations of them owing to their stage of the programme.
4. The relevance of significant others
This was a strong theme across the focus group data. The participants identified a range of individuals and university services that provided essential support throughout the programme. Not unexpectedly, the student's mentor was seen as a significant individual with a key role in giving feedback on the student's progress when in the practice setting. However, while the mentor's support was discussed, and seemed to be highly valued, the relationship still had the potential to cause anxiety for the student midwives.
‘Being able to cope with criticism, some people will take everything personally; some people don't want to analyse themselves or be willing for somebody to critically analyse them and I think if you can't cope with that then maybe you wouldn't stay on the course.’ Student midwife ISFG4
There was agreement among participants that it was not the university's responsibility to develop someone's resilience, but rather to signpost students when they required support and guidance. However, midwifery lecturers sharing their experiences was highly valued, as this made the students feel that the experiences they were having were normal and that it was all right to make mistakes.
‘I think when lecturers share their experiences and kinda say, “ohh you'll think me really silly for this” but you kinda go, “wow, even they're human like they've made all these mistakes through their careers as well, they've been through exactly what we are going through” so it helps.’ Student midwife ISFG1
The participants gave a number of examples of how doing something wrong had affected them and how they had taken it personally, but that they had needed to ‘move on’ and learn from the experience.
Participants described how they used other people's experience as a reality check to see whether what they were experiencing was normal. There were examples when other people had been able to play down the reaction of the participants to enable them to gain a different perspective on the issue. A phrase that was used on a number of occasions was: ‘My resilience is knowing who to go to.’ These participants, while seeing themselves as resilient, clearly recognised that they had to learn how cope to with many issues while being on the pre-registration midwifery programme. They recognised the importance of seeking the help of others in a timely manner.
5. Transferable resilience in midwifery practice
Within the midwifery programme, the support and care of the childbearing woman is paramount. Some of the comments revealed the importance of accepting the woman in one's care, and not taking what she says or does personally. However, participants used the term resilience in a particular way when referring to women. They described resilience as a ‘transferable’ trait where the student midwife's resilience was ‘given’ to the woman through the support and care provided in practice. The participants raised the issue of ‘getting it right for women’ and being resilient ‘for’ them.
There was a strong sense among participants that this was key to the woman being able to successfully get through her labour and birth, and was influential in the outcome for the woman.
‘And you give your resilience to that woman in that situation, she needs it because you are there doing the job as a professional.’ Student midwife ISFG3
The participants discussed the need to ‘carry on’ regardless of what was happening to them on the programme and whatever was ‘thrown at’ them. These reactions seemed imperative to the participants coping in both the theoretical and practice elements of the programme.
‘I've had it in practice when… something happened which was really upsetting and I remember my mentor saying… when we went into a different room to be [with a] different woman that we will have to put [on] a smile, it's fine, you did, you just had to force a smile and went in the door.’ Student midwife ISFG2
6. Different styles of resilience
The final theme that emerged from the interview data was that there are different styles of resilience. The participants repeatedly stated that they felt that resilience was personal and that it could not be taught. They felt that an individual either had resilience or did not. Every individual was seen to have different needs in terms of building resilience, and to be at different stages of doing this.
‘Everyone's resilience is very different and all at a different level to me.’ Student midwife ISFG2
Therefore, the participants described how some student midwives might take longer to develop the resilience they needed to cope with the programme and midwifery practice.
Discussion
This pilot study demonstrates that the midwifery programme and its components have had a major effect on the participants. These effects were sometimes contradictory; for example, the programme drove determination but was found to be hard by all of the participants. The participants were familiar with and able to define the term resilience (Masten, 2001; Ungar, 2008; Werner, 2012; Santos, 2015). They gave clear examples of how it was demonstrated within the midwifery programme, both in the theoretical and practical components (Hunter and Warren, 2013). The participants clearly articulated what they did to cope with the demands of the programme, and there was no suggestion that they were not going to complete their studies and become registered midwives. The dataset demonstrated the students' absolute confidence in their ability to succeed (Kjeldstadli et al, 2006). During the one-to-one interviews, participants described the characteristics of resilience that they felt they possessed. The dataset contained examples of the range of challenges that the participants had faced, and described a number of coping strategies (Hunter and Warren, 2013). These included the use of relevant significant others, both involved in and outside of the programme (Begley, 2001; 2002; Crombie et al, 2013). The one-to-one interviews raised more personal examples of what enabled the participants to cope. Grant and Kinman‘s (2012) toolbox was felt to be a useful analogy but was not found to be a one-size-fits-all strategy, as the participants described their toolboxes differently.
Wagnild's (2014) True Resilience Scale has been used with many different groups and across all ages but not, to date, with midwifery students. Although each participant could only complete it once during this pilot study, the main study will administer it on three separate occasions to determine whether or not the participants' resilience is being built during the study period. There was some evidence in the dataset that the participants had developed their resilience during the midwifery programme. Additionally, the scale findings reflected the strong views expressed by the participants about their own resilience, which reflected their determination to succeed on the programme.
Resilience was seen by these student midwives as an umbrella term that covered numerous elements. A subtheme that emerged from the participants' contributions to illustrate the diversity of the features of resilience was ‘resilience styles'. Additionally, the participants seemed to be comparing and contrasting themselves with others to verify what they were going through. They gave examples which implied that certain personalities were better suited to being a midwife and a belief that thinking about others was needed. This theme is one that should be explored in more detail in the main study.
A theme that emerged unexpectedly (although some of the subtext was not unfamiliar to the researcher) was ‘transferable resilience in midwifery practice’. The way the participants expressed this was unique and had not been previously heard by the researcher or identified within the literature reviewed to date. The participants expressed the importance of their resilience being tested and developed. However, they described the importance of them being able to ‘give their resilience’ to the women in their care. This raises a key question for the main study and a potential revision of one of the research questions. It could be suggested that students who would not define themselves as resilient may find the intense relationship with a woman—something that is essential in midwifery—personally very difficult. It could be suggested that they would not be able to ‘transfer’ resilience if they lacked this characteristic in the first instance.
This pilot study has several limitations. The demographic details show the limit of what can be claimed and on what basis; four of the students were active within the university, holding various student posts. Similarly, the average age profile of the sample was skewed by one participant being in her late 40s, but three of the participants were still older than the average profile of student midwives (which is 20–25 years) and did not meet the average age profile of a university undergraduate (Royal College of Midwives, 2011). All had worked for a number of years before coming onto the midwifery programme.
Although the participants felt that negative encounters made them more determined to succeed, it could be argued that this would not be the case for some individuals, particularly if they had any uncertainty about remaining on the programme or if the number of negative encounters outweighed the positive.
Conclusion
This pilot study has generated some findings that are reflected in the broader resilience literature. It has demonstrated the actions that a small group of second-year student midwives have taken to cope with the demands of the midwifery programme. The characteristics of resilience were articulated by the participants and the data contained examples of the range of challenges associated with the midwifery programme, and the role that resilience might play to reduce the negative impact on the individuals. The participants all described themselves as resilient, although their resilience was being tested by the demands of the midwifery programme and the number of components that had to be achieved. They gave examples of how they demonstrated resilience within the midwifery programme, both theoretically—with academic assessments—and in practice when they had to take on board constructive criticism and witness emergency situations.
One of the important lessons from this pilot study is that student midwives seem to use styles of resilience interchangeably depending on the circumstances, not consistently across all areas, and each person copes with challenges in their own way. There was a belief among participants that resilience cannot be taught, but is key to midwifery practice and the effective care of women and babies.
In light of the findings of this pilot study, midwifery students should be encouraged to reflect on their own practice to enable them to make sense of what they are seeing in practice.
A follow-up study is required to determine whether the findings from this study can be replicated with a larger number of student midwives. It is proposed to follow one undergraduate cohort over the first 18 months of their midwifery programme to get a longitudinal view of whether or not resilience develops in student midwives as they move through the 3 years of the midwifery programme.