An exploration of the development of resilience in student midwives

Retention on midwifery undergraduate programmes has been termed the ‘wicked problem’, as there is no simple solution and is so complex that it may never be completely addressed (Rittel and Webber, 1975). The Reducing Pre-registration Attrition and Improving Retention project reported that between the academic years of 2009/2010–2014/2015, the average attrition rate for midwifery students was 13.6%, with a rate of 15.9% being the highest rate during that period (Lovegrove, 2018).

It is very costly to lose a student midwife, not only to the Higher Education Institution (HEI) but also to the NHS; however, there is little research into the multifactorial reasons why students leave the programme (Green and Baird, 2009) and how institutions try holistically to manage the whole ‘basket’ of risk factors in a holistic way to achieve lower attrition rates (Department of Health, 2006). It has been argued that there are limited data that detail the factors that lead to both attrition and retention (Green and Baird, 2009). This study explored the role of resilience for a student midwife remaining on the midwifery programme.

Although the word ‘resilience’ is currently in popular use, Ahern et al (2015), in their review, found no universal definition of resilience. McAllister and McKinnon (2009) proposed that resilience is reflected by an individual having ‘an internal locus of control, pre-social behaviour, empathy and the ability to organise daily responsibilities … in addition, resilient individuals appear to be more adaptable to change…’. Therefore, it could be suggested that resilience could be defined as the ability to bounce back after a significant event.

The literature is complex regarding what risk factors may affect a person's resilience. Condly (2006) argued that as risk is ‘multifaceted’ then this might also be the case with resilience. Rutter (2006) considered that the term ‘resilience’ is used to describe individuals who, despite being subjected to challenging experiences, do not suffer long-term consequences. Rutter (2006) proposed that by becoming resilient, the individual undergoes some ‘physiological adaptation, psychological habitualisation, a sense of self-efficacy, the acquisition of effective coping strategies and/or a cognitive redefinition of the experience’. However, Rutter (2006) considered that the origin for the resilience could be due to the variation in the risk experienced. Therefore, this author concluded that resilience is not a ‘single quality’ or constant. This appears to be due to the variability in outcome even when people are exposed to the same hazards (Rutter, 2006).

The title and function of a midwife is protected in law (Nursing and Midwifery Council [NCM], 2018). Research has considered whether resilience is the key to being a successful midwife and to preventing attrition from the profession (Hunter and Warren, 2014). At the point of registration, the midwife's role is to provide midwifery care as an autonomous, accountable practitioner with a unique body of knowledge (International Confederation of Midwives, 2018; Royal College of Midwives [RCM], 2018). Arguably, student midwives require particular personal attributes to be able to undertake the role, with resilience being one of them.

Resilience has been considered a key personal characteristic for a healthcare professional to be able to cope with the demands of their profession (Grant and Kinman, 2014). There is an increasing volume of literature which suggests that if students were to be equipped to be resilient, they would be able to cope better with their undergraduate programmes (McGillivray and Pidgeon, 2015).

Hunter and Warren's (2013) research, ‘Investigating resilience in midwifery’, was key to increasing an understanding about resilience in registered midwives who are working in the NHS. The discussion within the literature about resilience raises the question of its significance to student midwives and whether the definition within the literature can be applied to them. There is a paucity of research that has considered resilience in midwifery and none has been found to date that has studied student midwives, which provided justification for this study.

Methods

This longitudinal research study adopted a case study approach with one cohort of participants over the first 18 months of their undergraduate midwifery programme. The aims of the study were to identify whether resilience developed or not during the first half of a three-year midwifery undergraduate programme and explore the views of student midwives regarding the concept of resilience. The research questions for the study are presented in Table 1. All of the data collection for the pilot (Williams, 2016) and the main study were undertaken with one cohort of student midwives in a HEI in the East Midlands region of the UK, within a school of health sciences.

The study cohort was selected purposively as it was important to involve a group of student midwives who would be best able to participate for the duration of the study, namely 18 months. Two months following the commencement of the programme, a direct email was sent to the whole cohort asking for volunteers to take part in the study; half of the cohort (25) expressed an interest in participating. Once the participants had volunteered, the aim was to commence data gathering prior to their first practice placement so that any potential impact of placements could be captured. It was recognised that the participants were not necessarily representative of the whole cohort of student midwives; some may have had particular characteristics not displayed in the rest of the cohort. However, the cohort was diverse in terms of age, ethnicity and type of qualifications completed to meet the entry requirements onto the midwifery programme and so was the sample of participants.

The students had received a workshop exploring resilience during the first theoretical module. The rationale for the participants volunteering to be part of the study was not explored, although some participants did share that they were interested in the concept of resilience. The study cohort was made aware that they would not be prejudiced on the midwifery programme if they withdrew from the study for any reason. A total of seven students from the initial 25 had to withdraw from the study due to leaving the midwifery undergraduate programme.

Five methods of data collection were selected, namely biographical data on entry to the programme, theoretical assessment scores for the 18-month period, the administration of Wagnild and Young's (2015) True Resilience Scale©, focus groups, and one-to-one interviews. Immediately prior to the administration of the scale, all the participants completed a form detailing their biographical data. It was acknowledged that using several methods would produce a large amount of data but nevertheless it was felt to be important to enhance the comprehensiveness of the findings about resilience. Each method in this study was specifically selected for its ability to answer the individual research questions and to enhance the range of data on the different aspects of resilience in student midwives to create more of a holistic picture of the concept.

The True Resilience Scale© had not been employed previously with student midwives and, therefore, as well as its use in providing resilience scores over time for the participants, there was an interest in exploring its appropriateness and applicability for a cohort of student midwives. Focus groups were selected to enable the participants to discuss their views on the concept of resilience and work as a group in a semi-structured way to present their ideas. Following preliminary analysis of the focus groups, a number of students who had particularly raised points of interest that warranted expansion were invited to attend a one-to-one interview to explore their contributions privately in more detail.

A total of 18 students completed the scale on three occasions and they were descriptively analysed. Version 24 of the SPSS package was also used to analyse the findings of the True Resilience Scale©. A one-way repeated measures ANOVA, (one-way analysis of variance), was conducted to compare the scores of the True Resilience Scale© between the first, second and third time of completion. As there were greater than two-paired samples, a one-way repeated measures ANOVA test was used. The mean and standard deviations are presented in Table 2. Pairwise comparisons revealed that there were significant differences in True Resilience Scale© scores between the first and second completion (p=0.034) and time one and time three (p=0.002); there were no significant differences between time two and time three (p=1.0) (see Table 3).

Thematic analysis was adopted as the method to identify themes and patterns across the data from the focus groups and one-to-one interviews, using the flexibility of Braun and Clarke's approach (2013).

Findings

The True Resilience Scale © demonstrated that over the 18-month period, five participants increased their resilience, seven participants increased then decreased their resilience over the 18 months and five participants decreased then increased their resilience over the 18 months, one participant increased their resilience and then remained static, and no participants decreased their resilience. Therefore, in this cohort, the majority of students did increase their resilience score over the first 18 months of the programme.

The mean and standard deviation is presented in Table 2. Pairwise comparison revealed that there were significant difference in the True Resilience Scale© scores between the first and second completion (p=0.034) and time one and time three (p=-0.002); there were no significant differences between time two and time three (p=1.0) (see Table 3).

The highest average score from the 25 statements was 5.5 for the two questions, ‘If something is worth starting, I'm going to finish it’ and ‘Looking back at my life, I feel satisfied’. The lowest average score was 4.2 for the statement, ‘I can say what I am good at’. Over the three occasions the scale was completed in this study, seven of the question responses to seven questions increased. One question had the smallest increase from 4.4–4.6 over the 18-month period. The largest variation in score over the 18-month period was for two statements, namely a score range of 4.2–5.3 and 3.8–4.9. The responses to nine of the statements increased then decreased over the 18-month period of the study and three statements increased, then remained static: two of the statement responses decreased then increased. In summary, the True Resilience Scale© results over the first 18 months of the undergraduate midwifery programme overall demonstrated that the resilience in the majority of the cohort had increased albeit at different rates.

The resilience scores and trends were examined in relation to the biographical details, age and assessment grades of the participants but they did not appear to be related in terms of whether the individual was resilient or not. Some of the True Resilience Scale© scores did demonstrate some of the traits that may be of interest to remaining on the programme and becoming a midwife. Within the group of students, there was a range of ages, entry qualification and previous experience in employment. The highest and lowest average resilience scores were slightly higher in the students who had been previously employed in healthcare.

Themes from the focus groups and one-to-one interviews

The data collected in the focus groups and the one-to-one interviews were merged as the primary aim of the one-to-one interviews was to further explore the topics that had been raised during the focus groups. Five key themes and some sub-themes emerged from the data (see Table 4).

Overall, there was general agreement amongst the participants about what was being said about resilience and they recounted similar experiences. They clearly articulated what resilience meant to them. They agreed it was needed for their longevity as midwives and to be able to deal with the range of stressful situations to ‘bounce back’ and ‘move forward’ on the programme.

‘I think it is being able to bounce back when something does not go as expected…’ (StMid/16/FG3/18 months)

‘Carrying on [the] ability to carry on [and] someone who can find strategies and answers and solutions if there is a problem.’ (StMid 4/FG2/18 months)

Within the focus groups that a student midwife needed to be proactive in their approach to the programme as well as having an optimistic demeanour to ensure resilience was maintained. There was also agreement that an individual was responsible for their own resilience.

‘…what I do myself helps me to be a resilient student rather than, you know, because of my personal traits or beliefs or whatever … it's quite a personal thing.’ (Stmid16/FG3/8 months)

The students in this cohort were all passionate about being midwives but they recognised that it was important to gain a ‘balance’ between their professional and personal lives; this was achieved by ‘compartmentalising’ the different parts of their lives and keeping them separate.

‘It's about trying to decompartmentalise things so you can still function, outside the wards, in your daily lives so that your emotions don't cross so much so you can have at least a positive outlook in at least one part of your life … there are layers in what we do … so if you can keep them slightly separate then you can deal with that…’ (StMid 25/FG4/18 months)

The student midwives in this study developed the term ‘reactability’ to describe the need to adapt and cope with the challenges that they came across in the programme.

‘It's like your reactability isn't it, because you chop and change so much in what you do. You go into practice, then you have to be a student again, an academic student and then having to chop and change between the two.’ (StMid 3/FG1/8 months)

Participants were clear that resilience could not be taught; it had to be tested through experience and built upon. Being a ‘reflexive’ student midwife enables them to make sense of what happened to them in midwifery practice, which could be used to cope with the same situation in the future. On the second occasion the focus groups met, they reported how their midwifery practice had changed between the first and second year, and the importance that resilience played in this.

‘… in the first year, every placement was like emotionally exhausting. I would find it hard to sleep, you know, when on placement. But now it's not so emotionally exhausting really because I know what I am doing … so it's not the first time you are doing anything.’ (StMid 3/Int./8 months)

‘It's almost like … playing with building blocks … you think you are building up this tower, you are building it up and then a bit falls off so it's okay, we'll pick that back up and then you get a bit higher and another few more bricks fall off and that all makes a few more fall off and I think it's how you pick yourself up … if you are passionate about something enough, then your resilience will keep propelling you forward to make sure you get to your end goal.’ (StMid 25/FG4/8 months)

Resilience was described as a trait that fluctuated from day to day. Midwifery lacks day-to-day routine and it is important for a midwife to be flexible in their approach to practice. There were a number of factors that seemed to both enhance and threaten the students' resilience, and they described what they were doing to keep resilient. For example, the described what they did to look after themselves, both physically and emotionally, which enhanced their resilience and their ability to cope with the demanding clinical environment. The importance of significant others, particularly the midwives who supported them in practice, were key to promoting their resilience. The mature students, over 25 years of age, described the particular challenges they faced to promote their resilience.

‘I've really struggled with life and balance, and that's hit me and I've had loads of meltdowns so I don't know whether it's like mature students it hits or it's a big shock coming to university…’ (StMid 11/FG4/8 months)

The students described the importance of needing to ‘belong’ in clinical practice and the midwives were key to this. They also discussed the need to have a realistic vision about what midwifery is about and not give up at the first hurdle, as there were many challenges to face. They recognised that they would face good and bad times in midwifery practice, and needed to learn to ‘roll with the punches’ and accept that what happens cannot be prevented from happening:

‘…all midwives have their own values and you can tell in their practice but I don't think it matters that everyone is slightly different…’ (StMid 5/FG1/18 months)

Of particular interest was how this cohort of student midwives described the importance of their resilience for the woman in their care. They felt that their resilience had a positive impact on how a woman coped with childbirth. Additionally, if a woman observes emotional responses in the midwife this can help to build a positive caring relationship.

‘I think it [resilience] rubs off on them [the woman] without us realising it.’ (StMid20/FG3/8 months)

Discussion

The UK NHS environment is a pressurised one, where current financial pressures and reorganisation are having an effect on the workforce (Sull et al, 2015). Midwives have also reported feeling stressed due to a heavy workload, staff shortages and not having time to do the job well (RCM, 2017). The RCM's membership survey concurred with the NHS Staff Survey (2017) that staff could not absorb any further work pressure and that staff satisfaction had decreased since the previous survey. An unanswered question is whether having resilience would make a difference to NHS staff.

Most attrition from the midwifery programme occurs in the first year when the individual encounters the clinical placement for the first time (Lovegrove, 2018). Thereafter, it tends to be academic failure, personal health or circumstances which forces the student to leave. The role that resilience might play in student midwives navigating the undergraduate programme was central to this research study.

If is accepted that it is unavoidable that students will encounter difficult situations in practice, it is critical to support them effectively to be able to cope when challenges arise. This study's participants clearly articulated a definition of resilience and its relevance to student midwife. Promoting resilience, therefore, assumes that it is a tangible trait that can be measured. It could be argued that sessions on resilience that will satisfactorily prepare students for what they will face in their daily lives as healthcare practitioners will not be effective.

Two key theories were reviewed prior to the study and they were both considered to be of potential benefit to the understanding of why students persisted on the programme despite challenges (Tinto, 1997; Frederickson, 2004). Frederickson's (2004) ‘broaden and build’ theory of positive emotions is of importance in promoting resilience in student midwives. While resilience was seen in this study as not being able to taught, the students agreed that it needed to be developed specifically for midwifery practice. Resilience was described as fluctuating and there was a need to look after oneself and access support when required.

Jackson et al (2011) proposed that students who manage to cope with stress in practice have a strong sense of professional identity. The integration of the student both into the university and the maternity settings while adopting the professional attributes of a midwife (NMC, 2018). The students in this study described the first year as being important for developing confidence and their belief that they could be a midwife and by 18 months describing themselves as being ‘professionals’ which reflects Tinto's (1997) work on social integration. As a result of this study, Tinto's (1997) theory was further developed to reflect the position of clinical placement that are undertaken for 50% of the programme. The adapted model reflects the place of integration into the midwifery professional as a pre-requisite to being able to demonstrate professional commitment to becoming a midwife.

This study was important as, to date, the importance of resilience for student midwife has not been researched. McGowan and Murray (2016) concluded in their literature review that finding an operational definition of resilience was complex. Nevertheless, as a result of this study's participants' contributions a conceptual model has been developed (see Figure 1).

Figure 1. A model of resilience for student midwives

A conceptual model of resilience for student midwives

It is proposed that the four components will together support student midwives to broaden and build their resilience with will result in successful integration into the midwifery profession. The model of resilience for student midwives presents four essential components, namely: reactability, reflection and reflexivity, relationships with significant others, and passion for midwifery. All components are interdependent, integral and essentials to resilience for student midwives; without one being more important than the other and they are not hierarchical in nature.

It is proposed that midwifery curriculum teams could adopt the conceptual model of student-midwife resilience to embed strategies that are tailored specifically to the student midwife.

The Tinto's (1975) adapted framework considers how integration into the midwifery profession is promoted and monitored. By applying Tinto's work to a midwifery programme, it is proposed that the academic and social aspects of the course as well as what the institution itself has to offer, could be made clearer for the student midwife and given value.

Cope et al (2016) also found that to be resilient required effort as well as a sense of commitment and passion within the professional role. These authors discussed the meaning of work for women who often merged their personal and professional selves in their jobs. In this model, integration into a professional life and midwifery as a career choice is the key to success.

To be able to make sense of what is happening in midwifery care, understanding is required in order to work out how to deal with the issues, thus adopting a proactive approach. Action could include the individual personally reflecting to make sense of what is happening to them as well as seeking external help. The process of reflection and reflexivity enables a student midwife to recognise when action should be taken in order to move forward successfully. Therefore, it is suggested that the more informed a student midwife is, by developing their personal insight, the more resilient they become in midwifery.

Resilience does not mean that an individual is not affected by a difficult situation but knows how to respond and gain closure. Therefore, when the student midwife asks for support and guidance, it should not be seen as a sign of weakness but a strength and part of their resilience; their relationships with significant others play a key role here.

Therefore, this unique model of resilience for student midwives is presented as a framework for student midwives and their significant others to consider strategies to foster resilience. If students are introduced, using the framework, to the essential components of resilience for student midwives, then they consider whether they have these traits and in what measure, so they can take specific steps to develop them further. It is proposed that the overarching component for the student midwife is integration and if all other components are aligned, then the student midwife is more likely to feel part of the profession and will wish to complete their undergraduate programme and practice as a midwife.

Conclusion

The role of resilience in supporting healthcare professionals' practice is not consistently articulated in the literature and there appears to be a lack of knowledge regarding the best approach to take to increase the knowledge about resilience (Aburn et, 2016; Thomas and Revels, 2016). This study produced rich data across all the methods used in relation to 18 student midwives' experiences of theory and practice over half of their programme. The study participants felt that the way the terms resilience is currently used does more to threaten it in midwives than promote it, therefore, this study challenges the current resilience discourse. Midwifery educationalists should work with their NHS colleagues to address poor practice in the clinical environments to challenge poor behaviour which could have a negative impact on student midwives. The adoption of the RCM's (2016) ‘Caring for You’ strategy within the midwifery curriculum would encourage it to be fully applied to student midwives in midwifery clinical placements.

This unique study has explored the concept of resilience and how it applies to student midwives; resulting in a model of resilience for student midwives. The study has concluded that resilience is a multi-faceted concept, an ‘umbrella’ term, that relies on a number of essential key attributes that can support a student midwife with the challenges that they encounter in midwifery practice. The idea that there are different levels of resilience, it is not a static concept and can fluctuate between contexts was supported by the participants in the study. Resilience cannot be taught but it can be promoted. The Wagnild and Young's (2015) True Resilience Scale© could be used as a tool for student midwives and the conceptual model of resilience to determine a student's level of resilience throughout the programme and to act as a trigger to access support and help as required.

Further research is recommended with a greater range of students across a number of HEIs and the individuals who support student midwives throughout the programme, to assess their views on the concept and significance of resilience in midwifery practice.

Key points

• This study has been the first of its kind to enhance the understanding of the concept of resilience for student midwives
• An individual being successfully integrated into the midwifery profession appears to safeguard student midwives when they encounter challenging or distressing situations
• The ability to understand what has occurred in the clinical environment using a process of reflection and reflexivity seems key to the student midwives being able to learn form the experience and move on psychologically
• A key contribution of this study has been the development of a conceptual model of resilience specifically for student midwives

CPD reflective questions

• Using the conceptual model, consider how you could use the four components in your support of student midwives
• What factors in your practice can enhance resilience in student midwives?
• How can you support student midwives to integrate into the midwifery profession?
• How do you protect your resilience in midwifery practice?