Resilience can be defined as ‘the ability to maintain personal and professional wellbeing in the face of ongoing work stress and adversity’ (McCann et al, 2013: 61). Stress is an individual's reaction to change: positive stress is beneficial as it can be motivational, thereby contributing to successful outcomes; conversely, negative stress can have an impact on the individual's confidence and self-esteem (Seaward, 2006; Rodder, 2012).
The literature conceptualises resilience through a number of lenses. Collins (2007) suggests it is both a personal trait and the ability to adapt to adverse situations. Lutha and Cicchetti (2000) argue that suggesting an individual is inherently resilient is misleading as, in their view, it involves a process whereby the individual learns to be resilient through coping with adverse situations. In addition to definitions of resilience as a personal quality and a learning process, Masten and Coatsworth (1998) view it as an outcome: the individual becomes competent in the skill of dealing with adversity. Regardless of whether resilience is conceptualised by trait, process or outcome, there is wide acceptance that it is the positive adaptation to an adverse situation (Adamson et al, 2012).
Stressors in contemporary maternity services
The midwife is the lead professional in providing care and support to women throughout the childbirth continuum and coordinates care in complex cases where a multi-professional approach is required. There were 695 233 live births in England and Wales in 2014 (Office for National Statistics, 2015), with an overall increase of 23% in the period 2001–12 (National Audit Office, 2013). In addition to a rising birth rate, midwifery practice is becoming increasingly challenging as a result of a rise in the proportion of complex cases owing to factors including (but not limited to):
Such social, economic and clinical challenges require greater levels of intervention and more complex support packages, thereby increasing workplace pressures on the midwife (National Institute for Health and Care Excellence, 2010; Centre for Workforce Intelligence, 2012; National Audit Office, 2013; RCM, 2015).
In relation to staffing levels, the recommended ratio of midwives to births is one full-time equivalent (FTE) midwife per 28 births in hospital or labour wards, and one FTE midwife per 35 homebirths. National Audit Office (NAO, 2013) statistics show that, in 2012, the ratio was 32.8 births per midwife, which signifies a workload above recommended levels. In 2013 there was a shortfall of 2300 midwives in England (NAO, 2013), which increased to 2600 in 2014 (RCM, 2015), exacerbated by the increase in part-time working and the rising age profile of the workforce: more than 66% of midwives were over 40 and 25% over 50, with an average age of 44.
While the number of midwives has increased since 2005 (RCM, 2015), 3106 (98%) of these additional midwives are aged 50 or over, with only 66 (2%) being under the age of 50. This contributes to what has been termed a ‘retirement time bomb’ by the RCM (2015: 2), meaning maternity services will soon lose a tranche of highly skilled and experienced midwives who, historically, have mentored and supported their less-experienced colleagues to develop skills and confidence. It is therefore imperative that measures are taken to support newly qualified midwives to stay in the profession to become expert practitioners and effective mentors. In terms of succession planning, it is also important that student midwives are supported to successfully complete their programme of study to join the workforce.
Professional, political and service user expectations
In addition to service demands, the midwife also has professional and political standards to meet to ensure women receive a high-quality service. The Nursing and Midwifery Council (NMC) has a remit to protect the health and wellbeing of the public by setting standards of education, training, conduct and performance to ensure people consistently receive high-quality, evidence-based care (NMC, 2008; 2015a).
The midwife is obliged to practise in line with legislation: Changing Childbirth (Department of Health (DH), 1993) identified choice, control and continuity of care as the most important elements of maternity care. Subsequent policy documents state that services should be high-quality, individualised and woman-centred (DH, 2004; DH/Partnerships for Children, Families and Maternity, 2007). Most recently, the key messages from Midwifery 2020: Delivering expectations (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010) are that women's needs must be met by ensuring they are supported to have a positive and life-enhancing transition to parenthood. From the service user's perspective, a ‘good midwife’ should possess attributes such as theoretical knowledge, clinical competency, good interpersonal skills and moral/ethical values in order to provide a service where women feel supported, empowered and informed (Borrelli, 2014). Such high professional, political and service-user demands serve to further exacerbate the stressors of overworked, understaffed midwives.
Resilience in midwifery
‘Stress and workplace adversity… contribute to increased sickness rates and poor staff retention.’
Hunter and Warren (2013) used online focus groups to explore the experiences of senior midwives who self-reported as being able to ‘bounce back’ after a difficult day, with the aim of identifying traits or characteristics of resilience. Participants felt they were resilient because they had a strong sense of professional identity and had learned to use a range of coping strategies, such as accessing support and having self-awareness and self-preservation to cope with the demands of their workplace. It was anticipated that findings could inform the development of better support systems for all practising midwives in order to reduce attrition rates by better preparing them to deal with the increasingly complex physical and emotional demands of their chosen profession.
Implications for pre-registration midwifery education
Hunter and Warren (2013) suggested that their findings could have implications for pre-registration midwifery education, with recommendations including the implementation of sessions to discuss the realities of practice and strategies to enhance student midwives' emotional awareness of self and others. Reflection was also identified as key to developing resilience, in order to consider the emotional implications of clinical practice as well as its practicalities.
Where do we go from here?
‘When there are not enough midwives it is the quality of the service that women receive that suffers.’
It is important for the future of maternity services that all students who commence their training complete it and qualify as midwives to join the depleting workforce (RCM, 2015). There are currently 92 universities offering approved midwifery courses in England (NMC, 2015b) and just over 2500 student midwife places were commissioned in England in each of the 4 years to 2012–13 (NAO, 2013). In an environment with a shortfall in the number of practising midwives (NAO, 2013) and an impending retirement time bomb (RCM, 2015), it is concerning to see that a proportion of student midwives are failing to complete their courses, with the RCM estimating an approximate attrition rate of 20%, and a further 5–10% attrition within 18 months of qualification (Centre for Workforce Intelligence, 2012). Figures show that 27% of midwifery students who should have qualified in 2011–12 failed to complete their programme of study (NAO, 2013).
There has, to date, been no research in the UK specifically focusing on student midwives' construct of resilience and their perceptions of the personal, academic and clinical enablers and barriers to its development. In the absence of primary research in this area, Hunter and Warren's (2013) recommendations for pre-registration midwifery education should be carefully considered. If student midwives are supported to develop their resilience during their training, they will qualify with the skills to better cope with the professional and emotional demands of their chosen profession.