Retention on midwifery undergraduate programmes could be termed the ‘wicked problem’, described originally by Rittel and Webber (1973), as there is no simple solution and the issue is so complex that it may never be completely addressed. The RePair (Reducing Pre-registration Attrition and Improving Retention) project reported that between the academic years of 2009/2010 and 2014/2015, the average attrition rate for midwifery students was 13.6%, with the highest rate being 15.9% and the lowest being 11.5% during that period (Lovegrove, 2018). Children's nursing was the only field that presented a lower attrition rate, with 13.0% being the average rate, 15.5% the highest and 9.9% the lowest.
It is very costly to lose a student midwife, not only to the Higher Education Institution 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 to manage the whole ‘basket of risk factors in a holistic way to achieve lower attrition rates’ (Department of Health, 2006). Lovegrove (2018) reported that financial worries were the key concern for healthcare students, as without long holidays of traditional university courses, there was limited opportunity to earn enough to support themselves. Additionally, the relentless workload and level of responsibility was also of great concern to healthcare students and a consideration in whether they can remain and complete their programme.
The title and function of a midwife is protected in law (Nursing and Midwifery Council, 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, 2017; Royal College of Midwives, 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 that suggests that if students were 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 understanding about resilience in registered midwives who are working in the NHS. The discussion in 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 used a resilience scale over the length of the midwifery programme.
Williams et al (2021) presented a model of resilience for student midwives that offered four essential components: reactability, reflection and reflexivity, relationships with significant others and passion for midwifery. It was proposed that these four components would together support student midwives to broaden and build their resilience. The model was developed from a doctoral research study that explored the development of resilience in student midwives through the use of focus groups, one-to-one interviews and the true resilience scale (Williams et al, 2021).
Methods
This study aimed to assess the usefulness of the true resilience scale (Wagnild and Young, 1993, updated version from 2015 sent to authors in personal communication from Gail Wagnild) in examining resilience in student midwives over a 3-year midwifery programme. The resilience scale was used on three occasions during the study and completed 18 months into the midwifery programme. Student midwives requested to complete the scale on two further occasions extending the use of the scale over 3 years.
The study cohort was purposively selected from a cohort of student midwives who were able to complete the original 18-month study (Williams et al, 2021). Volunteers were asked to take part and half of the cohort (n=25) expressed an interest.
The true resilience scale is a Likert scale, with scores ranging from 1–5. A score of 1 indicates ‘strongly disagree’ and 5 represents ‘strongly agree’ with 25 statements on the scale. An example of some of the statements include ‘I depend on myself to find a way of surviving’, ‘I remain calm under pressure’ and ‘disappointment does not stop me from trying again’. The total score for each of the 25 statements was calculated for each occasion that the scale was completed for each student midwife. A low score suggests low resilience and a high score denotes high resilience.
Table 1. Distribution of true resilience scale scores across the cohort of student midwives
| Score | Descriptor | Number of student midwives |
|---|---|---|
| 25–85 | Very low | 0 |
| 86–98 | Low | 2 |
| 99–111 | Low end | 0 |
| 112–124 | Moderate | 9 |
| 125–137 | Moderately high | 4 |
| 138–150 | High | 0 |
Cronbach's alpha was used to assess for internal consistency of the Likert scale questionnaire items. It measures how closely related a set of items are as a group and is used to measure reliability. There is inconsistency in the agreement of acceptable values of Cronbach's alpha for scale reliability. Sekaran (2006) considers an alpha of 0.60 to be acceptable, while Tolmie et al (2011) comment that an alpha between 0.70 and 0.80 is good. The Likert scales had an alpha of 0.912, indicating high internal consistency of the data, which demonstrated the data were reliable.
The scale was offered to the cohort on five occasions: prior to commencement of the student midwife's first clinical placement, at 6 months, 18 months and 30 months into the programme and on the final day of the programme. None of the scores or their interpretation were given to participants until the completion of data collection and analysis. Results were sent individually to student midwives around 3 months after they had completed the programme, with an offer to discuss any concerns with the author. No participant asked for any follow up.
The true resilience scale scores were descriptively analysed and subject to analysis using the Statistical Package for Social Sciences (version 28.0). The data were entered into a Microsoft Excel 2016 spreadsheet and analysed. Standard approaches to statistical analysis of the data were used. These included computing frequencies to check for accuracy and by identifying outliers (data inputted out of the expected ranges), which need to be examined further for errors in inputting (Stewart, 2016). Missing data analysis was computed to check for the amount of data missing, which may affect the results (Field, 2017). However, this was found to be minimal as all students did score against each statement but not all completed the true resilience scale on all five occasions. Frequencies (or percentages), means, ranges and standard deviations were calculated (Field, 2017). Wagnild (2014) provides an interpretation of the characteristics of resilience for the scores ranging from very low to high.
A non-parametric test was run to see if there was a significant difference between mean scores for each occasion of completion.
Ethical considerations
Ethical approval was gained from both universities for the doctoral of education study and the student midwives gave their consent and agreement to continue to complete the resilience scale throughout their midwifery programme. All students were aware of and reminded throughout the study that they could access support if required. All students were continuing to access their personal tutors throughout the study who would have been giving support as required. The researcher was made aware of the issues concerning the student who scored the lower scores and it was confirmed with them that they were receiving the support they needed.
Results
From an original cohort of 25 participants, 15 participants completed the scale five times. Of the 18 students that completed three scores 18 months into the programme, three students had incomplete scores at end of the programme. One student interrupted their programme, with the intention to rejoin later, and two students were not present on the final day of theory so were unable to complete the scale on the fifth occasion.
Table 2 presents the students' total scores across five completions of the scale, showing the trend and mean interpretation. The mean across all five scale scores for the 15 participants was 122; the range of mean scores was 92–135. The majority of participants (n=13) had average, moderate or moderately high resilience and all student midwives except one increased their resilience between the first and fifth completion of the scale. No students were found to have high resilience by the end of the programme but the overall mean student scores indicated moderately high resilience as detailed by Wagnild (2014). Four students had moderately high mean resilience scores overall, nine had moderate mean scores overall and two had low mean scores.
Table 2. True resilience scales by participant remaining and completing midwifery programme
| Student midwife | 1 | 2 | 3 | 4 | 5 | Total | Mean | Trend | Mean interpretation |
|---|---|---|---|---|---|---|---|---|---|
| A | 89 | 132 | 116 | 142 | 146 | 625 | 125 | ↑↓↑↑ | Moderately high |
| C | 88 | 119 | 126 | 116 | 117 | 566 | 113 | ↑↑↓↑ | Moderate |
| G | 84 | 111 | 88 | 102 | 101 | 466 | 97 | ↑↓↑↓ | Low |
| K | 127 | 115 | 140 | 138 | 127 | 647 | 129 | ↓↑↓↓ | Moderately high |
| L | 93 | 118 | 119 | 126 | 133 | 589 | 118 | ↑↑↑↑ | Moderate |
| M | 110 | 131 | 119 | 139 | 137 | 636 | 127 | ↑↓↑↓ | Moderately high |
| P | 117 | 119 | 127 | 125 | 125 | 613 | 123 | ↑↑↓= | Moderate |
| Q | 117 | 128 | 126 | 126 | 122 | 619 | 124 | ↑↓=↓ | Moderate |
| S | 115 | 129 | 108 | 135 | 125 | 612 | 122 | ↑↓↑↓ | Moderate |
| U | 111 | 131 | 140 | 148 | 147 | 677 | 135 | ↑↑↑↓ | Moderate |
| V | 119 | 128 | 127 | 146 | 150 | 670 | 134 | ↑↓↑↑ | Moderate |
| T | 130 | 120 | 132 | 118 | 129 | 629 | 126 | ↓↑↓↑ | Moderately high |
| X | 110 | 115 | 116 | 116 | 120 | 461 | 92 | ↑↑=↑ | Low |
| Y | 115 | 123 | 132 | 132 | 138 | 640 | 128 | ↑↑=↑ | Moderate |
| Z | 129 | 122 | 131 | 138 | 139 | 659 | 132 | ↓↑↑↑ | Moderate |
Over the 3-year midwifery programme, eight students of the 15 total participants increased their scores; four students' score increased and then decreased, one student decreased after the initial score but remained overall moderately high. Comparing the first and fifth scale scores, 13 student midwives had increased their resilience, one had remained static and one participant had a one point decrease.
One student had a low score at the first completion and their scores remained consistently lower that the rest of the cohort, and was the lowest at the fifth completion.
One student reported an increase in their resilience across all five completions compared to the pattern for the rest of the cohort. The rest of the cohort's scores were more variable.
The mean for the scores in the Likert scale was 4.966 (range 1–5 in the Likert scale), with a standard deviation of 0.535, indicating that on the whole, students scored towards the ‘agree’ and ‘strongly agree’ for all statements. Frequencies for the total number of scores for all students for each occasion the scale was completed were calculated. The total scores ranged from 84 (lowest) to 150 (highest score possible indicating high resilience). The most frequently occurring score was 131 on six occasions that the scale was completed, again affirming moderate resilience.
The overall mean total score for the first completion of the scale was 110.27. The mean score increased on the second occasion the scale was completed to 122.73. A slight increase was seen on the third completion (mean=123.13). The mean total scores continued to rise on the 4=fourth and fifth completions (mean=129.8 and 130.4 respectively), demonstrating that the students' resilience increased on average on each occasion. The results of the non-parametric test showed no significant difference between mean scores for each occasion of completion (P=0.406).
The mean score for each individual statement in the scale was also calculated. The responses to seven of the statements demonstrated an increase in score over the five occasions the scale was completed by the participants.
The highest mean score from the 25 statements was 5.5 for two questions, ‘if something is worth starting I'm going to finish it’ and ‘looking back at my life I feel satisfied’. The lowest mean score was 4.2 for the statement ‘I can say what I am good at.’ The smallest increase in the mean score was in the question ‘I rely on my sense of humour to improve my outlook’, changing from 4.4 to 4.6 over the programme. The responses to nine of the statements increased then decreased over the 18-month period of the study. Two responses decreased then increased: ‘I'm not upset for too long when life does not go my way’ and ‘I am excited about the plans I have’.
The responses to seven of the questions demonstrated an increase in score over the five occasions the scale was completed by the participants.
Discussion
The concept of resilience is portrayed in the literature as being essential for midwifery practice (Hunter and Warren, 2014). However, to date, no research studies have been identified that used a resilience tool to assess resilience in student midwives over their programme of study. The use of the true resilience scale on five occasions over the entirety of a midwifery programme aimed to establish how useful the tool was in determining whether student midwives' resilience developed over the 3-year pre-registration midwifery programme. The tool was quick and easy to administer and demonstrated interesting trends in the development of resilience in the cohort over the 3-year programme. Compared to using the tool over half of the programme, the scores showed the self-reported pattern of resilience in student midwives over a longer period and how it fluctuated.
An increase in score over the five questionnaire completions towards seven of the statements indicates that the students were continuing on the programme and likely felt that they had made the correct career choice. There also seemed to be a pattern in the grouping of the statements in terms of determination and commitment.
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’. If applied to these participants and assessing whether they had made the correct choice to become a midwife, this high score in the true resilience scale could be argued to be particularly relevant in terms of their commitment to complete the programme.
The lowest average score was 4.2 for the statement ‘I can say what I am good at.’ This score potentially indicates that the student midwives on the midwifery programme lacked confidence in their own abilities. As some scores increased then remained static, it could be argued that student midwives need to have more confidence in their own abilities. Confidence could be the coping strategy needed for students where resilience remained static 18 months into the programme, in contrast to the rest of the student cohort. Additionally, the low score in this element may indicate a reduced ability for the student midwife to reflect in and on practice (Collington and Hunt, 2006). This is of interest, as the participants in this study stressed the importance of reflecting to develop resilience.
The smallest increase in score was in the question ‘I rely on my sense of humour to improve my outlook’ changing from 4.4 to 4.6 over the 3-year midwifery programme. This may be because a sense of humour is not such a significant trait to hold in midwifery as it does not align itself particularly to the professional traits demanded of a midwife, namely the 6Cs: care, compassion, competence, communication, courage and commitment (NHS, 2012; Nursing and Midwifery Council, 2015). Therefore, there are some attributes demonstrated in the true resilience scale scores that are perhaps more likely to be required for a student to complete the midwifery programme and become a successful midwife; all of these particular attributes had increased in this cohort of student midwives.
The responses to nine of the statements increased then decreased over the 18-month period of the study. The applicability to midwifery of the increased then decreased trend is that this group of statements has the potential to indicate how a student is reacting to the programme overall. For example, in the curriculum, the aim is to develop critical, analytical midwives and yet in this survey, the scores for the statements ‘I can see most situations from different points of view’ initially increased and then decreased. One possible explanation for the increase and then decrease in scores was the stage of the programme when the third and final survey was completed. The second year of the programme is demanding for student midwives, as there is an increase in expectations for both theory and placement (Lovegrove, 2018). The initial excitement of commencing the programme may have been lost or diminished by the second year and, although students remain committed, the reality of the professional responsibilities of a midwife became evident and for some, can prove quite daunting.
The two responses that decreased then increased, ‘I'm not upset for too long when life doesn't go my way’ and ‘I am excited about the plans I have’, perhaps demonstrate that 18 months into the midwifery programme, these students were still committed to midwifery. This commitment to midwifery remains in spite of being adversely affected by the initial reality of practice and/or the programme (Williams et al, 2021). Additionally, the statements also demonstrate determination in student midwives, who will not give up even when things are challenging.
Taylor and Reyes (2012) found that over one semester, two measures on Wagnild and Young's true resilience scale had statistically increased in the statements: perseverance and existential aloneness. The authors explained these changes as the students potentially increasing their determination and self-efficacy to succeed. Nevertheless, it could still be argued that this can only be supported if the right conditions are in place and are experienced. Therefore, in this study cohort and using a resilience scale, resilience was reported as developing over the their 3-year undergraduate programme. It was recognised that assessing resilience at the 18-month point in the programme may have influenced how these students reported their resilience scores, as the second year of the programme was reported as being both challenging and difficult. The opportunity to extend the period of reporting, such as to the end of the programme, may have produced different results. As this resilience scale was used for the first time with midwifery students, further studies using the scale with a greater number of student midwives are needed to compare and contrast with the findings of this study.
In this sample, it could be argued that the use of the true resilience scale was a valid measure of student midwives' resilience.
There are some attributes demonstrated in the true resilience scale scores that are perhaps more likely to be required to sustain the midwifery programme and become a successful midwife; all of these particular attributes had increased in this cohort of student midwives.
Williams et al (2021) presented a model of resilience for student midwives. The model has four essential components: reactability, reflection and reflexivity, relationships with significant others and passion for midwifery. All components are interdependent, integral and essential to resilience for student midwives; without one component, a student midwife's resilience may be weakened. None of the components are more important than the other and they are not hierarchical in nature. Using a resilience scale could potentially offer early identification of a student midwife's resilience being affected and the model can then be used to explore what specific additional support the student midwife needs.
Limitations
One issue to note is the limitations with the use of Likert scales to gauge scores for resilience. Sullivan and Artino (2013) consider that Likert scale data from individual questions should be considered as ordinal data. In ordinal scales, each item is ranked but the exact differences between the items is not clearly defined. Therefore, it cannot be presumed that the difference between responses in the scale are equal even though the numbers assigned to those responses are. Consequently, there can be issues with interpretation between scores, particularly the differences between ‘strongly agree’ and ‘agree’ and ‘strongly disagree’ and ‘disagree’ and as such this needs to be considered in the interpretation of the findings.
Conclusions
This study explored the use of a resilience scale throughout a 3-year undergraduate midwifery programme. The scale was simple and easy to use and has some useful indicators to consider how a student midwife is faring at the various stages of the midwifery programme. Although the student midwives in this cohort demonstrated that their resilience was different at the various stages of the programme, this cohort of student midwives did develop their resilience throughout the midwifery programme, as shown by their overall scores on the resilience scale.
It is suggested that when used with the model of the integrated resilient student midwife (Williams et al, 2021), the scale offers an early warning tool for determining student midwives' needs and could have value as part of as part of the admission and selection processes.
Key points
- The Wagnild and Young true resilience scale is a useful tool for student midwives to determine their level of resilience throughout the programme and can act as a trigger to access support and help as required.
- Midwifery curriculum teams should consider the adoption of the conceptual model of student midwife resilience.
- The use of the model enables strategies to be developed which are tailored specifically to the student midwife.
CPD reflective questions
- How can a student midwife's resilience be best assessed?
- How do you ensure a student midwife is integrated into the midwifery team?
- Do you know what support is available to student midwives who identify they are struggling on the midwifery programme?
- What do you do when a student midwives has had a challenging experience in practice?