Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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Midwives' experiences of workplace resilience$ Billie Hunter, PhD, BNurs, RM (Royal College of Midwives (RCM) Professor of Midwifery)n, Lucie Warren, PhD, BMid (Hons), RM (Lecturer/Research Associate) School of Health Care Sciences, Cardiff University, Cardiff, UK

art ic l e i nf o

a b s t r a c t

Article history: Received 21 January 2014 Received in revised form 12 March 2014 Accepted 17 March 2014

Background: many UK midwives experience workplace adversity resulting from a national shortage of midwives, rise in birth rate and increased numbers of women entering pregnancy with complex care needs. Research evidence suggests that workplace pressures, and the emotional demands of the job, may increase midwives' experience of stress and contribute to low morale, sickness and attrition. Much less is known about midwives who demonstrate resilience in the face of adversity. Resilience has been investigated in studies of other health and social care workers, but there is a gap in knowledge regarding midwives' experiences. Objective: to explore clinical midwives' understanding and experience of professional resilience and to identify the personal, professional and contextual factors considered to contribute to or act as barriers to resilience. Design: an exploratory qualitative descriptive study. In Stage One, a closed online professional discussion group was conducted over a one month period. Midwives discussed workplace adversity and their resilient responses to this. In Stage Two, the data were discussed with an Expert Panel with representatives from midwifery workforce and resilience research, in order to enhance data interpretation and refine the concept modelling. Setting: the online discussion group was hosted by the Royal College of Midwives, UK online professional networking hub: ‘Communities’. Participants: 11 practising midwives with 15 or more years of ‘hands on clinical experience’, and who self-identified as being resilient, took part in the online discussion group. Findings: thematic analysis of the data identified four themes: challenges to resilience, managing and coping, self-awareness and building resilience. The participants identified ‘critical moments’ in their careers when midwives were especially vulnerable to workplace adversity. Resilience was seen as a learned process which was facilitated by a range of coping strategies, including accessing support and developing self-awareness and protection of self. The participants identified the importance of a strong sense of professional identity for building resilience. Key conclusions: this study provides important new insights into resilience within UK midwifery, of relevance to the wider profession. Some findings echo those of other resilience studies; however, there are new insights such as the importance of professional identity which may be relevant to other health care workers. Through understanding more about resilience, it may be possible to facilitate positive adaptation by midwives and ameliorate the effects of workplace adversity. Implications for practice: This study indicates that resilience is a complex phenomenon, which warrants serious consideration from clinical midwives, managers, educators and researchers. & 2014 Elsevier Ltd. All rights reserved.

Keywords: Midwives Resilience Workforce Stress Emotion

Introduction Midwifery is acknowledged as emotionally demanding work, as evident in a growing number of studies (Hunter, 2004; Leinweber ☆

Funding: Project funded by the Royal College of Midwives UK (RCM UK). Correspondence to: School of Health Care Sciences, Cardiff University, East Gate House, 35-43 Newport Road, Cardiff CF24 0AB, UK. E-mail address: [email protected] (B. Hunter). n

and Rowe, 2010; Rice and Warland, 2013; Hunter and Warren, 2013). Caring for women and their families requires midwives to deal with anxiety, pain, fear and sometimes grief, as well as excitement and happiness. Working in these emotionally intense situations requires emotion work skills that are largely unrecognised and undervalued (Hunter, 2010). In addition to these ‘ordinary’ challenges, midwives in the United Kingdom (UK) are facing other pressures. The birth rate is rising, growing numbers of women enter pregnancy with complex social

http://dx.doi.org/10.1016/j.midw.2014.03.010 0266-6138/& 2014 Elsevier Ltd. All rights reserved.

Please cite this article as: Hunter, B., Warren, L., Midwives' experiences of workplace resilience. Midwifery (2014), http://dx.doi.org/ 10.1016/j.midw.2014.03.010i

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and physical care needs, and there is a national shortage of midwives (Campbell, 2012; Warwick, 2012). These pressures potentially affect the emotional well-being of individual midwives and also the morale of the profession. These concerns have been well documented in UK midwifery and national press (Warwick, 2011) and are not unique to the UK, with similar issues being discussed in Australia (Australian Health Workforce Advisory Committee, 2002) and some European countries (Hunter et al., 2008; Royal College of Midwives, 2013). It is hardly surprising that low morale and stress are reported within the midwifery workforce, or that staff retention is problematic in many areas (Royal College of Midwives, 2010). These concerns are not new. A decade ago, a series of UK reports (Ball et al., 2002; Curtis et al., 2003; Kirkham et al., 2006) investigated why midwives leave the profession and why they stay. The key reason for leaving was dissatisfaction with midwifery, in particular the way that it was practised within the UK National Health Service (NHS), lack of workplace autonomy and poor support (Ball et al., 2002). However, there is another side of the picture: some midwives do stay in the profession, not just from economic necessity but because they want to (Kirkham et al., 2006). Studies of employee well-being indicate that a key issue is ‘resilience’ (Jackson et al., 2007). Resilience has become an increasingly popular term, used to apply to a diverse range of situations from community responses to disasters to businesses which survive economic pressures (Office for National Statistics, 2013). However, its popular appeal means that the term may be used rather loosely, hence it is important to clarify the definition. Put simply, resilience describes relative resistance to adversity (Rutter, 1999). Its conceptual roots are primarily within child development, psychology and physiological stress literature (Hodges et al., 2008). Most definitions refer to a positive adaptation to adversity (Luthar et al., 2000), without residual significant psychological or physiological disruption (Seery et al., 2010). That is, resilience is when an individual, group or community responds more positively to an adverse situation than might be expected. Opinion is divided on the origins and characteristics of resilience. There is debate about whether resilience is a stable personality trait, a set of constructive coping mechanisms or a process of emotional adaptation over time (Neenan, 2009). There appears to be consensus, however, regarding the typical features of resilient responses. These are characterised as habitual patterns of cognition, behaviour and emotion which consistently draw on effective resources to reduce risk to the self from adversity (Luthar et al., 2000), rather than being isolated or occasional episodes of effective coping. In other words, resilience is the ability of an individual to respond positively and consistently to adversity, using effective coping strategies (Hart et al., 2007; Neenan, 2009; Seery et al., 2010). Given that the challenges currently facing the UK midwifery profession are not likely to be easily or quickly resolved, understanding more about why and how some midwives are able to withstand workplace adversity and remain positive and motivated could benefit the profession as a whole.

Literature review A literature review of current evidence relating to resilience in midwifery identified no midwifery specific studies, hence the search was extended to include other health and social care professions. Relevant papers were identified through searches of databases including ASSIA, BioMed Central, CINAHL, OVID, PubMED, and Wiley, using key terms which included: resilience, professional well-being, burnout, stress, coping, job satisfaction and workplace adversity.

A small number of studies explored resilience within health and social care professions. These predominantly focussed on nursing although some studies involved social workers (Kinman and Grant, 2011; Adamson et al., 2012), general practitioners (Jensen et al., 2008; Cooke et al., 2013) or a combination of different health professionals (McAllister and Mckinnon, 2009; McDonald et al., 2011; Bringsen et al., 2012; McCann et al., 2013). Midwives had participated in one Australian multiprofessional study, however it was not possible to differentiate between the responses of midwives and nurses (McDonald et al., 2011). Many studies aimed to identify how best to foster resilience and promote career longevity. Findings indicated certain factors that appear to mediate resilience: positive perceptual and attributional styles, self-actualisation, self-awareness, reflexivity, selfefficacy and active coping techniques (Garrosa et al., 2010; Larrabee et al., 2010). Most authors argued that resilience can be developed (Grafton et al., 2010), recommending various educational strategies, including identifying effective coping strategies (Grafton et al., 2010), developing self-awareness via reflection (Jackson et al., 2007), and clinical supervision (Arvidsson et al., 2008; Howard, 2008) aimed at enhancing confidence and selfefficacy via stress management techniques (Gillespie et al., 2007; Arvidsson et al., 2008). However, there is currently limited evidence that these interventions enhance resilience in midwives or nurses, and we found no report of the use of resilience theory to underpin midwifery or nursing education. Given the lack of research focused specifically on resilience in midwifery, an exploratory descriptive study was designed to ascertain whether the concept of resilience was relevant for UK midwives and worthy of further investigation. The study aims and research questions were developed from the literature review, and informed by insights from other studies of practitioner resilience. The aims of the study were (i) to explore clinical midwives' understanding and experience of resilience using a professional online discussion group, and (ii) to model the concept in collaboration with an Expert Group. The research questions were: (1) How do clinical midwives describe their experience of resilience? (2) What personal, professional and contextual factors contribute to resilience? (3) What factors act as barriers to being resilient? (4) In the opinion of participants, how could the resilience of student and newly qualified midwives be enhanced?

Methods A qualitative descriptive approach was used to describe midwives' understanding and experience of professional resilience. Qualitative description has been identified as the method of choice in areas where little theory exists and when a rich, straight description of the phenomena from the participants' perspective is required prior to the development and testing of further theory (Sandelowski, 2000), as is the case in this study. Qualitative description is also particularly beneficial in studies with limited resources and time (Neergaard et al., 2009). Although qualitative description has been criticised by some for not being theoretically driven (Thorne, 2008) it does not mean that this approach should be viewed as being atheoretical (Sandelowski, 2010). Rather qualitative description should be seen within the context of the existing evidence base, the work of others within the field, as well as the researchers' own clinical experience (Neergaard et al., 2009).

Please cite this article as: Hunter, B., Warren, L., Midwives' experiences of workplace resilience. Midwifery (2014), http://dx.doi.org/ 10.1016/j.midw.2014.03.010i

B. Hunter, L. Warren / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

A two-stage exploratory descriptive qualitative study was undertaken over six months (September 2012–March 2013). A closed online discussion group was conducted with qualified midwives (Stage One), followed by discussion of the findings with an Expert Group representing midwifery workforce research and resilience studies (Stage Two). Stage One

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Liz is a midwife working full-time on a busy labour ward. She has been in practice for 15 years and describes herself as someone who is able to bounce back after a difficult day. How do you think Liz feels about her working life? o

What aspects about her work life do you think she may enjoy?

o

What aspects about her work life do you think she may not like?

What is it about Liz that makes her stay in practice? When Liz has a difficult case, how does she manage to bounce back?

Recruitment A convenience, self-selected sample of midwives was recruited with the assistance of the Royal College of Midwives UK (RCM), who publicised the study in the RCM Journal and electronic newsletter. The inclusion criteria were:
Practising midwife in hands-on clinical practice in one of the four UK countries,
Member of RCM (necessary to access RCM discussion groups),
Practising as a midwife for more than 15 years (that is, midwives who demonstrated resilience through career longevity),
Self-categorising as ‘resilient’ (defined colloquially as ‘someone who can bounce back after a stressful or difficult day at work’). Midwives who were interested in participating contacted the research team directly. Once eligibility was confirmed, they were sent information about the study's purpose, what participation would entail and how the data would be used. It was emphasised that the level of engagement was at the participant's discretion, with the right to opt in and opt out as desired. Sample Eighteen midwives expressed an interest in participating, 12 registered as discussion group members and 11 midwives eventually participated in discussions. Data collection Data were collected via a closed online discussion group, hosted by the Royal College of Midwives UK Online Communities. The group ran for four weeks between October and November 2012. The research team accessed the discussions daily, using a ‘light touch’ approach to facilitation, so that the natural flow of the online ‘chat’ was not interrupted. We occasionally posed questions if there had been no posts for a while, and also gave brief feedback to encourage further contributions. Initially, there were frequent participant contributions to the discussion which lessened over the life of the group. It was not the intention of the researchers to reach data saturation, given the short timeframe possible for data collection. However, the decrease in posts might indicate data saturation was achieved, although it is not possible to establish that this was the case. A vignette about a fictional ‘resilient midwife’ was also used to encourage discussions (see Fig. 1). The vignette was piloted with two non-participating clinical midwives. Although the original intention was to post the vignette at the outset to prompt contributions, group discussions commenced spontaneously, so the vignette was not introduced until half-way through data collection. Data analysis Data were entered into NVivo and analysed thematically using the three stage approach described by King and Horrocks (2010). Firstly descriptive codes were generated based on the views and perceptions of participants. In the second stage of interpretive coding, descriptive codes were examined for common themes and

What sources of support might she use? How do you think Liz manages to balance her work and home life? Do you think Liz’s resilience would be affected by changing her hours to part-time or by moving to another area such as out in the community? What prevents Liz from leaving the profession? / What keeps her going?

Fig. 1. Vignette.

meanings. Finally in stage three, overarching themes were identified. Data analysis was an iterative process. The full discussion data were referred back to during all stages, to ensure that the codes were developed within the context of the original conversation. Coding was undertaken ‘blind’ with both authors coding transcripts independently, followed by joint cross checking of the themes and critical appraisal of the coding. In addition, a third research team member independently checked the coding to enhance analytic rigour. Following some refinement of themes, there was mutual agreement regarding the defined codes.

Ethical considerations A positive ethical review was obtained from the Research Ethics Committee, Cardiff School of Nursing and Midwifery Studies, Cardiff University. The online nature of the discussions required particular ethical consideration. A closed group was set up so that only those consenting midwives who had been formally admitted to the group could take part. RCM members accessing any other online discussion group were unable to identify the participants or view the discussions. We requested that all participants keep their personal identity and the identity of their workplace anonymous. Identifiers were removed from data prior to analysis. All data were stored securely. Electronic data were stored on a password-protected computer, and hard copies of research material were kept in a locked filing cabinet. Only fully anonymised data were shared with research team and Expert Panel.

Stage Two In Stage Two, an Expert Panel of four representatives from midwifery workforce and resilience research reviewed the thematic analysis and a selection of illustrative data extracts, with the aim of enhancing data interpretation and refining the concept modelling. Expert Panel members commented on important characteristics of the findings, whether there was congruence between data and interpretation and how the findings related to other literature. The Expert Panel's comments generally confirmed the data interpretation. The findings were thought to corroborate those of other studies of workplace resilience and add to the empirical evidence. In addition, issues of particular interest and importance were noted, such as the themes relating to Self-Awareness and Building Resilience.

Please cite this article as: Hunter, B., Warren, L., Midwives' experiences of workplace resilience. Midwifery (2014), http://dx.doi.org/ 10.1016/j.midw.2014.03.010i

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Findings The first discussion thread: ‘How I cope’ had 233 views and a total of 33 replies. The second thread: ‘What do you think?’ relating to the vignette had 118 views and 26 replies. The number of posts per person varied from one to 10 with the majority contributing posts at least three times (n ¼8). These statistics, and the detailed nature of the posts, suggest the participants' keen interest; it was evident from the site data that participants often visited the virtual group to read the posts. Data analysis identified four overarching themes relating to the contextual, professional and personal factors involved in resilience. The first major theme Challenges to Resilience, related to experiences of workplace adversity. The other three major themes comprised the resilient responses to workplace challenges: Managing and Coping, Self-awareness and Building Resilience. Each major theme had several sub-themes. These themes are discussed in turn using verbatim extracts from the online discussion group data to illustrate. Challenges to Resilience Workplace adversity was a common experience. Participants identified numerous challenges that required resilience, categorised into the sub-themes: professional challenges, workplace conditions and concerns regarding quality of care. Professional challenges Participants frequently referred to professional stressors, which included perceived constraints on professional practice and occupational autonomy, at both micro and macro levels. At a micro level, individuals' clinical decision-making and approach to practice could be restricted by hospital policies and protocols. When these policies and protocols were perceived as privileging a risk-centred approach, participants felt their individual autonomy as midwives was compromised. Referring to balancing the needs of women and institution, one participant stated: Sometimes I feel as though I am involved in some sort of duel, so appropriate care is given (i.e. normalising pain in labour etc) (Midwife 3) At a macro level, participants referred to the challenges of hospital ‘politics’, characterised by bureaucratic management styles which controlled practice, hindered flexible working and undermined occupational autonomy: [Referring to the vignette] She works hard at being the best she can be – often in difficult circumstances – due to shortage of staff, increasing complex cases, more medicalisation and ‘hospital politics’…she will hate hospital politics and things that get in the way of doing a good job. (Midwife 1)

I was talking to 2 very newly qualified midwives and they both spoke about the high confidence levels they had being senior 3rd year students, only to lose it when qualified. (Midwife 8) Have recently been investigated and cleared of – what I would call every MW [midwives'] nightmare, it took 10 months. I was taken out of clinical practice but never went off sick once, I was cleared and am now back clinical – how? I don’t know. It nearly broke me but I would not let it. (Midwife 1) Workplace conditions The workplace created stressful situations over which midwives felt they had little or no control. Stressors were often intertwined and included: excessive workload, staff shortages, being unable to take breaks, excessive paperwork, and stressed colleagues. Several midwives described how high workload and low staffing levels meant that they often went without breaks, and finished late: Closing the unit one shift, nearly closing the next, having to go into work on days off to do supervision stuff and then another shift that nearly runs away from you (Midwife 1) Several described a managerial expectation that some administrative tasks (such as online training programmes) would be undertaken in personal time although, where possible, this was resisted: We often don't get meal breaks and stay late, so more unpaid work at home is a no-no! (Midwife 8) Quality of care Compromised quality of care was also a source of stress. This occurred when midwives felt that they had too little time to care, too few resources or when the managerial focus on administration and documentation took them away from providing womancentred care. Quality of care could also be affected by the increasing medicalisation of childbirth. Sometimes these situations were interlinked. Underpinning these concerns was a mismatch between professional ideals and the realities of everyday practice: [Referring to the vignette] I am sure that the aspects that she least enjoys are the paperwork/computerwork which sometimes midwives feel takes over and takes them away from giving the care that they want to give to women (Midwife 11) Managing and Coping This theme comprised the day-to-day resilient responses to workplace challenges. These were pragmatic and proactive strategies that participants described developing over the course of their careers. Five sub-themes were identified: gaining perspective, work–life balance, mood changers, social support and self-efficacy.

Some participants also alluded to a ‘bullying culture’: …a perceived ‘bullying’ culture does not make for a good working environment and is counter-productive, and how can we possibly give the women our best in these circumstances?!! (Midwife 4) Participants identified ‘critical moments’ in a midwife's career when these professional challenges were perceived as being could be most keenly felt and having most effect: being newly qualified, after an adverse incident or case with a poor outcome, and being ‘under investigation’ by their employer and/or regulatory body:

Gaining perspective Participants described how they used reflection to gain a sense of perspective on adverse situations. Following a difficult experience, some would use solitary reflection (for example, on the journey home or when walking the dog) whilst others chose to gain perspective by talking through with colleagues: What helps me is getting on the bus and the train after the shift and watching other people in their lives with their conversations and just emptying my brain or slowly pondering an event at work… One thing childbirth taught me personally is that no

Please cite this article as: Hunter, B., Warren, L., Midwives' experiences of workplace resilience. Midwifery (2014), http://dx.doi.org/ 10.1016/j.midw.2014.03.010i

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matter how horrible or hard it feels, it will end! I remember this during difficult days and it gives a bit of perspective by allowing me to step back for a few seconds and refocus. (Midwife 3) Mood changers It was notable that many participants described being able to ‘switch off’, leaving work problems at work and home concerns at home. ‘Switching off’ was facilitated by using mood changers, which varied from calming activities such as alcohol, music and warm baths, to the positive stimulation of exercise and outside interests. Interestingly, there was frequent mention of pets, in particular the benefits of dog walking! I have had a dog (well two) since 1985, when I had been qualified 2.5 years and I am now beginning to think that dogwalking is key, having read various other comments. There's not much a good dog-walk doesn't solve. (Midwife 10) These mood changers were described as being actively utilised to improve how participants felt. A distinction was made between positive and negative strategies. For example, small amounts of alcohol could act positively as a relaxant whereas excess alcohol was seen as negative and likely to exacerbate the sense of adversity: I find that whilst alcohol can help me unwind after a difficult day, drinking more than 2 or 3 units just makes me maudling! [sic – means maudlin i.e. over-emotional] (No 9) Social support Social support was frequently mentioned as important for resilience. Sources of social support varied: some participants found family and friends gave a sense of perspective on work problems, whilst others avoided taking work difficulties home: [I] need to de-brief for 2–3 minutes with my husband. Sometimes that happens as soon as I get home and sometimes after I've slept off night shift. He nods and quietly lets me blow off steam. (Midwife 5) I don't tend to take work problems home, as my partner tends to see things in black and white and we know things are not like that. (Midwife 8) Participants frequently described how trusted, like-minded colleagues provided a source of empathic, ‘safe’ support and personal affirmation. Such relationships were often described as mutually supportive and reciprocal: It is good to talk over a particular issue with one or two trusted colleagues – to establish one's position and next step or response and then stop. (Midwife 10) Work–life balance The importance of having a ‘work–life balance’ was frequently discussed. For some, this meant creating a clear separation between work and home lives by developing interests outside of work: I agree with the comment about having other interests – I am always busy out of work and this does help to detach yourself in your time off. (Midwife 11) Self-efficacy Participants had a sense of belief in their capabilities as midwives, feeling confident at work and in their ability to effect change. Although many aspects of work were outside their control, participants nevertheless demonstrated self-efficacy: they attempted to

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control what they could, based on realistic expectations of themselves and others. Some participants described how they thought they had become resilient by ‘finding a niche’ where they felt a strong sense of personal and professional ‘fit’. For others, the resilient response was to take control by making changes, for example by seeking out new midwifery roles or moving employment: A change is often better than a rest. Also I am not bored. It also builds resilience more directly as it is a challenge settling into a new place, learning the job, getting to know people, taking nothing for granted, finding the way around and how things are done. (Midwife 10) Self-awareness The third theme encompassed various elements of the self, with midwives highlighting the importance of ‘knowing yourself’, drawing on personal resources and core sense of self. Selfawareness was described as being partly developed over time, but also underpinned by existing personal attributes. Central to this theme was identity. Identity There were many examples of a strong sense of personal and professional identity, illustrated by participants' descriptions of their love of midwifery practice and feeling of belonging to a professional ‘family’. A sense of vocation was referred to, with midwifery commonly described as something someone is rather than what they do – that is, professional identity was integrated with personal identity. Many viewed their profession as being a core part of themselves: I feel midwifery has been my vocation and is part of a bigger say ‘karmic’ picture and that I am sustained in my midwifery by a spiritual impulse of some sort (can't really put it into words but I know it is there). (Midwife 10) A midwife is what I am. It's written through my body like a stick of rock. (Midwife 9) Underpinning this love of midwifery practice was a commitment to ‘making a difference’, at both an individual and wider societal level. The importance of public service and contributing to the greater good were common themes in the discussions. Work seemed to have a moral dimension for these midwives, which gave them a great sense of purpose and fulfilment: I love this job and feel genuinely sad that with looming retirement it is going to end soon (Midwife 8) These aspects of professional identity were particularly apparent in the discussions about the vignette. When discussing what ‘kept Liz going’, the participants' responses focused on making a difference and contributing to a ‘greater good’: She thinks she has a fantastic job – interesting, varied, worthwhile, reasonably well-paid, secure, stimulating, and often fun. It accords with her sense of purpose and her sense of the importance of public service. (Midwife 10) Autonomy A sense of being an autonomous individual appeared central to participants' perception of themselves as resilient midwives. Integral to this autonomy was the ability to exercise choice and control, in order to manage the challenges of practice: I love my work and do feel in control of what I do, there are very few shifts where I have felt as though I was not in control

Please cite this article as: Hunter, B., Warren, L., Midwives' experiences of workplace resilience. Midwifery (2014), http://dx.doi.org/ 10.1016/j.midw.2014.03.010i

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… I do think that if midwives feel that they have some control over their situation then they will feel better able to manage the stresses that inevitably occur (Midwife 4) Obligation to oneself Throughout the discussions participants described the importance of ‘obligation to oneself’. Self-protection was thought to be essential, achieved through awareness of personal capabilities and limitations, and by managing self-expectations and the expectations of others: No matter how busy or stressful it can be it is important to acknowledge that we are dealing with a 24/7 situation and others will pick up where I have left off ….Part of the price for aiming high and ‘giving your all’ while on duty is that occasionally you can't do the impossible, we must tell ourselves that it is the system that is failing, not us! (Midwife 4) Attributes Participants described a range of personal attributes which contributed to their resilience, including optimism, confidence, self-esteem, and a pragmatic, adaptable response to difficult situations: I have always believed myself to be very resilient with high levels of stamina and energy which have been with me throughout life… as I am naturally optimistic and find change a challenge to be welcomed and embraced. (Midwife 9) Whilst most referred to these as lifelong attributes, others described actively developing these characteristics (for example, finding ways to manage anxiety). Building Resilience The final theme was concerned with developing resilience in both self and others and focused on learning protective selfmanagement, and investing in colleagues. This theme is linked to the day-to-day strategies outlined in the Managing and Coping theme, but refers to a long-term investment in creating sustainable ways of being and interacting. The data suggested that those who feel themselves to be resilient may also be able to contribute to developing resilience in colleagues, with implications for building team resilience as well as wider professional and organisational resilience. These longer-term approaches to building resilience drew on the self-awareness described in the previous theme, but focused on how this might be fostered. Developing self-knowledge to make constructive use of anxiety and recognise personal limitations was seen as essential for resilience. Learning protective self-management Many of the participants described how they had learnt, and used, ‘protective self-management’. Underpinned by emotional awareness, this proactive approach included anticipating stress and recognising triggers and warning signs, in oneself and others, and taking steps to avoid challenging situations or hindering relationships: I stayed away from those who I knew would make me feel undermined or negative. (Midwife 9) Being able to leave work at work [i.e. leaving the stressors of the job in the workplace] is something that comes with experience-initially I brought my work home with me and over time learnt that you had to be able to separate work and home life or something would suffer. (Midwife 11)

Experience of considerable adversity (for example, personal experience of being ‘under investigation’) in which participants had coped and ‘come through’ was described as a key ingredient in building resilience: I never thought I would have coped but I did and bounce back I have, learnt resilience, how – I don't know if it was that or I just found an inner strength I never knew I had. (Midwife 1) Investing in colleagues There was consensus that accessing collegial support was beneficial for building and sustaining resilience. In particular, student and newly qualified midwives were identified by participants as potentially needing investment in the form of focused support and nurturing by experienced midwives: We must support and empower younger colleagues so that they will stay with us and not be frustrated by the realities of working in the NHS. … I think the simplest things can empower them and make them feel good about themselves, this will surely help them to become more resilient... (Midwife 4) I see it as my responsibility to avoid reducing their optimism, and to encourage them in their development. (Midwife 7) The quality of support was highly important. Support from trusted, empathic colleagues offered opportunities for reflection, including how to gain a sense of perspective on adversity. For some participants, Supervisors of Midwives were sources of support, though the need for this to be ‘non-threatening’ was emphasised. Role modelling by supportive colleagues was also identified as an important mechanism for learning resilient approaches. Interestingly, it was not just receiving support that was thought to be beneficial for building resilience. Providing emotional support was also described as an affirming experience, suggesting that there are particular benefits to be gained from mutuality and reciprocity: I wonder if being an ‘oldie’ and feeling that we have to look after the newer midwives takes away some of the personal stress? (Midwife 4) I love being a midwife and learned very early in my career to seek out like minded individuals and also other individuals who I knew would be supportive in certain situations. I also know that others use me for support and that mutuality helps build resilience. (Midwife 9)

Discussion This is the first study to focus specifically on resilience in midwifery. The findings indicate that the concept has salience for the profession and warrants further enquiry. It provides important insights into workplace resilience from the perspective of experienced clinical midwives. Participants identified personal, professional and contextual factors which contributed to or hindered resilience, and suggested how midwives' resilience might be enhanced. The participants' understanding of resilience broadly supported theoretical definitions (Neenan, 2009; Seery et al., 2010) of resilience as positive adaptation to adversity without significant residual disruption. The analytic themes identified are reminiscent of the resilience framework devised by Hart et al. (2007), which proposes four ‘noble truths’: accepting what is and who people are; conserving anything good that has gone before; commitment; and enlisting the help of others. Hart et al. (2007) suggest that

Please cite this article as: Hunter, B., Warren, L., Midwives' experiences of workplace resilience. Midwifery (2014), http://dx.doi.org/ 10.1016/j.midw.2014.03.010i

B. Hunter, L. Warren / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

these processes are underpinned by concepts relating to belonging (attachment), learning, coping and the core self, similar to our findings relating to building resilience, managing and coping, and self-awareness. The challenges presented by workplace adversity are well documented in midwifery and workplace resilience literature, and were thus an expected finding (Jackson et al., 2007; Warwick, 2011; McCann et al., 2013). Staff shortages, inflexible management, unsupportive organisational culture and dissonance between ideal practice and reality are frequently cited in studies of midwives' dissatisfaction and stress (Sandall, 1998; Hunter, 2004; Kirkham et al., 2006; Mollart et al., 2011). These negative experiences reflect Marmot's (2004) explanation of occupational stress as resulting from an imbalance between workplace demands and personal control, and between effort expended and rewards received. However, discussions did not remain focused on negative experiences; instead participants described proactive strategies for redressing this sense of imbalance. This is an important insight into how resilient responses may mitigate stress. Particular attention was given to critical moments in a midwife's working life when adversity might be experienced most strongly, and how resilience might be promoted at these times. The vulnerability of newly qualified midwives is described in other research (Hughes and Fraser, 2011; Fenwick et al., 2012), but the impact of experiencing an adverse incident or undergoing a professional investigation has only recently begun to be researched (Hood et al., 2010; Rice and Warland, 2013; Robertson and Thomson, 2013). Our findings suggest that for some, coming through such experiences enhances a sense of resilience: positive adaptation to adversity confers ‘stress inoculation’ (Lyons et al., 2009). Why some midwives positively adapt in such situations whilst others experience considerable personal trauma (Robertson and Thomson, 2013) is outside the remit of this study, but certainly worthy of further research. Resilient responses to acute workplace adversity focused on immediate coping strategies. Getting a sense of perspective via informal reflection, solitary or shared, was seen as essential. To facilitate this, coping mechanisms similar to those identified in other studies of occupational stress and resilience were drawn on: mood changers (Burnard et al., 2000), social support (Hodges et al., 2008; Adamson et al., 2012) and separation of home and work life (Jackson et al., 2007; Adamson et al., 2012; McCann et al., 2013). There was an emphasis on proactive use of these coping strategies, having them to hand rather than turning to them as a last resort. Often coping strategies had been incorporated into daily activities: solitary reflection while dog walking or on the journey home. Such proactivity reflects the participants' sense of self-efficacy: controlling what it is possible to control. Self-efficacy was an unexpected finding, not often reported in studies of resilience (although it has been identified as a variable by Gillespie et al (2009)). Self-awareness was seen as an essential resource for building resilience, developed over time. Self-awareness has much in common with emotional intelligence (Goleman, 1996), both of which have been identified as core attributes of exemplary midwives (Nicholls and Webb, 2006; Byrom and Downe, 2010; Hunter, 2010). It is therefore unsurprising to find self-awareness in accounts of midwifery resilience. However, there was an interesting emphasis on self-protection and self-obligation, which may be elements of self-awareness critical for resilience but seldom discussed. Underpinning self-protection was acceptance: having a balanced evaluation of one's potential, realistic self-expectations and being alert for the unrealistic expectations of others. Current thinking suggests that resilience is a combination of internal character traits and external learnt factors (Tugade and

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Fredrickson, 2004). This thinking was reflected in the discussions. While some participants referred to innate personal attributes such as confidence and optimism, others described ‘working’ on developing these qualities. It was generally agreed that resilience was something that could be enhanced, and that peers could play a key role in building the resilience of their colleagues. An unexpected finding was the significance of professional identity for developing resilience. A strong sense of collective identity and public service ran though the discussions, and there was consensus that a feeling of professional ‘belonging’ and ‘love of the job’ contributed to resilience. Adamson et al. (2012) made a similar observation in their study of resilient social workers. Interestingly, however, discussions of a ‘love of midwifery’ rarely mentioned service users, as might have been expected. It could be that interactions with women were not seen as contributing significantly to resilience, although this would conflict with evidence indicating that meaningful relationships with women are important for midwives' job satisfaction (Sandall, 1998; Hunter, 2006; Kirkham et al., 2006). Alternatively it may be a taken-for-granted element of work, which participants did not feel the need to make explicit. The role played by relationships with clients in the development of resilience is worth exploring further. The potential for building long-term resilience in oneself was frequently discussed by participants and reflects the wider literature (Neenan, 2009; Grafton et al., 2010). Participants described developing enduring resilient approaches, in which a key element was ‘protective self-management’. This drew on self-awareness to recognise stress triggers or warning signs and take active steps to minimise their impact. Recognising potential stressors and addressing them is discussed in the resilience literature on autonomy, control and self-care (Gillespie et al., 2009; Grafton et al., 2010; Adamson et al., 2012). However, our study gives no insights into how these protective self-management strategies might have been experienced by colleagues; for example, an individual's resilient strategies might be perceived as emotional withdrawal or evading responsibility. Further research could explore a range of workplace experiences to provide a more well-rounded view of the phenomenon. Participants did acknowledge the importance of peer support for promoting resilience, reflecting the evidence (Hodges et al., 2008; Jensen et al., 2008; Adamson et al., 2012). Providing nurturing relationships for vulnerable colleagues was identified as especially valuable. Participants described ‘facilitating empowerment’ in junior colleagues, promoting optimism via workplace mentorship and role modelling, in line with literature which advocates this approach (Hart et al., 2007; McDonald et al., 2011). The reciprocal benefits of peer support were also noted: not only was it beneficial for recipients but it was also thought to enhance resilience in the providers. Building self-resilience through supporting others appears to be a novel finding with implications for building mutual resilience within the profession.

Implications This study has implications for midwifery education, practice and research. The concept of resilience resonated with participants, suggesting resilience could be proactively fostered in the initial and continuing education of midwives, as well as informing approaches to midwifery supervision. Building resilience via education and supervision should pay attention to several factors identified in this study: the importance of developing selfawareness and protective self-care, valuing professional identify, and the critical moments in a midwife's career when additional support is needed. Workplace challenges, and how these may be

Please cite this article as: Hunter, B., Warren, L., Midwives' experiences of workplace resilience. Midwifery (2014), http://dx.doi.org/ 10.1016/j.midw.2014.03.010i

B. Hunter, L. Warren / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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approached in ways that are resilient and sustainable, need frank discussion rather than glossing over. Further research is warranted. A large scale study with a representative sample of midwives at different career stages and in different clinical roles and settings would provide a deeper insights into resilient practices and how they are experienced by all concerned, and could lead to the development of an intervention to support resilience promotion in midwifery.

Limitations The study has a number of strengths and limitations. The virtual approach to data collection had advantages over a conventional focus group discussion, as it enabled participants to contribute at a time and place convenient for them, and also to return to the discussion as often as they wished over the month of data collection. Group members commented on each other's posts, and minimal researcher involvement was needed. Analytic rigour was enhanced by cross checking of coding and the additional scrutiny of the Expert Group. Nevertheless, the findings should be interpreted with a degree of caution. They represent the experiences of a small self-selected sample of UK midwives with 15 years' clinical experience, all of whom were RCM members and had self-identified as being able to ‘bounce back’ after a difficult day at work. Very different data might have been generated by midwives with less clinical experience. It is also recognised that ‘bouncing back’ may not reflect everyone's experience of resilience, and the study publicity which referred to this may have deterred some potential participants. Importantly, no demographic data were obtained, which prevented additional insights into the possible influence of age, gender, role and work context.

Conclusion This small exploratory descriptive study provides some initial insights into how workplace resilience may be experienced within UK midwifery. Some findings echo those of other resilience studies, whereas other findings, such as the importance of professional identity, provide novel insights which may be relevant to other health care workers. The findings reflect those of studies which characterise resilient individuals as adaptable and selfaware (Jensen et al., 2008; Grafton et al., 2010; Jackson et al., 2011), rather than rigid thinking or hardened in attitude. It is clear that resilience is a complex phenomenon, with implications for education and support, and there is considerable scope for further research. Resilience has become a popular word in the contemporary lexicon, and we caution against uncritical adoption before more is known about its potential relevance for midwifery. It is important that resilient practitioners are not only effective self-carers, but also need compassion and empathy for clients and colleagues. Any resilience building initiatives need to be mindful of this, as well as ensuring that they give proper attention to organisational context as well as individual development.

Conflict of interest statement BH's post as RCM Professor of Midwifery at Cardiff University is partly funded by the Royal College of Midwives. This research study was funded by RCM.

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