Dear Anne, 
I am excited to be reading a nursing Living Theory research account because yours is a rarity and has the opportunity to influence research methods in healthcare.  You are timely in focusing on technological methods of transmitting knowledge and learning in this age of social change and widening influences. From your description of the research process it is clear that you learned from reflecting-in-action and that you made adaptations as a result.    This is indeed an action research account and your learning and use of personal/professional values as standards of judgement show your commitment to using your practice values as a researcher.  I would love to work with you in responding to the Editorial board comments about '... developing a clearer sense of living values being enacted in practice...'  if you would like to develop the 'living' nature of your theorising and how you put it into practice for publication.

I read your paper and made comments as I read it as if I was having a conversation with you.  This is never the same as having a face to face conversation but I hope it shows my immediate responses, how ideas grew and themes emerged.  It is the themes emerging that I will respond to here.  But first, who am I to respond to your paper?  Where am I coming from as reader?

I am a UK health visitor who found living theory as a way of researching what I was actually doing in practice while I was doing it.  Because of the complications and split that would have been necessary if I was to research discrete aspects of my work, as 'add on' separately from my daily tasks, I was delighted to discover that researching and reflective practice could become one and the same.  This is why 'listening' and 'participatory approach' that you name as values speak to me. I called my version 'alongsideness'. The added extra that Living Theory gives that action research doesn't get near is the living, developing nature of uncovering and explaining uniquely personal knowledge you as practitioner (midwife manager, researcher) brings to the social context you work in.  Your research will speak to other midwives and managers in ways traditional research avoids and can give practitioners in your field hope they can explain what is really important to them in how they work effectively.  This is so important at this time when nurses feel stretched and constrained and unheard.

For your research to be a livng theory it needs to give the reader access to who is speaking.  I was not clear if you were a midwife until the end when you called yourself a midwife manager.  I needed to know that to begin to understand where your values were coming from. To build an understanding bigger than the words. I as a nurse began to form assumptions that I was reading words of another nurse.  My assumptions may not have been accurate but we all use our own current knowledge as a start in understanding another person.  Readers look to the text to tell us what unique perspective the writer holds and if we need to put our own perspective to one side to truly hear the other.  I believe this is what you are referring to in your value of 'listening' and 'participatory approach.' 

Is it possible to know more about you as practitioner and the social/practical context that leads you to value listening and a participatory approach.  I know developing Q-Pulse was your aim but there needs to be some lead in to explain why Q-pulse is a useful option for training midwives. I am not questioning it, but your reasoning seems important if colleague resitance is to be tackled because they don't know what you know about the usefulness of this technology.  I needed to wait to page 66 to see values of midwives mentions.
'My values have developed from the espoused midwifery values such as normality, woman-centered and partnership in care, respect, client-first, evidence-based care and advocacy (ABA, 2000). All of these values mentioned can only be lived by listening to and involving women in their care, hence my values of listening and participatory approach evolved'.

Moving your closing paragraphs to the start by way of introduction would be useful.  I can only guess, having practiced in health care during similar training evolution, that resistance might be grounded in practitioners' fear that their own values/ interpretation of ABA values may be dismissed as unimportant by on-line training? I wonder if you can set Q-pulse into the context of the  bigger picture of training so midwives can be reassured that the qualities of relationship and partnership they value so much can be acknowledged and developed either in this or in parallel training.   If I know midwives at all, I would suggest there is a strong healthy belief that they each have special complex knowledge of relationship, how to be with women and how to fine tune their midwifery skills for good outcomes for the person in front of them.  You are on to a winner if you can firmly embed the specific advantages of Q-pulse learning and wider technology into their bigger picture of the midwifery training that they already value.  If midwives could be invited into a Living Theory approach as part of their training they would feel heard and valued as practitioners.  Acknowledging their exisitng practice knowledge, including the relational aspects not currently accessible through written text ot technology, would present the bigger picture of midwifery training in which Q-pulse has a useful place.  I do hope this makes sense.

I really believe you do have a contribution to make here in bringing together the relational qualities you value and the knowledge created by all individual practitioners in the course of their work with training using on-line technology.   If you like these ideas you will find the comments i made on first reading attached here.

Regards

Robyn Pound

Re: How do I improve my practice of training midwives and nurses in the use of Q-Pulse?

Dear Anne,

            Although we share a valuing of living theory, I am reading and reviewing your article from quite a different context and perspective otherwise. I am an independent educational psychologist, retired teacher (secondary school and university), and active teacher-researcher, living in Canada. Currently, I mentor secondary and university level teachers in their professional development within a framework of action research, living theory, and narrative inquiry. I found living theory during my doctoral studies when I experienced myself as a living contradiction, claiming to love and value my students above all else, and discovering, on careful scrutiny of evidence gathered over many years of teaching, that I had put my students at risk when they left my self-contained special education classroom for mainstream education.

            I will begin this review by saying that I am enjoying reading and rereading your article very much. I sense your dedication to the profession and to the action research process. I believe that practitioners in the service of the public have a great deal of knowledge to offer to theorists and policy makers, and your report is evidence of that. I am grateful for this opportunity, and hope you find my comments useful and supportive.  Next, I will offer comments on context.. Finally, I will comment on the action research process as you have reported it.

Contextualizing the Research

            I began to read your article from a distance – I am neither a nurse, midwife, manager, nor have I any idea of what is means to be a health-care worker in a woman/infant facility in Ireland. An internet search explained Q-Pulse to me, and introduced me to the history of The Coombe, giving me a picture, and some feeling of connection. I imagine that, like teaching, the work in your hospital can be ill-defined, messy, tiring, yet very rewarding. I know that when faced with school reforms, particularly in the area of technology, there was reticence approaching rebellion on the part of many teachers, the cry being, “It takes more time than it saves!”

            While my search gave me a better idea of your context and practice, I feel that there is more to your story to be told that may benefit both your report and the reader. A more elaborate description of your (and your participants’) experience and context would bring all of us out here into a bigger picture. Connelly and Clandinin (1995) write “Humans are storytelling creatures who, individually and socially, lead storied lives and tell stories of those lives.” We engage with others, become participants in their stories, make meaning of experience, and learn. So, I find myself, asking, “Who is Anne, beyond her title of manager?” “Who are the participants (co-researchers?) in this endeavour?” “To whom does Anne listen, and what does she hear?” Who are the people who have earned her respect?” “In what, beyond this inquiry, do they participate?” I wonder, too, “Is gender an issue?”  Jack Whitehead and Jean McNiff (2006) ask, as action researchers, “What experiences can we describe to show why we are concerned?” and they answer with examples of stories of learning from experience, stories with a generative transformational capacity.

AR Methodology

            It is important to tell your story in a way that others might learn from your experience (Whitehaed and McNiff, 2001). In the abstract, you have referenced Jean McNiff’s (2010) action planner as guide for your action research, however the source is not included in your list of references, therefore, I have used the following points to guide my reading of your cycles and steps:

·       What is my concern?

·       Why am I concerned?

·       What kind of evidence can I generate to show the situation as it is and as it unfolds?

·       What can I do about it?

·       How will I ensure that any conclusions I come to are reasonably fair and justified?

·       How do I modify my ideas and my practice in light of my evaluation? (Whitehead 1989; McNiff and Whitehead 2006; Whitehead and McNiff 2006)

             I recognise your research as systematic, however, I do not see a clear design to for your study.  I wonder when, how and why the managers were brought in as participants. A data collection/analysis schedule might help the reader. An important question for me here is “How will I ensure that any conclusions I come to are reasonably fair and justified?” Your descriptive statistics might be tabled with a breakdown across questions, and groups of participants. The voices of those supporting your living standards of judgement are clear and encouraging, and additional verbatim data chunks would further support your claim. How was your validation group formed? What might others have had to say? Their voices combined with yours would serve as a linguistic description of embodied values, and put a human face on the work that you are doing together. Other questions came to mind. Your values of openness and a participatory approach, of respect and listening are claimed in your report. Would you say this work is democratic? Are you doing research with the managers, nurses and midwives, or on them, or for them?

             Anne, I hear a strong commitment to solving a problem, a commitment to the learning of nurses and midwives thus contributing to quality caregiving in your hospital, and to a living theory approach. I have asked lots of questions (my nature) and hope that these are of use to you.

Looking forward to the conversation,

Judy

Thanks Robyn, Máirín and Judith for you valuable comments.

I have made the necessary amendments in my paper.

Attaching same.

Kind Regards

Anne