CONTEXT The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence.METHODS This paper outlines four major research paradigms and examines the methodological questions that underpin the development of knowledge through medical education research.DISCUSSION This paper explores the rationale behind different research designs, and shows how the underlying research philosophy of a study can directly influence what is captured and reported. It also explores the interpretivist perspective in some depth to show how less familiar paradigm perspectives can provide useful insights to the complex questions generated by modern healthcare practice.CONCLUSIONS This paper concludes that the quality of research is defined by the integrity and transparency of the research philosophy and methods, rather than the superiority of any one paradigm. By demonstrating that different methodological approaches deliberately include and exclude different types of data, this paper highlights how competing knowledge philosophies have practical implications for the findings of a study.

These findings demonstrate that teams share their knowledge because they believe it has value, not because they are driven by external incentives or are monitored. This challenges the prevailing assumption that, to be effective, interprofessional learning should be externally managed. As health care develops, it will become increasingly important to consider how to support the internal learning processes of care teams as they navigate complex organisational changes and the shared learning experiences that characterise those changes. Those who support learning and development within the NHS should therefore focus on how relational processes, as well as educational content, contribute to a team's collective learning capability and the quality of care its members provide.

Core contextual conditions are identified as, first, the requirement for strong and visionary leadership. Leaders who support and develop others, ask challenging questions, are willing to be learners themselves, see possibilities and make things happen, facilitate learning environments. The second core condition is the involvement and empowerment of staff where changes grow from the willing participation of all concerned. The third prerequisite is the setting-aside of times and places for learning and reflection. This paper contributes to the wider quality improvement debate in three main ways. First, by highlighting the local contextual issues that are most likely to impact on the success or failure of a Practice's attempts to work towards a learning culture. Second, by demonstrating that the very same factors can either help or hinder depending on how they are manifest and played out in context. Third, it adds to the evidence available to support the case for LOs in health care settings.

Characteristics of LPs include flatter team-based structures that prioritize learning and empowered change, involve staff and are open to suggestions and innovation. Potential benefits include: timely changes in service provision that are realistic, acceptable, sustainable, and owned at practitioner level; smoother interprofessional working; and fast flowing informal communication backed up by records of key decisions to facilitate permanent learning. Critical comment on potential pitfalls and practical difficulties highlights features of the present system that hinder development: tightly defined roles; political behaviours and individual-oriented support systems; plus the ongoing difficulties involved in tolerating errors (whilst people learn). This paper contributes to the wider quality improvement debate in the area in three main ways. First, by locating Government's desires to create health systems capable of learning within the theoretical and empirical evidence on LOs. Second, it suggests what an LP could be like and how its culture and structures might benefit both staff and patients in addition to meeting externally driven reforms and health priorities. Third, it extends the application of LO concepts to the health care sector locating the principles in bottom-up change.

Steps taken to enhance both individual and organizational learning begin the process of moving towards a learning culture. Attention is given to the routines that can be established within the practice to make learning systematically an integral part of what the practice does. This involves focusing on all three of single-, double- and triple-loop learning. Within the paper, a distinction is made between individual, collective and organizational learning. We argue that individual and collective learning may be easier to achieve than organizational learning as processes and systems already exist within the Health Service to facilitate personal learning and development with some opportunities for collective and integrated learning and working. However, although organizational learning needs to spread beyond the LP to the wider Health Service to inform future training courses, policy and decision-making, there currently seem to be few processes by which this might be achieved. This paper contributes to the wider quality improvement debate in three main ways. First, by reviewing existing theoretical and empirical material on LOs in health care settings it provides both an informed vision and a set of practical guidelines on the ways in which a Practice could start to effect its own regime of learning, innovation and change. Second, it highlights the paucity of opportunities individual general practitioner practices have to share their learning more widely. Thirdly, it adds to the evidence base on how to apply LO theory and activate learning cultures in health care settings.