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.

CONTEXT Health care organisations are increasingly conceptualised as complex, indivisible entities made up of web-like networks of staff that connect to each other in changeable ways. This study draws on the theoretical framework of activity theory and the concept of knotworking to illustrate how health professionals improvise collaboratively to negotiate everyday challenges and contribute positively to patients' health priorities.OBJECTIVES The aim of this paper is to contribute to evolving ideas about collective learning, change and improvement in secondary care by exploring how health professionals work and learn together and how this compares with earlier findings from primary care.METHODS This study applied a constructionist methodology within the research paradigm of interpretivism. Qualitative data were gathered through 26 hours of observations and 17 field interviews within the natural environment of a working hospital over a 3-month period. The research site encompassed a medical receiving ward, a chronic ward, an outpatient clinic and the connecting corridors. Staff participants included a range of clinical, nursing, ancillary and clerical staff. RESULTSThe study found a recurring pattern of spontaneous team forming and interprofessional shared learning to respond to care needs within the hospital as they arise. These are presented in four analytical themes: motion, flux and the unpredictability of 'team spirit'; adaptive, responsive learning through seeing, doing and asking questions; the collective learning gap between doctors and other staff; and frustration, compassion and the desire for improvement.CONCLUSIONS Health care professionals in the hospital setting both create and experience complex inclusion and exclusion behaviours that define who is empowered to act with professional authority in any given moment of care. This paper discusses issues of power, the particular exclusion of doctors from interprofessional knotworking, and the greater emphasis on questions as the pivotal aspect of shared collective learning when compared with primary care.

This article reports the first stage of a national programme instigated by the Healthcare Chaplaincy Training and Development Unit of NHS Education for Scotland and supported by the Scottish Government. In the first stage Chaplains were invited to join an action research project with the purpose of designing listening services in GP surgeries. Some of the chaplains were already offering listening services. Chaplains and researchers worked together to co – create and design a spiritual listening intervention based on prior experience and research evidence which was then introduced into four Health Boards in Scotland. Qualitative data about the intervention was then gathered by the researchers from chaplains, patients and referrers, usually GPs. This data shows that the intervention, in its first incarnation, was well received. The findings are reported and the next two phases outlined.

This trial of the learning practice programme shows that, with facilitation and the appropriate input of resources, general practice teams can successfully apply learning organization principles to produce quality improvement outcomes. The study also demonstrates the value of action research in researching iterative change over time.