This paper provides empirical evidence that challenges the view that methods of clinical assessment and decision making should not rely solely on logical positivist approaches. Whilst the National Health Service (NHS) Executive currently takes a hard positivist line on what constitutes evidence-based practice, data reveal that it is not always appropriate to disregard the tacit knowledge and intuition of experienced practitioners when making assessment decisions in mental health nursing practice. Data support the case for a holistic approach which may draw on intuition and tacit knowledge, as well as traditional approaches, to meet the requirements of clients with complex mental health problems. A model based on Schon's notion of reflection in and reflection on practice is proposed which demonstrates the value of intuition and tacit knowledge. This model allows the generation of insights which may ultimately be demonstrated to be acceptable and empirically testable. It is accepted that an element of risk taking is inevitable, but the inclusion of a formal analytical process into the model reduces the likelihood of inappropriate care interventions. The cognitive processes which experienced nurses use to make clinical decisions and their implications for practice will be explored.

There is emerging evidence that crisis resolution services can provide alternatives to hospital admission, reducing demand on inpatient beds. Following a public consultation exercise in Lancashire (England), a team of nurses undertook a study, using interactive research methodology, to gain an understanding of how users and carers define a crisis and what range of crisis services, resources and interventions service users and carers thought would help avoid unnecessary hospital admission. Data collection comprised postal questionnaires and 24 group meetings with service users and carers, which were held during 2006. Data were analysed, and seven themes were identified: (1) definitions of a crisis; (2) access to services; (3) interventions; (4) range of services required (before, during and after crisis); (5) place of treatment; (6) recovery and rehabilitation; and (7) community support. We conclude that expressed preferences of service users and carers for pre-emptive services that are delivered flexibly will present a challenge for service commissioners and providers, particularly where stringent access criteria are used. Home-based pre-emptive services that reduce the need for unnecessary hospital treatment may avoid progression to social exclusion of service users.

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In recent years, efforts to combat stigma and discrimination experienced by mental health service users have ranged from small local initiatives to national and international campaigns. Success has been mixed, with significant, lasting benefits appearing to be elusive. This paper explores the current nature and extent of stigma and discrimination in an area of the north of England and compares findings with those from a study undertaken a decade previously in 1997. Qualitative responses to a postal questionnaire received in 2007 were thematically analysed and compared and contrasted with findings from the 1997 study. Four broad categories of discrimination--(1) employment; (2) professional; (3) communities; and (4) family and friends--arose from the 2007 data, the most common being discrimination in employment. There were close similarities in both sets of data. Stigma and discrimination remain largely as strong, damaging and enduring as they were a decade ago. A range of pre-emptive interventions that support people prior to the escalation of mental health crises could limit the impact of stigma.

As the case study approach gains popularity in nursing research, questions arise with regard to what it exactly is, and where it appears to fit paradigmatically. Is it a method, a design, are such distinctions important? Colin Jones and Christina Lyons review some of the key issues, with specific emphasis on the use of case study within an interpretevist philosophy.