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Mothers with a dual diagnosis (mental ill health and substance use) have delays in accessing services, or their care may be interrupted prior to therapeutic relationships being formed. The purpose of this paper is to explore and describe how engagement merges in the context of mothers with a dual diagnosis.

This is a qualitative, focused ethnographic study at a low-threshold service for substance abusing families. The data contain interviews, observations, field notes, and reflections. The analysis followed several systematic steps.

Engagement is the co-creation of possibilities between workplace staff and the client in different interfaces. It is not a single act, emotion, or verbal communication, but a complex intertwined system of events that can awaken or enable the client to get a grasp on life. The sensitivity of the worker is one tool for engaging the client in manifold ways in different interfaces: even the smallest events with connection are viewed as valuable. Engagement involves the intentional client in the process of interaction: the client needs to participate and become an acting and sensing part of the change, which occurs on an experiential level. The process is described with the metaphor of a seed.

Engagement as inner involvement challenges the current working methods, and requires sensitivity, because the mothers with a dual diagnosis may not have verbalisable goals when arriving to the services.

The purpose of this paper is to characterize issues related to head nurses’ decision making when managing ethical dilemmas.

The study is qualitative descriptive, in which researchers stay close to the data. The data were collected in the format of unstructured written reflections. Inductive conventional latent qualitative content analysis was applied to the data.

The issues of head nurses’ management of decision making in ethical dilemmas relate to the following aspects: taking risks in deviating from the formalities, balancing power and humaneness, maintaining the professional hierarchy, managing resistance to change, managing with limited options, and experiencing the decline of nurse’s professional and/or human dignity.

Reflections in written form were preferred to semi-structured interviews and the researchers were unable to contact the participants directly and to ask additional questions. All the reflections were produced in a language other than English.

The issues of head nurses’ management of decision making in ethical dilemmas reveal the gap between societal expectations and the opportunities to improve nursing leadership in health care organizations.

The issues of head nurses’ decision making when managing ethical dilemmas are related to contexts that reflect the attitudes of society and health care system toward nursing management.

The study adds to the understanding of issues of the management of decision making in ethical dilemmas. It is an ongoing systematic process that encourages head nurses to learn from practice and manage the quality of care by empowering themselves and nurses to take responsibility for leadership.