Purpose - The purpose of this study was to identify and critically discuss how healthcare middle managers’ (HMMs) development of the capacity and capability for leadership are experienced to influence quality improvement (QI) in nursing homes.Design/methodology/approach - This study had a critical hermeneutic perspective with data gathered using focus groups, one individual interview and participative observations. Analysis was guided by a qualitative interpretive approach.Findings - The results show how HMMs’ development of the capacity and capability for leadership are experienced to influence QI in nursing homes through grasping complexity in a conflicting practice. This involves continuous knowledge development and compensating contrasted by resource shortages, role conflicts, and the lack of trust and cooperation.Originality/value - HMMs have a key role in implementing QIs in healthcare. There are few studies on how HMMs develop the capacity and capability for leadership and it is unclear how clinical contexts are influenced by HMMs’ development. This study provides new knowledge supporting a change facilitating HMMs’ developmental processes targeting practical influence; it emphasizes continuity, coherence, presence, and trust.