Aim This article reports the results of a study that gives an insight into ward leaders' perspectives of their leadership role and explores how they deliver leadership at ward level within organisational constraints and processes. Previous studies have been evaluations of clinical leadership in general, or literature reviews of the ward leader role. The aim of this study was to examine the leadership role of ward sisters and to understand how they lead improvements in quality of care on their wards. Methods A qualitative methodology was used, incorporating 19 in-depth interviews with ward leaders and modern matrons. Results Three main themes were identified: empty conformity, authority and autonomy, and visibility and leading by example. Participants aimed to be role models in leading and maintaining standards of care for patients, but this was sometimes constrained by organisational processes, lack of authority and autonomy, and lack of support and preparation. Conclusion Perceived differences between nursing and health service management mean that ward leaders' efforts to lead improvements in quality care are often undermined. Ward leaders must strike a balance between leading high-quality nursing care, in the context of organisational and political performance requirements, and the demands of administrative work, while often lacking autonomy and authority.