Aim  To gain a deeper understanding of how Swedish head school nurses perceive their leadership in developing school health care. Background  A well-functioning school health care is important for promoting the health of children and young people. Method  Constructivist-grounded theory was used to analyse 11 individual interviews with nine head school nurses. Results  Head school nurses strive to find a balance between what they experience as vague formal goals and strong informal goals which leads to creating local goals in order to develop school health care. Conclusion  The head school nurse’s job is experienced as a divided and pioneering job in which there is uncertainty about the leadership role. They provide individual support to school nurses, are the link between school nurses and decision makers and highlight the importance of school nurses’ work to organizational leaders. Implications for nursing management  This study shows that school health care needs to be founded on evidence-based methods. Therefore, a structured plan for education and training in school health care management, based on research and in cooperation with the academic world, would develop the head school nurses’ profession, strengthen the position of school health care and advance the school nurses’ work.