Abstract
BACKGROUND: First-line managers in healthcare operate in increasingly complex environments marked by high demands, rapid change, and limited resources. These conditions impact their health, leadership capacity, and the sustainability of their roles. While previous research has addressed various aspects of leadership in healthcare, there is a lack of studies focusing specifically on how first-line managers perceive the conditions for sustainable leadership in a changing and resource-demanding organizational context. The aim of this study was to explore the conditions for sustainable leadership among first-line managers in healthcare settings. METHOD: Using an exploratory qualitative design with an inductive approach, individual interviews were conducted with 25 first-line managers from diverse healthcare areas in southern Sweden between February and July 2024. Three main themes, and nine sub-themes related to sustainable leadership emerged from the qualitative content analysis. RESULTS: Providing resilient organizational structures was characterised by support functions that met operational requirements, adequate resource allocation, and coordinated work routines, enabling managers to carry out leadership tasks over time. Fostering supportive collaborations comprised supervisory and peer support, opportunities for collegial exchange, and access to administrative assistance. These forms of support affected how managers handled their responsibilities and responded to organizational change. Cultivating leadership for innovation included linking leadership tasks to a clear purpose, managing changing expectations, and balancing operational duties with broader development goals. CONCLUSION: Sustainable leadership among first-line managers depends on the alignment of structural, social, and individual conditions. The findings indicate that resilient organizational systems, accessible support networks, and possibilities to integrate purpose with daily leadership are crucial for maintaining leadership capacity over time. These insights can guide organizational strategies aimed at strengthening managers’ prerequisites for sustainable leadership in complex healthcare settings. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-026-14412-6.