Our study uses qualitative and interpretative design to analyse what hybrid nurse middle managers do in their managerial practice, what affects this, and to what effect, focusing upon implementing policy-driven guidelines on the clinical frontline. Examining two comparative hospital cases and drawing upon Scandinavian institutionalism, we conceive their role as one of ‘translation’. On the one hand, they exhibit strategic agency. On the other hand, their managerial role not only influences, but is influenced by, professional and managerial hierarchies. In both hospitals, in the short term we see how hybrid nurse middle managers are able to mediate professional and managerial hierarchies and implement clinical guidelines through translational work. However, in one case, they less effectively accommodate policy-driven, managerial pressure towards compliance with government regulations and financial parsimony. In this case, the outcome of their translational work is not sustained in the longer term, as professional and managerial hierarchies reassert themselves. Drawing upon the example of their managerial role in healthcare, we highlight that hybrid middle managers enact a strategic translational role and outline situational constraints that impact this more strategic role.