An increasing number of nursing home quality improvement efforts are aimed at reducing avoidable hospitalizations of residents. The current study focused on the experiences of nursing home nurses as ‘boundary-spanners’ in the implementation of initiatives aimed at this effort. In-depth, semi-structured interviews were conducted with 76 nursing staff members within 38 nursing homes. Data were analyzed using thematic analysis and an inductive category development approach. Nursing staff described multiple scenarios where they had acted to negotiate the hospitalization decision and described themselves as working both within the nursing home boundary and within the larger system of external stakeholders to avoid a hospital transfer. There is potential for role overload and strain, as nurses are required to provide for complex medical needs within facilities designed to encourage relationship-driven, home-like care. Future efforts to reduce avoidable hospitalizations may benefit by ensuring needed resources are in place to provide clinically complex care and by making efforts to reduce the challenges that emerge when nurses are in the position to span the boundary between the nursing home and outside stakeholders.