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We know more about the operational coordination carried out by head nurses (HNs) than we do about their abilities to change work organization and care practices. In this article, we explore organizational projects led by HNs. Depending on the situations, they may involve their health care team, the institutional hierarchy, or other teams. We build upon an intervention study, which enabled us to follow seventeen organizational projects led by HNs for one year. The results of this study highlight the HNs’ efforts to enable mutual understanding with other interested actors as the main condition for success. HNs who involve their health care team in the development of solutions achieve sustainable results. When problems involve the hierarchy, HNs focus on the development of personal relationships. When problems involve other departments, which they depend on, then they engage themselves in integrative negotiations. These results suggest the need to launch a discussion about work organization and to formalize organizational projects. This intervention study also highlights the relevance of operational audit training for HNs.