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The role of nurses in leading the design and delivery of primary health care services to address health inequities is growing in prominence, specifically in rural Australia. However, limited evidence exists to inform nurse‐led primary health care in this context. Based on a focus group with nursing executives and semi‐structured interviews with registered nurses we describe nurse experiences of leading the design of a primary health care service in rural Australia and nurse transition to and practice in this service. Nurse experiences were analysed using reflexive thematic analysis. The study reveals the centrality of relational integration in service design and nurse acquisition of relational practice as it relates to nurse to care recipient and nurse to nurse relationships. Tensions between primary health care nurses and their peers, and resultant de‐valuing of primary health care practice, are described. The acquisition of nurse professional agency draws attention to investments required to position nurses to lead and sustain care innovations external to hospital settings. The authors propose that relational approaches may provide nurses with the opportunity to reframe their leadership and service contributions towards community literate primary health care provision and provide a pathway to professional emancipation from constrained practice expectations. [ABSTRACT FROM AUTHOR]