Background <p>In light of labour shortages, complex care needs and tough working conditions, creating health-promoting working environments in nursing homes is a challenge. Participation is a core principle of health promotion, and is highly relevant for workplace health management. In this study we focused on how management can promote workplace health with and for their employees through participation and what opportunities and challenges are associated with such approaches.</p> Methods <p>For this qualitative cross-country study we conducted semi-structured interviews (<i>n</i> = 16) and focus groups (<i>n</i> = 11) with a total of 43 managers and staff working in different areas in nursing homes in Austria, the Netherlands and Sweden. The interviews were analysing using thematic coding.</p> Results <p>Analysis of the participants statements identified three central elements pertinent to promotion of employee participation and health in the investigated nursing homes. (1) A philosophy and core values of health- and participation-oriented cooperation between managers and staff. This is salient in (2) the orientation on employees’ personal and professional concerns, resources and problems – in particular by promoting skills and trustworthy handling of employees’ work situations, personal issues and sickness – and (3) in the orientation on discussions, empowerment and decision-making in teams mediated through promotion of cooperation and assumption of responsibility within and between teams and support for teams, including in challenging psycho-social situations.</p> Conclusions <p>Health- and participation-oriented leadership in nursing homes is an ongoing process that demands strong reflective abilities and organisational skills of those involved.</p>