Objective To explore the experiences of nursing managers in implementing hierarchical and graded management within hemodialysis specialty. Methods A descriptive qualitative research design was adopted. Semi-structured interviews were conducted with 16 clinical nursing managers. The data were analyzed and summarized using Braun and Clarke′s thematic analysis method.Results Four main themes and twelve sub-themes were identified:core values and clinical necessity (precise resource allocation and efficiency improvement, assurance of patient safety and treatment quality, and promotion of nursing specialization and stan-dardization); implementation barriers and systemic contradictions (lack of assessment tools and institutional frameworks, contradictions between clinical feasibility and operability, and disconnection of actions following grading along with increased burden);key supportive conditions for successful implementation (development of multi-dimensional assessment tools, recognition and support at the institutional and policy levels, and formation of systematic training and team consensus); practical suggestions for optimizing implementation pathways (step-by-step implementation with priority for high-risk cases, establishment of dynamic assessment and feedback adjustment mechanisms, and systematic guarantee mechanisms). Conclusion The implementation of hierarchical and graded management is a pivotal strategy for achieving the precise allocation of hemodialysis nursing resources and enhancing safety and quality. The factors influencing this implementation are multifaceted and interconnected. To effectively advance this model, it is essential to systematically address core obstacles, including the lack of standardized assessment tools, challenges in human resource allocation, and insufficient institutional support. Overcoming these barriers will provide a robust guarantee for the delivery of high-quality hemodialysis nursing services.