Background: Pro-social rule breaking (PSRB) is when an employee chooses to break an organization's rules in order to meet organizational goals, or to help others. It is relatively new area of study; there are no studies conducted on public health administration. This exploratory study examines why and how mid-level public health practitioners make decisions to engage in, and what and how organizations can learn from this practice. Methods: This qualitative study used a purposive sampling strategy to recruit 12 participants from among state directors and managers of programs funded by CDC's Division of Cancer Prevention and Control. Data was collected through semi-structured interviews conducted from March to May 2013. Results: Participants averaged 16 years of experience and worked under an average of five sets of rules. Seventy-five percent worked on more than one program. Over 80% participants reported engaging in PSRB. Instances of PSRB were mostly likely to be in response to state and organizational level rules. Key themes include: participants believe they are breaking the rules to meet programmatic goals and help the public; the need to meet multiple sets of expectations causes high levels of frustration; participants generally see positive outcomes from PSRB; they sometimes break the rules because they cannot figure out any other way to get their work done and meet goals; and making the rules clearer and more flexible will make them easier and more likely to be followed. Participants suggested examining the unintended costs of rules; relationship-building across offices, and establishing productive dialogue as ways of reducing the incidence of PSRB and improve organizational functioning. Conclusions: PRSB appears to be a positive way of responding to difficult and sometimes absurd situations. Participants displayed good leadership and management skills in response to organizational barriers. The organizational climate--rules, flexibility, degree of centralization, levels of approval--acts as mediator for participants' decisions to engage in PRSB, and changes to the organization climate may decrease PSRB and improve functioning and results.