Aim The present study provides insight into nurse manager cognitive decision-making amidst stress and work complexity. Background Little is known about nurse manager decision-making amidst stress and work complexity. Because nurse manager decisions have the potential to impact patient care quality and safety, understanding their decision-making processes is useful for designing supportive interventions. Methods This qualitative descriptive study interviewed 21 nurse managers from three hospitals to answer the research question: What decision-making processes do nurse managers utilize to address stressful situations in their nurse manager role? Face-to-face interviews incorporating components of the Critical Decision Method illuminated expert-novice practice differences. Content analysis identified one major theme and three sub-themes. Results The present study produced a cognitive model that guides nurse manager decision-making related to stressful situations. Experience in the role, organizational context and situation factors influenced nurse manager cognitive decision-making processes. Conclusions Study findings suggest that chronic exposure to stress and work complexity negatively affects nurse manager health and their decision-making processes potentially threatening individual, patient and organizational outcomes. Implications for Nursing Management Cognitive decision-making varies based on nurse manager experience and these differences have coaching and mentoring implications. This present study contributes a current understanding of nurse manager decision-making amidst stress and work complexity. © 2012 Blackwell Publishing Ltd.