Decision making is a fundamental element of nursing work, one that is essential to understand as organizations explore cost effective ways to deliver quality health care. While the importance of decision making has been well articulated, previous descriptions of nursing work have had difficulty describing completely this cognitive component. This paper identifies critical elements within the process of nursing decision making that have not been addressed adequately within current decision making frameworks. In this exploratory research, nursing personnel described their work; qualitative content analysis was used to categorize components of nursing decision making within these descriptions. Revealed are complex nursing decisions that occur after the selection of nursing intervention, and prior to the implementation of that intervention. These decisions address the complex network of interactions involved with enactment of the nursing role, the repertoire of leadership skills such as collaboration, negotiation, and delegation required to elicit the involvement of other individuals; discretionary decisions made in the allocation of resources; priority setting; and strategizing. These findings have implications for nursing competency and quality of care, cost-effective delivery of health care, and nursing education.