Aims and objectives To identify and summarise factors and processes related to registered nurses’ patient care decision‐making in medical–surgical environments. A secondary goal of this literature review was to determine whether medical–surgical decision‐making literature included factors that appeared to be similar to concepts and factors in naturalistic decision making (NDM). Background Decision‐making in acute care nursing requires an evaluation of many complex factors. While decision‐making research in acute care nursing is prevalent, errors in decision‐making continue to lead to poor patient outcomes. Naturalistic decision making may provide a framework for further exploring decision‐making in acute care nursing practice. A better understanding of the literature is needed to guide future research to more effectively support acute care nurse decision‐making. Design PubMed and CINAHL databases were searched, and research meeting criteria was included. Data were identified from all included articles, and themes were developed based on these data. Results Key findings in this review include nursing experience and associated factors; organisation and unit culture influences on decision‐making; education; understanding patient status; situation awareness; and autonomy. Conclusions Acute care nurses employ a variety of decision‐making factors and processes and informally identify experienced nurses to be important resources for decision‐making. Incorporation of evidence into acute care nursing practice continues to be a struggle for acute care nurses. This review indicates that naturalistic decision making may be applicable to decision‐making nursing research. Relevance to clinical practice Experienced nurses bring a broad range of previous patient encounters to their practice influencing their intuitive, unconscious processes which facilitates decision‐making. Using naturalistic decision making as a conceptual framework to guide research may help with understanding how to better support less experienced nurses’ decision‐making for enhanced patient outcomes.