Abstract This paper is concerned with the development of intelligent decision support methodologies for nurse rostering problems in large modern hospital environments. We present an approach which hybridises heuristic ordering with variable neighbourhood search. We show that the search can be extended and the solution quality can be significantly improved by the careful combination and repeated use of heuristic ordering, variable neighbourhood search and back-tracking. The amount of computational time that is allowed plays a significant role and we analyse and discuss this. The algorithms are evaluated against a commercial Genetic Algorithm on commercial data. We demonstrate that this methodology can significantly outperform the commercial algorithm. This paper is one of the few in the scientific nurse rostering literature which deal with commercial data and which compare against a commercially implemented algorithm.