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To illustrate the need for and suggest strategies that will enhance sustainable management of a large intensive care unit (ICU).The challenges faced by intensive care nursing in South Africa are well documented. However, there appear to be no strategies available to assist nurses to manage large ICUs or for ICU managers to deal with problems as they arise.Data sources to illustrate the need for strategies were challenges described by ICU managers in the management of large ICUs. A purposive sample of managers was included in individual interviews during compilation of evidence regarding the challenges experienced in the management of large ICUs. The challenges were presented at the Critical Care Society of Southern Africa Congress held on 28 August to 2 September 2012 in Sun City North-West province, South Africa.Five strategies are suggested for the challenges identified: divide the units into sections; develop a highly skilled and effective nursing workforce to ensure delivery of quality nursing care; create a culture to retain an effective ICU nursing team; manage assets; and determine the needs of ICU nurses.ICUs need measures to drive the desired strategies into actions to continuously improve the management of the unit. Future research should be aimed at investigating the effectiveness of the strategies identified.This research highlights issues relating to large ICUs and the strategies will assist ICU managers to deal with problems related to large unit sizes, shortage of trained ICU nurses, use of agency nurses, shortage of equipment and supplies and stressors in the ICU. The article will make a contribution to the body of nursing literature on management of ICUs.