Document Type




Publication Date



Decker School of Nursing, Binghamton University

Source Publication

Online Journal of Rural Nursing and Health Care

Source ISSN


Original Item ID

doi: 10.14574/ojrnhc.v14i2.328



The United States has about 2100 rural hospitals. Approximately 1300 are Critical Access Hospitals (CAHs) with 25 beds or less. CAHs receive cost-based reimbursement through the federal Flex program with the goal to improve quality and access to health care. Reports on quality of care (QOC) and factors that influence quality in CAHs are mixed. This study compared QOC and factors that influence QOC in CAHs and other rural hospitals.

Sample: 385 staff nurses in 6 CAHs and 9 other rural hospitals in North Carolina and Virginia.


Descriptive cross-sectional design using nurse surveys aggregated to the hospital level, data from provider of services file, and the United States Department of Agriculture, Economic Research files. Variables on community, hospital, and nursing unit characteristics, the nurse work environment, nurse rated QOC and community perception of hospital quality were compared using t-test or chi-square.

Findings: There were no differences in the majority of factors influencing QOC. A culture of safety, the nurse work environment, and QOC were rated high in all hospitals. Compared to other rural hospitals CAHs tend to be located in communities with better economic status and their nurses had more years of nursing experience. More nurses in CAHs felt their community recognized their hospital as a good place for minor health issues and would recommend the hospital to family and friends.


The high ratings of QOC were accompanied with the presence of safety cultures and work environments rated as highly as in Magnet hospitals. The lower poverty levels in communities with CAHs suggest possible community financial benefits from CAHs. More studies are warranted to explore these relationships. Further reporting to public quality indicator databases by all CAHs should be encouraged and QOC measures relevant for small rural hospitals should be developed.


Published version. Online Journal of Rural Nursing and Health Care, Vol. 14, No. 2 (2014). DOI. © 2014 Rural Nurse Organization and Decker School of Nursing, Binghamton University. Used with permission.

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