What the Research Says About Leading a Critical Access Hospital, and Why the Loneliest Job in Healthcare Deserves Better Support

If you run a critical access hospital, you already know the financial numbers. The Chartis Center for Rural Health reported in 2025 that 46% of rural hospitals were operating with a negative margin and 432 were vulnerable to closure. Their 2026 update showed modest improvement, with 41.2% still in the red and 417 facilities in danger of closing. You have likely quoted figures like these to your own board.

What gets far less attention is the research on you.

In 2024, the Journal of Rural Health published one of the only studies to examine the well- being of rural healthcare executives directly. Sullivan and colleagues surveyed 288 rural health leaders and found that 40.2% reported burnout and 49.8% intended to leave their role within two years. Read that second number again. Half of the people holding rural healthcare together are planning their exit.

That study deserves to be better known, because it puts evidence behind something rural administrators have described for years: the hospital’s financial distress and the leader’s personal distress are the same story. This article looks at what the research actually says about the second one, and what a realistic path forward looks like for a leader with no slack in the budget and no time to leave the building.

The job the data describes

The Sullivan study grouped executive stressors into three categories: industry pressures such as reimbursement and regulation, daily operational strain, and relational demands from boards, providers, and community. One participant summarized the operational reality in a line that has circulated widely since: “We don’t get to be innovative for fun, it’s out of survival.”

The operational strain has a specific shape in a small hospital. Researchers and practitioners consistently describe rural executives wearing multiple roles at once. The CEO is often also the compliance officer, the HR department, and the grant writer. Titles like “CEO and CFO” held by one person are common in facilities under 25 beds. Erin Sullivan of Suffolk University, the study’s lead author, has noted that when everyone holds several jobs, a single departure can stop multiple functions at once. Leaders in the study reported

skipping vacations for years because there was no one to cover.

The relational strain is just as well documented, and it is unique to small communities. The Michigan Health & Hospital Association put it plainly: in a small town, there is nowhere to hide when the hospital struggles. Your employees are your neighbors. Your patients sit behind you at church. A systematic review by Mills and colleagues, also published in the Journal of Rural Health in 2024, found that per capita income in a community drops between 2.7% and 4% after a rural hospital closes. Administrators carry that number personally. Montana and North Dakota CEOs have said on the record that they lose sleep over aging buildings and fear being remembered as the leader who let the hospital fail.

Then there is the isolation, which may be the least discussed factor and the most consequential. A critical access hospital has no second executive team down the hall. The nearest peer may be a two-hour drive away. The rural health field has responded by building peer networks and mastermind groups specifically designed, in the words of their organizers, to bridge the isolation gap. That infrastructure exists because the problem is real and widespread. You cannot process doubt with a board that needs your confidence, a staff that needs your steadiness, or a community that is watching everything you do.

Why leadership development rarely happens here

Given all of this, you might expect leadership support to be a priority in rural healthcare. The research shows the opposite, and the reasons are practical rather than cultural.

The first is turnover itself. The UND Center for Rural Health cites rural hospital CEO turnover at roughly 18 to 20% annually, reaching 30% in some states, and notes that data on the topic remains thin. Boards facing that churn spend their energy on recruitment rather than development, which perpetuates the cycle. When succession does happen, it frequently happens from within and without preparation. An Idaho CNO described becoming a leader much sooner than planned. Some version of that sentence appears in nearly every published interview with a rural health leader.

The second is program design. The Rural Health Information Hub documents that rural healthcare workers are often unable to leave their facility for training because of travel distance, staffing coverage, family commitments, and cost. Most leadership programs were built for urban health systems with deep benches and assume the participant can disappear for three days. A CAH administrator cannot. Rural leaders also report that urban-designed content simply does not fit. A saying repeated across the field captures it: if you’ve seen one critical access hospital, you’ve seen one critical access hospital.

The third is money, and here the picture is changing. Several state Flex programs already reimburse leadership certification costs for CAH executives and nursing leaders. North Dakota’s Flex program, for example, has covered portions of national CFO certification

tuition since 2022. More significantly, the Bipartisan Policy Center reports that all 50 states have proposed using Rural Health Transformation Program funds, the new $50 billion federal investment, for workforce development. The dollars for developing rural leaders exist in more places than most administrators realize. The constraint is knowing where to look and how to frame the request.

What a realistic path looks like

The evidence points to three design requirements for leadership support that actually works in a rural setting.

It has to come to you. Virtual and hybrid delivery removes the travel and coverage barrier that the research identifies as the single largest obstacle. One-on-one executive coaching by video requires no backfill and no windshield time.

It has to reflect your reality. Content built for a 400-bed system will miss you. Development for a CAH leader has to account for role-stacking, thin teams, board relationships in small communities, and the specific weight of being the town’s largest employer.

It has to address the isolation directly. Cohort models and confidential coaching give leaders the one thing their position structurally denies them: a place to think out loud without an audience. The retention math supports the investment. The 2025 NSI National Health Care Retention Report puts the average cost of replacing a single staff RN at $61,110. Replacing an executive costs more, takes longer, and in a small facility destabilizes everything underneath.

I have spent more than twenty years in healthcare workforce and leadership development, much of it in Montana, and the pattern I have seen matches the research: the leaders most likely to stay are the ones who stopped carrying the job alone. The data now says the same thing. Half of your peers are planning to leave. Support that fits rural reality is one of the few levers that changes that number, for your hospital and for you.

References

Chartis Center for Rural Health. (2025, 2026). Rural Health State of the State annual reports.

Sullivan, E., et al. (2024). Workplace factors related to health care leader well-being in rural settings. Journal of Rural Health.

Mills, C., et al. (2024). The impact of rural general hospital closures on communities: A systematic review of the literature. Journal of Rural Health.

University of North Dakota Center for Rural Health. CEO turnover in rural hospitals.

Michigan Health & Hospital Association. MHA CEO Report: Prioritizing rural health.

Rural Health Information Hub. Education and training of the rural healthcare workforce.

Bipartisan Policy Center. Addressing workforce challenges through the Rural Health Transformation Program.

NSI Nursing Solutions. (2025). National Health Care Retention & RN Staffing Report.

Anna Smith, MHA, CPTM, is the founder of Wildbrush Collective, a boutique leadership institute based in Missoula, Montana, serving healthcare organizations nationally. To talk about what leadership support could look like at your hospital, schedule a conversation.