Background: The Critical Access Hospitals (CAHs) system was developed to bring health care to rural populations. Although CAHs lack equipment and resources, CAH nurses still provide end-of-life (EOL) care to critically-ill and dying patients. Objectives: To determine the largest and smallest ranked obstacles and helpful behaviors to providing EOL care to rural patients as perceived by CAH nurses. Also, to determine how CAH nurses' perceptions of obstacles and helpful behaviors to providing EOL care compare to that of their urban counterparts. Methods: A cross-sectional, nationally representative sample of nurses working in 39 CAHs were sent a questionnaire. Nurse participants were asked to rate obstacle and helpful behavior item sizes to providing EOL care to critically-ill patients. Current data were analyzed and compared with previously collected data obtained from urban-working critical care nurses. Results: Seven of the top 10 largest obstacle items were related directly to family behaviors and attitudes such as families not understanding what lifesaving measures entail and intra-family disagreements about life support. Largest helpful behavior items ranked in the top 10 included interventions which the nurse controls and items that impacted nurses having adequate time to deliver EOL care. The majority of the top 10 largest obstacle and helpful behavior items from the 2015 study, as ranked by urban critical care nurses, remained in the top 10 for the current study. Obstacle and helpful behavior items unique to CAHs such as a lack of resources and the nurse knowing the patient or patient's family fell below the top 10 largest items in ranking. Conclusion: As perceived by nurse participants, obstacles and helpful behaviors to providing EOL care remain similar despite location (rural versus urban). CAH nurses are accustomed to working without typical resources found in urban hospitals and therefore did not perceive resource deficits to be among the largest-ranked obstacles to providing EOL care. Family behaviors and attitudes remain the most dominant obstacle noted by nurses.



College and Department

Nursing; Nursing



Date Submitted


Document Type





Critical Access Hospital, nurses, end-of-life care, obstacles, helpful behaviors, rural nursing



Included in

Nursing Commons