American Research Journal of Nursing

 In 1997, federal legislation was enacted as part of the Balanced Budget Act which authorized States to create a State Flex Program. The State Flex Program allowed certain healthcare facilities participating in the Medicare program to become Critical Access Hospitals (CAH). Critical Access Hospitals are hospitals certified to receive cost-based reimbursement from Medicare. This reimbursement is intended to optimize their financial performance and decrease hospital closings. Currently, the state of New Hampshire has 13 hospitals that have been designated as Critical Access Hospitals (Rural Assistance Center, 2014). Every CAH must meet federal standards in order to maintain this special designation. These standards include a rural location and the provision for 24-hour, 7-day-a-week emergency care services for patients of all ages and with varying types of medical and psychiatric needs. Critical access hospitals in New Hampshire provide local residents and tourists with a variety of health care services, some of which are related to primary care, while others involve life-saving interventions. The nurses working in these rural areas are expected to demonstrate excellence in clinical decision making and to function as independent practitioners meeting the holistic needs of patients of all ages (Hurme, 2009). However, there is a gap in the literature related to the lived experience of nurses working within these settings. Examining how nurses in CAHs perceive their role and experiences will provide insight into the systems necessary to support the professional and practice needs of this unique cohort of nurses.