Most of the world's population is rural and 45% of all United States hospitals are small or located outside of urban centers. The interdependence of rapidly changing rural communities and hospitals is described in this study of nursing directors' jobs. Findings provide needed information about the challenges and demands of nursing administration in small organizations useful for development of curriculums sensitive to values, politics, and economies; and for all nurse executives eager to understand the complexity of decisions and actions, whether in small organizations or in large multi-institutional systems compromising hospitals of varying sizes.