Rural hospitals are confronted with multiple challenges to survive in the competitive health care environment of today's world. Declining population, corporate mergers and downsizing, transportation, cost of technology, and health manpower shortages are only a few of the issues rural hospitals must be prepared to address in order to survive. Federal- and state-administered programs are available that can contribute to the survival of the rural hospital. The nurse executive has a key role in contributing to the planning, development, and implementation of survival strategies.