BACKGROUND: Recent trends indicate that the frequency of major incidents (MIs) is increasing. Healthcare systems are vital actors in societies' responses to MIs. Well-prepared healthcare systems may mitigate the effects of MIs. Disaster preparedness is based on region-specific risk and vulnerability analyses (RVAs). Hospital incident command groups (HICGs) are commonly formed per hospital's contingency plan MI to aid in disaster response. Acquiring situational awareness and decision-making in the face of uncertainty are known challenges for HICGs during MIs. However, the remoteness of rural hospitals presents unique challenges. AIM: The aim of this study was to explore HICG leaders' perceptions of disaster preparedness in rural hospitals. METHODS: A qualitative study with semi-structured, focus group, and individual interviews was used. The data were analyzed through inductive content analysis. RESULTS: The analysis generated the main category, HICGs' confidence in handling major incidents and four categories. These were Uncertainty and level of recognition (containing two subcategories)
Awareness of challenges and risks (containing two subcategories)
Factors that facilitate preparedness, response, and leadership (containing three subcategories)
and Prerequisites for decision-making (containing three subcategories and four subcategories). CONCLUSIONS: HICG leaders generally perceived their hospital's disaster preparedness as adequate. However, preparedness was found to be influenced by several factors. The findings revealed a complex interplay of factors influencing preparedness and response, particularly highlighting challenges related to geographical isolation and resource constraints. Effective preparedness requires a comprehensive understanding of local contexts, hospital capabilities, and risks, which directly impacts training, decision-making, and resource allocation. Addressing the identified vulnerabilities necessitates targeted interventions focused on situational awareness, decision-making, collaboration, and training. CLINICAL TRIAL NUMBER: Not applicable.