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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.