Jennifer Werthman, PhD, RN, MBA, NE-BC
Rural nurses are at the center of care in their communities. They often care for patients across
multiple settings, build long-standing relationships with close-knit communities, and work with
limited staffing and specialty resources. In these environments, effective communication directly
influences patient safety, nurse well-being, and team functioning. Civility is especially important
because it helps nurses feel comfortable speaking up, asking difficult questions, and sharing concerns
(American Association of Critical-Care Nurses, 2016; Ulrich et al., 2022).
Psychological safety refers to a workplace climate in which people feel comfortable speaking
honestly, admitting uncertainty, and raising concerns without fear of punishment or embarrassment
(Edmondson, 1999). A psychologically safe nurse may identify a medication error, recognize a subtle
change in a patient's condition, or question a care plan before patient harm occurs. In contrast, nurses
who do not feel safe may remain silent because speaking up feels risky. Incivility undermines
psychological safety and effective communication. Examples include sarcasm, interruptions,
disrespectful tones, and public criticism (Atashzadeh Shoorideh et al., 2021). The effects of these
behaviors can accumulate over time, contributing to lower job satisfaction, increased intent to leave,
and poorer patient outcomes (Lee et al., 2024).
In rural healthcare settings, where staffing shortages and limited resources remain prevalent,
the effects of interpersonal conflict and turnover may create complex workforce challenges
(American Hospital Association, 2021). However, promoting civility does not mean avoiding
conflict. In healthcare, respectful disagreement is often necessary. Psychological safety is
strengthened when nurses feel confident questioning orders, clarifying priorities, and challenging
assumptions. Positive professional relationships support effective communication and patient safety.
Organizations can foster civility and psychological safety by establishing and consistently enforcing
codes of conduct that address disruptive behavior. These standards should apply to all members of the
healthcare team. Interprofessional teams can also strengthen collaboration by identifying shared
patient care goals. In addition, role modeling respectful interactions helps new employees and
students develop expectations for a culture of civility and psychological safety (Geiderman et al.,
2024; Scott & Gerardi, 2011).
When conflict occurs, approaching conversations with curiosity rather than blame can
promote respectful behavior and preserve collegial relationships. Addressing disrespectful
interactions early and moving discussions to a private setting can help de-escalate tension. Simple
statements such as, "Can we discuss this in a different way?" can redirect communication without
creating confrontation. TeamSTEPPS 3.0, developed by the Agency for Healthcare Research and
Quality, is an evidence-based framework that supports high-functioning teams. Its tools focus on
communication, leadership, situation monitoring, and mutual support as essential skills for safe
patient care (Agency for Healthcare Research and Quality, 2023). In addition to TeamSTEPPS,
organizations are increasingly using structured post-event debriefings, peer support programs, and
resilience rounds to create opportunities for reflection, learning, and emotional support following
challenging patient care situations (Edrees et al., 2016; Rushton et al., 2015).
For rural nurses, creating and maintaining civility is complex and evidence shows it is both
ethical and necessary for psychologically safe work environments (Geiderman et al., 2024). For rural
nurses, this work is especially important because healthy teams sustain local care. Civility protects
those who provide care, strengthens trust among colleagues, and increases the likelihood that nurses
will speak up when concerns arise. In rural communities where healthcare resources are sparse, every
team member plays an essential role and psychological safety can promote retention and teamwork,
strengthening quality care. Building this culture requires an ongoing commitment to respect,
accountability, and valuing every nurse's voice.
References
Agency for Healthcare Research and Quality. (2023). TeamSTEPPS 3.0.
https://www.ahrq.gov/teamstepps-program/index.html
American Association of Critical-Care Nurses. (2016). AACN standards for establishing and
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American Hospital Association. (2021). Rural report: Challenges facing rural communities and the
roadmap to ensure local access to high-quality, affordable care.
https://www.aha.org/system/files/media/file/2021/02/rural-report-2021.pdf
Atashzadeh Shoorideh, F., Moosavi, S., & Balouchi, A. (2021). Incivility toward nurses: A
systematic review and meta-analysis. Journal Of Medical Ethics and History of Medicine, 14, 15.
https://doi.org/10.18502/jmehm.v14i15.7670
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