We Are Not OK

I’ve been a nurse for over 20 years, and I’ve spent most of my career at Good Shepherd Medical Center (GSMC), a 25-bed acute care hospital in Hermiston, Oregon. I was a supervisor in the medical-surgical unit before I transferred to general surgery, where I spent almost 15 years. Now, I work as an IV therapy and wound care nurse in the treatment center. I love being a nurse. I love my colleagues. I absolutely love caring for my patients. But every week, just the thought of coming in for my shift gives me mind-numbing anxiety: unrelenting headaches, an upset stomach and tight chest, a constant feeling of impending doom. I dread even driving down the road leading to my hospital, let alone opening the front doors and walking in.

How did I get here?

I have always loved taking care of people. When my children were younger, our house was known in the neighborhood as Cline’s House of Wayward Children. I can’t tell you how many kids spent the night or even lived with us for a time because they were in bad situations. Once my children were in junior high, it made sense for me to return to school for my nursing degree so I could use my caregiving skills in a professional role. Plus, as a cattle ranching family, we’d had our share of financial struggles, and I knew nursing was a good path to stability and a better life. So I became an RN at 40 years old and joined GSMC in 2001.

I have also always been proudly pro-union and an outspoken advocate for those whose voices need to be heard. I suppose I inherited some of this from my father, a pipe fitter and a union member until the day he died. When I was a teenager, his union went out on strike for months, which eventually meant we had no food in the house. But my father was passionate and never wavered in his conviction that what they were asking for was nothing more than what they deserved as humans. So when I was approached on my first day at GSMC and given paperwork to join the Oregon Nurses Association (ONA), I signed without hesitation.

It seems that I have been fighting for the respect and conditions needed to take care of my patients, my nurses, and myself nearly ever since.

Patients First, Nurses Last

I quickly learned that the life of a nurse is hard. We take care of our patients first before anyone else, even when that means putting our own lives on the line. Many of us take on every aspect of the caregiver role thinking no one else can, and our dedication is easily taken advantage of and unappreciated.

This became especially clear to me in 2009, when ONA entered contract negotiations with GSMC. We were told that all nurses do is stand around and draw paychecks, and that we could be replaced immediately. We’d asked for help—we needed more nurses because we were overworked. Instead, we were laughed at and told we weren’t working hard enough. Administrators later brought in productivity “experts” to tell us how many full-time nurses we actually needed, based on a calculation of patient load and how many hours a nurse is at the bedside. Their expert calculators didn’t account for patient acuity or nurse skill level. They didn’t account for what we’d already been saying for years: the system we had in place wasn’t working, and we weren’t able to take care of our patients properly.

I became the bargaining unit leader after those negotiations because I could no longer just pay my union dues and stand by quietly. I needed to step up and fight for nurses. And while we were able to win some marginal improvements to our workplace conditions over the next few years—Oregon strengthened its safe staffing law in 2015, for instance—management continued gaslighting nurses while repeatedly telling us how lucky we were to have our jobs. In one memorable round of negotiations, we fought for lower interest rates on employee hospital bills because the hospital was charging 11 percent interest and referring to collections when staff members couldn’t pay. The finance manager rejected this, saying that a car loan was more secure than a nurse’s hospital loan—and proceeded to offer us credit cards at 26 percent interest.

By 2019, I was working in the surgery unit and had become ONA’s treasurer. But we were still regularly being asked to do more with fewer resources and not enough nurses, and we were exhausted. For years, we would be on call for 24 weekday hours plus a weekend that started at 3 p.m. Friday and ended at 6:30 a.m. on Monday. We would sometimes work over 24 hours straight, and when the 3 p.m. call time came, there was no one to give us a break because we did not have enough staff. There were times I would clock out from my shift, drive home, fall asleep in my truck in the driveway, and wake up with no memory of getting there. Other times, I would just barely get home and in the door before I was summoned right back to work. And although the staffing law offered nurses some measure of protection, other colleagues, like scrub techs and our certified registered nurse anesthetists (CRNAs), weren’t protected—so there were times that they’d have to put in even longer hours.

We were losing nurses, nurse assistants, and CRNAs because of these working conditions, and we kept telling management that we needed more help. They kept answering that we had no more staff and, besides, the productivity numbers didn’t support what we were seeing on the floor. We were asked to do more and more work. We’d have to pick up all the cases for nurses who called in sick. We were required to volunteer in the afternoons after our shift ended. Management just started signing us up for late shifts if no one was scheduled—so a shift that was supposed to end at 3 p.m. would be extended to 7:30 p.m. We had no say, no choice. When we tried to push back, we were told, “This is what you signed up for. It’s part of the job description.”

As the workload changed for the worse, so did the workplace. We had gone through multiple managers in the surgery unit, and by the end of 2019, things had become toxic. The assistant manager was pitting nurses and scrub techs against each other, leading to coworker bullying—particularly of younger or less experienced nurses. I stood up for myself in the few instances that coworkers tried to bully me, and I also stood up for the nurses I worked with. So many nurses in my department were being bullied and had no voice; they were afraid to speak up because of the consequences—including receiving the worst shift assignments and being demeaned by their peers. Where did our humanity and our compassion for each other go?

I was constantly advocating and standing up for my nurse colleagues—on the floor, as part of our union’s staffing committee, and as a member of our union’s program and policy council. I refused to allow them to be mistreated. I also fought to get a better call schedule implemented at GSMC so that my nurses weren’t working shifts longer than 24 hours. But the stressors and exhaustion of short staffing, our relentless schedule, and constantly fighting for the conditions we deserved wore on me. I also changed, and not for the better.

I used to be the colleague who always had a smile for everyone and walked the halls with pep in my step. But I had become dissatisfied with my job, and increasingly, I was no longer a happy person, but an angry person. At home, I was mean to my husband, shutting him out when he tried to understand what was happening with me. At work, I would still smile, and my patient care never suffered, but I was dismissive and short with my colleagues. I was no longer as compassionate with them. I was emotionally shutting down. And a few coworkers who were closest to me saw it. Once, in the middle of a shift, a nurse told me, “I don’t even recognize you anymore. Where’s the Tamie you used to be?”

“I don’t know,” I said. “I don’t know who that Tamie is anymore.”

By the end of 2019, I’d had enough. I asked to transfer out of my unit and into the hospital’s treatment center.

Then COVID-19 hit, and everything became much, much worse.

From Desperate to Unimaginable

I didn’t realize at the beginning of the pandemic that the stress, anger, and loss of compassion I was experiencing were signs of burnout. I just thought I needed a change of pace. So I moved to the treatment center on April 1, 2020, just weeks after the country went into lockdown. I’d barely gotten used to my new unit when it seemed the entire medical profession was turned upside down.

In May, GSMC laid off more than 20 nurses because departments were closing due to the extended lockdown. By that time, I was the chair of our bargaining unit and I was on the ONA board of directors; although I was not laid off, I felt it wasn’t right to still be working while my nurses couldn’t. I volunteered to take a layoff because the only way I knew how to support them was to show them that they weren’t alone. The layoff lasted for a month. And just weeks after we all returned to work, our region became the epicenter of COVID-19 in the state.

COVID-19 ran rampant through our community and hit our hospital extremely hard. We had no beds. Some days, there were no beds anywhere in the region, so we had to send patients to other states for care. We shut down the hospital to outside visitors. Nurses became unable to touch our patients or colleagues. Ours is a compassionate, nurturing profession, and touch is one of our key assessment tools. But our patients were dying, and we were putting gloves filled with warm water in their hands so that they would feel some kind of touch. We were calling families over iPads to say goodbye as their loved ones died, because they weren’t allowed to come in and hug them. Our colleagues were in pain, and we could only give them air hugs in the hallways.

In the treatment center, we were administering monoclonal antibody infusions in addition to IV therapy and wound care. We were one of the only hospitals in the area where patients could get the infusions, so they came from all over. We had been short on resources and staff before the pandemic—now, we were drowning. Simply surviving each shift became our priority.

Just like everybody in our hospital and throughout the nation, I was also picking up extra shifts. On my few days off, I volunteered to come in and just do infusions so that my nurses didn’t have to. I didn’t want to volunteer, but I couldn’t say no. Nurses are conditioned to feel like we’re letting our coworkers, communities, and families down if we don’t run ourselves ragged. And some supervisors are happy to use that to ask us to work beyond our capacity: “We really, really need you. Can’t you do it just this once?” But it’s never just once.

For months on end, we cared for our patients at the expense of ourselves, doing all we could to protect our families from exposure to the virus. Nurses were parking in their garages and sleeping in tents to make sure their families weren’t exposed. I kept a shoebox in my truck to store my work shoes so I didn’t have to bring them in the house with me after a shift. My grandchildren live close by, and I didn’t want to take any chances. I wouldn’t let them hug me when I came through the door. I’d go straight to the bathroom, throw my clothes in the washer—I can’t even estimate how much bleach I used on my scrubs—and hit the shower first, all before I was able to relax or hug my grandkids.

We were doing everything in our power to get through the pandemic, but the hospital did little to support us or keep us safe. They would occasionally throw a pizza party or bring in cookies, but they never gave us what we really needed. We were told to wear the same gowns from patient to patient and use masks for 12 hours a day and then re-sterilize them. When we asked for proper protective equipment and hotel rooms when we were on shifts so that we didn’t have to worry about exposing our families, we were accused of trying to profit from the pandemic. And if all that were not enough, while COVID-19 was still spreading rapidly, the then-CEO changed GSMC’s policy on contact tracing so that we were not told if we had been potentially exposed to the virus.

So much of what we experienced went against our professional ethics and changed our whole perspective of nursing. No longer were we there to take care of patients to our best ability. Instead, we were told to keep quiet and do our jobs. One manager even emailed the nurses on the med-surg floor, telling them that they were privileged to work through the pandemic and experience something they would never see again in their careers.

In truth, we were being pushed past our capacity, guilted into coming in for “just one more shift” with administrations shoving money at us to keep showing up. And nurses were committing suicide because they couldn’t—and they had nowhere else to go.¹ Our lives didn’t seem to matter.

Meanwhile, our patients were still dying. During one shift, I was called to a room to give an IV for a patient who was very sick. Just a few hours later, a nurse asked for another IV and sent me to the same room.

I asked, “Did the patient pull it out?”

She said, “No, it’s a new patient.”

The patient had not made it. I went into the bathroom, and I let myself cry for five minutes. Then I wiped my tears, put on my mask, and walked back out into the hall like nothing was wrong.

But something was very wrong. Nurses felt it during the worst of the pandemic, when it was all we could do to survive. And we were still feeling it two years later, when the tide had seemingly turned. When one of my nurse colleagues was injured by a patient who had become violent, management asked what the nurse did wrong. Our request for extra security was refused because in management’s view, the nurse could have done something different to avoid the attack. By asking to be safe, we were asking for too much.

Dying Inside

For two years, I acted like everything was normal, but internally I was angrier than I’d ever been. I was the chair of the hospital bargaining team, and I had run for and become ONA president so that I could fight for the rights of our nurses. But every day that I stepped into that hospital, I was dying inside.

I had stopped most self-care. I would wash my hair in the bathroom sink before work but sometimes went a month without taking a bath because I just didn’t want to. I used to exercise all the time, but now I no longer had the energy. All I would do was go to work, come home, sit in my chair, and read. I gained 50 pounds. I didn’t sleep. My blood pressure was out of control. For a solid six months, I had a headache that no medicine could take away. I was an emotional wreck.

In early October 2022, I saw my primary care physician in the hallway and spontaneously said, “I think I’m experiencing some burnout.”

He looked right at me. “Tamie, I know you are. Do you need time off?”

“No, I’ve got this,” I said. “I just feel that way.”

He told me, “Well, when you hit your brick wall, come see me.”

A couple of weeks later, I did. One morning I clocked in for my shift at 7:30 a.m., and by 8:30 a.m. I wanted to walk out the door. I told my boss, “I can’t do this. I can’t be here.” I finished my shift that day, and then I took the rest of the week off. I saw my doctor again on November 1. When he walked into his office and saw me waiting, he said, “You hit your brick wall, didn’t you?”

I started crying.

He suggested I take a month off to start, and while I agreed, I couldn’t imagine ever coming back. Yet, as I took the elevator up two floors to my manager’s office with my paperwork in hand, I felt so sick to my stomach that I wanted to throw up. I almost turned around and changed my mind about the whole thing. But I walked into my manager’s office and handed her the paperwork. She told me to take all the time I needed.

Another nurse was sitting in the office when my manager stepped out to print my leave paperwork. “Have a great vacation,” she told me.

I don’t think she meant it the way it sounded, but it made me feel worthless. Why was I taking time off for myself when I still had a job to do and there was so much need? My coworkers and community were counting on me to keep showing up. How could I let them all down?

I looked at that nurse and said, “I will.” And I left.

It’s OK to Not Be OK

I was off work for five months, and much of that time is a blur because of how numb and traumatized I was. I couldn’t even think of going back to work. Just turning down the road that led to the hospital on my way into town sent me into a panic attack. My headaches returned, and my anxiety went through the roof. So, I stopped taking that road. I found another way to town or left the area altogether—my family’s cabin in the mountains became my safe place.

I began counseling, grateful that it was offered through my employer. As I started talking over my feelings and experiences with my counselor, I became angry all over again that my nurses and I—and nurses all over the country—endure mistreatment, disrespect, violence, and more in order to care for our patients. I was furious that it’s the culture of nursing to put ourselves last and feel guilty for taking any time at all to care for ourselves.

As I talked with my counselor and started using the education resources offered by the AFT, I started learning more about what I was going through. The AFT offers training classes on burnout, moral injury, and posttraumatic stress disorder (PTSD), and I attended a session during the AFT Nurses and Health Professionals’ Professional Issues Conference in Chicago. As the trainer discussed the signs of PTSD, my experiences and emotions of the last three years made sense. I stood up and said, “I think I have PTSD. I know I have burnout. You are describing me.”

That was the beginning of my journey in understanding moral injury, which the trainer introduced as what happens when I’m made to do something that violates my ethics.* Listening to examples of situations that can cause it—like not being able to give my patients the care they need and deserve because of short staffing—I realized that not only did I have moral injury, but that many of my nurses and colleagues did, too. And like me, they had no idea that there is a name and help for what they’re experiencing.

Shortly afterward, I contacted ONA and told them we need to do more to get the word out. I recorded a podcast (available at oregonrn.org later this year) to share what led to my breakdown and how I learned to recognize moral injury, PTSD, and burnout. I talked about suicide. I explained that while I never really thought about committing suicide, I did wonder who would miss me if I weren’t around, whether anyone would show up for my funeral. It was a dark place to be.

Most importantly, I acknowledged that I wasn’t OK. It’s a hard thing to admit. And it took a lot of time and counseling for me to believe that nothing is wrong with me. I’m not defective. It’s OK to not be OK.

That’s the message that I needed years ago, and that nurses across the nation need now more than ever.

I returned to work at the end of April, when my short-term disability ran out. I certainly did not want to come back, and emotionally, I wasn’t ready. But I’m a nurse who still wants to care for my patients. To keep my license, I need a certain number of hours at the bedside. Still, what primarily drove my decision was that my job security was in question. If I didn’t come back after my leave of absence ended, I would have lost my seniority at GSMC. So, while there is no timeline for healing from burnout, PTSD, and moral injury, my time was up. I had to return to the bedside to protect my job.

I didn’t sleep the night before my first shift back. The next morning, my anxiety, pounding headache, upset stomach, and chest tightness returned like old friends. I had to convince myself to walk through the hospital doors.

I was nervous to see my coworkers again. I thought I had let them all down. But my crew was amazing. Everyone was excited to see me and glad that I had taken care of myself. I worked three days in a row because I knew if I didn’t, I would never return. After the third day, I left as soon as I could get out of the hospital. I decided to work just one day a week for a while. Because I’m per diem, I can work when I want to. Having some control of my schedule gives me back a little bit of the power and identity that I lost because I was running on empty for so long and pretending I was OK.

Many coworkers and other nurses who have heard my story contact me because they are also experiencing burnout, moral injury, and/or PTSD. They want to know how I got through this. I tell them the truth: I’m not through it. I’m still not OK, still not back to the happy person I used to be years ago. I don’t know if I’ll ever be. I’m still seeing a counselor, and even though I’ve returned to work, things are really, really hard right now.

I don’t know how long I’ll struggle with anxiety and fear. I’m hoping that by returning and learning to work through it, I’ll get some measure of healing. I’ve been lucky to have this time away from work because it was a viable financial option for me; many others don’t have the option of taking an extended leave for self-care.

Things have to change. Too many of us are hurting. We cannot continue in the way that we are, or our healthcare system will implode.

That’s why I continue fighting. I recorded the podcast and am transparent with my nurses and anyone who will listen about what I’m experiencing and how they can get help. And I fought to pass a landmark bill this summer, HB 2697, that strengthens Oregon’s safe staffing legislation. This bill will help save lives, reduce hospital admissions and readmissions, and change our profession for the better.^†

I don’t know if our profession—or even our generation—will ever fully recover from the trauma of the last few years. The pandemic and increasing corporatization of healthcare, in which hospitals put profits over patients and staff, have changed nursing. In many ways, they’ve changed who we are.

So where do we go from here?

If we are going to see change in our healthcare system for ourselves and our patients, we need to start with taking better care of our nurses and healthcare workers. But this requires changing the culture of nursing.

Caring for Ourselves

So much is wrong with the current, corporate model of healthcare,^‡ not the least of which is that it is dehumanizing and keeps nurses from really caring for our patients in the ways they deserve. But another failure of the corporate model is that it teaches nurses that caring for ourselves is not important to patient care—when the reality is that if we don’t take care of ourselves, we can’t take care of our patients.

For months during the pandemic, I asked that we stop scheduling patients for every minute of the day so that nurses could have a break. But my request was ignored. Every week, the ward clerk would send out an all-department message outlining everything that needed to be done for the week and information on any new patients we had. One week, the ward clerk wrote at the top of the outline in bold letters, “I know Tamie wants her breaks, but patient care comes first.”

I immediately looked at her and said, “You’re wrong. The law comes first. And the law tells me I am entitled to a break.”

We can’t put patients first if we haven’t eaten or had a moment to breathe or use the bathroom. But that’s the culture that has been created because of corporatization. In this culture, everything is a numbers game, and the end goal is money. So we check boxes on computer screens to speed up our assessments and notes. But nursing is not checking a box and calling it productivity. And it’s not sacrificing ourselves and calling it “patient care.”

Taking care of ourselves starts with admitting that we’re not OK and then seeking help. But I don’t think we push hard enough to get our members and all nurses the education and resources they so desperately need to improve their mental health and well-being. We need to reach out through every avenue available, including through commercials and on social media, because no one is talking about why nurses are experiencing burnout. No one’s saying, “It’s OK to leave the bedside if you need to.” In my experience, most nurses leave when they hit their brick wall, like I did, or when something traumatic happens in their care that they blame themselves about. And we lose nurses to suicide when they can no longer sit in their pain and they don’t have the physical or mental ability to find help. So, we need to let them know that it’s OK to start taking care of themselves long before they reach that point. It’s OK to take a day off whenever they need to reset. It’s OK to get help.

We also need to normalize counseling. It’s not the culture to talk to someone unless we’re in crisis. But nurses in every hospital and every care setting need regular access to behavioral health counseling. Dropping in to see a counselor, whether one-on-one or in groups, should be as common a practice as getting a meal in the cafeteria. It is a vital self-care tool that we shouldn’t have to beg for or pay for out of our own pockets.

I have heard from nurses throughout Oregon that while some hospitals offered counseling and other well-being supports during the height of the pandemic, most withdrew them when the worst was over—right when many people were realizing they needed help. Nurses throughout this nation are desperate right now.² The crisis point of COVID-19 may have passed, but the mental health crisis is just beginning. And we’re not OK. We need to acknowledge it now, because I can’t stand the thought of losing even one more nurse when help is out there.

Caring for Each Other       

To change our system and nursing culture, we also need to change how we treat each other. We need more respect and kindness for our coworkers. Nurses aren’t trained to be bullies. Bullying stems from being under pressure; when we are unable to control a situation, we project our anger onto someone more vulnerable. The problem is those vulnerable nurses—usually our new grads or younger nurses who are still trying to learn the profession—have no way of protecting or defending themselves, and no voice to speak up for themselves.

We need to speak out against bullying and start teaching in nursing schools, hospitals, and all healthcare settings that bullying culture is unacceptable. If we don’t push our new nurses out of the profession, they will be caring for us someday. They should be mentored and supported, not isolated and harassed.

One of the many lessons of the pandemic is that nursing has to completely change. But a safe staffing law alone won’t accomplish that. Counseling and education alone won’t accomplish it. It will take all of us fighting together for each other and for this profession that we love.

To nurses and other healthcare workers who are experiencing PTSD, burnout, and moral injury: Please know that you are not alone, and you haven’t let your families, coworkers, or communities down. Maybe one day, we will all be OK. But until then—and long after—we’ll fight for and support each other because we are stronger together. We are in a special moment now: our voice is strong, and we have the power to make a difference like never before. Together, we can lead a movement to change nursing and rehumanize healthcare. Together, we can be healthy again.

---

Tamie Cline, RN, is the president of the Oregon Nurses Association (ONA) and a bargaining unit leader at Good Shepherd Medical Center in Hermiston, Oregon. She has served on the ONA Professional Nursing Care Committee since 2020 and has been a delegate to the AFT’s convention since 2018. She is currently an IV therapy and wound care nurse in the Good Shepherd Treatment Center.

*To learn more about the causes of moral injury and what it will take to protect healthcare workers and enable them to heal, see “Clinicians in Distress: Addressing Moral Injury in Healthcare” and “Moral Injury: From Understanding to Action” in the Spring 2021 issue of AFT Health Care. (return to article)

^†To learn more about this legislation and how we won passage, see “Historic Staffing Win for Oregon Health Professionals.” (return to article)

^‡For details, see “Bedside Medicine to Corporate Medicine” in the Spring 2023 issue of AFT Health Care. (return to article)

Endnotes

1.M. Davis et al., “Association of US Nurse and Physician Occupation with Risk of Suicide,” JAMA Psychiatry 78, no. 6 (2021): 651–58, jamanetwork.com/journals/jamapsychiatry/article-abstract/2778209; R. Chatterjee, “A Nurse's Death Raises the Alarm about the Profession's Mental Health Crisis,” National Public Radio, March 31, 2022, npr.org/sections/health-shots/2022/03/31/1088672446/a-nurses-death-raises-the-alarm-about-the-professions-mental-health-crisis;%20; and E. Youngman, testimony, Oregon State House of Representatives, February 28, 2023,  olis.oregonlegislature.gov/liz/2023R1/Downloads/PublicTestimonyDocument/58179.

2. J. Christensen, “‘A Crisis in Nursing Is upon Us,’ Nursing Survey Shows, Even After the Pandemic,” CNN, May 1, 2023, cnn.com/2023/05/01/health/nurses-unhappy-survey/index.html; and K. Russell, “About 100,000 Nurses Left the Workforce Due to Pandemic-Related Burnout and Stress, Survey Finds,” CNN, April 14, 2023, cnn.com/2023/04/13/health/nurse-burnout-post-pandemic/index.html.

[illustrations: Nicole Xu]