Rainier Olympic Nurses Association is proud to celebrate Tami Green, BA, RN, PMH-BC as a Washington State Nurses Association all of Fame inductee!

Induction into the Washington State Nurses Hall of Fame is WSNA’s highest honor, given to nurses who have made significant contributions to the profession of nursing. This is where we recognize the pioneers, the groundbreakers, and the heroes of nursing in Washington state.

Tami has been a passionate advocate for her patients, her fellow nurses, and the communities she serves. Her name had been well known among RONA members in Pierce County when, as a nurse, she ran for and was elected as a Washington State House of Representatives. For 10 years, Tami fought for nursing practice, mental healthcare, developmental disability services, as well as nursing practice and education.

Tami first came to RONA in 2017 as a write in candidate for president elect. She served one year as president elect and became president in 2018 and has served 4 terms as president while balancing work and family and continuing to serve as an advocate for patients and nurses as well as leading RONA through the COVID pandemic. Under her leadership, RONA grew from a district of one county to a region of seven counties, increasing the voice and power of nurses.

Tami currently serves as a member pro tem of the Washington State Board of Nursing, where her deep experience in mental health has proven invaluable on the Substance Abuse Disorder Review Panel and the Case Disposition Panel for Discipline. She continues to care for patients at Community Healthcare Clinic in Pierce County while launching a coaching business to help others achieve their goals.

Tami is an exemplar of service, commitment, and community. Her work has improved Washington state healthcare policy, nursing practice, and the lives of countless patients. Like her hero, Florence Nightingale, Tami works humbly and diligently to promote the nursing profession.

Congratulations Tami!

This month our President elect Gordy West will begin his term as president. I am confident that he will bring his own brand of color, optimism and hope to RONA, just like Spring replaces Winter.

My departing request is to encourage you to participate in RONA activities. There really is somet

By Scott Jahner PMH-ARNP-BC

“Within nursing, MoraI Injury is increasingly prevalent due to systemic factors such as chronic staffing shortages, resource rationing, and perceived institutional betrayal.”

Moral injury is the profound psychological, social and spiritual distress resulting from actions – or inaction- that violate deeply held moral beliefs. The American Psychiatric Association now includes “moral problems” in the latest DSM-5-TR, acknowledging it as a significant issue for clinical attention.

Summary

Moral injury (MI) represents a profound psychological syndrome resulting from actions or events that transgress an individual’s deeply held moral beliefs. The formal recognition of MI in the September 2025 Diagnostic and Statistical Manual Disorders (5th e., Text Revised) update under Z-code Z65.8 marks a critical shift in validating these psychological sequelae as a legitimate focus of clinical attention (Wortham & VanderWeele, 2025; U.S. Department of Veteran Affairs, 2025). Within nursing, MI is increasingly prevalent due to systemic factors such as chronic staffing shortages, resource rationing, and perceived institutional betrayal. These drivers lead to significant occupational hazards, including a heightened risk of suicide. Distinguishing MI from related constructs like burnout (Z73.0) and PTSD (F43.1) is essential for effective intervention (De Hert, 2020; Egan, 2025). Recovery necessitates a systemic approach, utilizing validated screening tools like the Moral Injury and Distress Scale (MIDS) and organizational support strategies such as Schwartz Rounds—which have demonstrated a 35.5% reduction in reported moral distress among nurses—to protect the moral integrity of the workforce (The Schwartz Center, 2024).

Evolution of Clinical Recognition in the DSM-5-TR

In September 2025, the updated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) officially recognized Moral Injury (MI). The American Psychiatric Association (APA) expanded the diagnostic category for “Religious or Spiritual Problem” to “Moral, Religious, or Spiritual Problem,” assigned as ICD-10 Z-code Z65.8 (Wortham & VanderWeele, 2025). This taxonomic shift validates that moral suffering—experiences that disrupt an individual’s understanding of right and wrong, or their sense of goodness regarding themselves, others, or institutions—is a legitimate focus of clinical attention (Wortham & VanderWeele, 2025; U.S. Department of Veteran Affairs, 2025).

Conceptual Genesis: The Moral Trauma Spectrum

Initial conceptualizations of MI focused on the experiences of military soldiers tasked with situations that created moral dilemmas with “no right answer,” similar to Philippa Foot’s “Trolley Problem” (Wortham & VanderWeele, 2025). During the COVID-19 pandemic, a global lack of preparedness forced healthcare workers, most notably nurses, to face choices that carried these same agonizing moral dilemmas (Wortham & VanderWeele, 2025).
Moral injury is best understood not as a binary state but as a dimensional construct residing on a “moral trauma spectrum”. This spectrum accounts for the variations in persistence and severity of the distress, ranging from the transient “moral dilemma” or “moral challenge” to the more enduring “moral distress,” and finally to “moral injury” or “moral injury disorder” A moral dilemma involves a situation where no option feels entirely right, yet the individual must choose; moral distress arises when the individual knows the correct path but is constrained from taking it; and moral injury occurs when the subsequent psychological, emotional, and spiritual damage becomes a persistent feature of the individual’s identity. (Koenig, 2026)

A decade of research led by the Human Flourishing Program at Harvard University sought to understand these experiences to ensure leaders in “high-stakes roles” possess the tools necessary to identify injury and promote recovery (Wortham & VanderWeele, 2025). This work, in partnership with the APA, facilitated the addition of “moral problems” and a specific Z-code for MI into the DSM taxonomy (Wortham & VanderWeele, 2025; Norman & Maguen, 2025). This framework locates Moral Injury on a “moral trauma spectrum,” acknowledging it as an enduring psychological impact resulting from exposure to Potentially Morally Injurious Events (PMIEs).

Distinguishing Moral Injury from Related Constructs

Nurses encounter MI when their action or inaction goes against their beliefs, or when they witness behaviors that violate their values, causing psychological, behavioral, social, and spiritual distress (Norman & Maguen, 2025). It is clinically distinct from related constructs:

• Moral Injury (Z65.8): Characterized by profound guilt, shame, and a sense of betrayal. Unlike burnout, which implies an individual’s inability to cope, MI indicates a failure of the organizational moral climate driven by structural issues such as unsafe staffing and misaligned institutional priorities (Norman & Maguen, 2025).
• Burnout (Z73.0): An occupational stress syndrome caused by chronic exposure to job stress that manifests as emotional exhaustion, cynicism and depersonalization, reduced professional efficacy, and personal accomplishment (De Hert, 2020).
• Posttraumatic stress disorder (PTSD) (F43.1): A psychiatric condition presenting in individuals who experience or witness a traumatic, emotionally or physically harmful or life-threatening event or series of traumatic events. Symptoms include nightmares, flashbacks, severe anxiety, dissociation, and uncontrollable thoughts about the event or events (Egan, 2025).

Prevalence and the Critical Association with Suicide Risk

Evidence indicates that MI is a significant systemic challenge with prevalence rates varying by clinical setting. ICU and Critical Care nurses report the highest burden (40–55%), followed by Emergency Departments (35–50%) and Long-Term Care (30–45%) (Moral injury prevalence and triggers in nursing post-pandemic, 2025).

A concerning factor associated with these psychological sequelae is the high risk of suicide. In a population-based study of 1,232 participants, individuals screening positive for probable MI had significantly higher odds of current suicidal ideation (66%) and lifetime suicide attempts (41%) compared to those without the injury (Griffin et al., 2025). This data underscores the urgent need for healthcare leadership to maintain vigilant awareness following adverse or sentinel events to prevent potentially fatal outcomes (Griffin et al., 2025).

Evidence-Based Screening and Recovery Strategies

Due to the potential urgency associated with unrecognized moral injury, identification becomes critical as well as nurturing the development of moral resilience. Organizations can transition from reactive support to proactive stewardship by working towards a multilevel approach to address the drivers of MI, such as chronic staffing shortages and resource limitations (Moral injury prevalence and triggers in nursing post-pandemic, 2025).

A multilevel strategy for mitigation, focusing on individual, organizational, and policy interventions. Individual solutions such as self-reflection, emotional management, and mindfulness activities. Organizational support such as Schwartz Rounds, the Concentrate, Unrush, Reflect, and Act (CURA) reflection tool, Moral Case Deliberation (MCD), and ethical awareness can cultivate strong team cohesion and reduce moral injury. Policies to protect whistleblowers, uphold ethical standards, and mandate ethics consultation services critically safeguard health care worker’s moral agency to limit moral distress. Policy reforms that address structural barriers like staffing ratios are ways to help nursing staff to avoid institutionally created “Trolley Problems” from being a prominent experience. (Masdar et al, 2025).

Cultivating moral resilience allows nurses to remain undiminished by centering their values in the midst of adversity (AACN standards for establishing and sustaining healthy work environments, 2024). Moral Resilience is defined as the capacity to restore integrity in the face of moral adversity through self-awareness, moral efficacy, and relational integrity. (Masdar et al, 2025). Schwartz Rounds have been shown to reduce reported moral distress by 35.5% specifically among nurses by providing a structured forum for sharing the emotional dimensions of care (The Schwartz Center, 2024).

Once potential MI is identified, utilizing validated self-screening tools to identify MI among staff can be a helpful way of helping health workers to visualize and identify needs for further support. Some peer reviewed and validated self-screening tools include:
• Moral Injury and Distress Scale (MIDS): An 18-item tool assessing exposure to PMIEs and functional impact; a score of 27 or higher indicates clinically meaningful MI (U.S. Department of Veteran Affairs, 2025).
• Moral Injury Events Scale-Civilian (MIES-C): A 9-item scale that measures violations of beliefs across dimensions of self-transgression, transgression by others, and betrayal (Thomas et al., 2024).
• Expressions of Moral Injury Scale-Civilian (EMIS-C): A 17-item tool used to measure behavioral and spiritual sequelae of MI over time (Thomas et al., 2024).

Fostering a culture of ethical stewardship and team-based reflection is crucial for transitioning from reactive distress to proactive ethical empowerment in healthcare settings. (Masdar et al, 2025). By implementing these systemic strategies, nursing leadership can protect the moral integrity and mental health of the profession.

References:
American Association of Critical-Care Nurses. (2024). AACN standards for establishing and sustaining healthy work environments. https://www.aacn.org/nursing-excellence/standards/aacn-standards-for-establishing-and-sustaining-healthy-work-environments

De Hert, S. (2020). Burnout in healthcare workers: Prevalence, impact and preventative strategies. Local and Regional Anesthesia, 13, 171–183. ((https://doi.org/10.2147/LRA.S240564))

Egan, D., M.D. (2025, March). What is Posttraumatic Stress Disorder (PTSD)? Retrieved March 28, 2026, from https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

Griffin, B. J., Maguen, S., McCue, M. L., Pietrzak, R. H., McLean, C. P., Hamblen, J. L., Jendro, A. M., &

Norman, S. B. (2025). Moral injury is independently associated with suicidal ideation and suicide attempt in high-stress, service-oriented occupations. npj Mental Health Research, 4(1), Article 32. https://doi.org/10.1038/s44184-025-00151-9

Healthcare. (2025). Moral injury prevalence and triggers in nursing post-pandemic. Healthcare, 13. https://pmc.ncbi.nlm.nih.gov/articles/PMC12610207/

Koenig HG, Carey LB, Wortham JS. Moral Injury in the DSM-5-TR: Syndrome Spectrum vs. Categorical Disorder. J Relig Health. 2026 Mar 23. doi: 10.1007/s10943-026-02632-3. Epub ahead of print. PMID: 41872581.

Masdar M, Lusmilasari L, Sholikhah EN, Effendy C. Facing Moral Distress: Why We Need to Enhance Moral Resilience in Palliative Care Nursing. Indian J Palliat Care. 2025 Oct-Dec;31(4):405-409. doi: 10.25259/IJPC_196_2025. Epub 2025 Aug 29. PMID: 41342017; PMCID: PMC12670416.

By Karli Kooi, BSN, RN

“As the summer heat only grows, it is essential for nurses to anticipate and recognize summer concerns for health.”

The Nurse & Summer: Hot and Fun in the Sun?!

By Karli Kooi, BSN, RN

1000 words – approximately a 10-minute read

As the seasons have shifted from the temperamental grays of spring to the growing heat of summer, us nurses begin to observe the effects in our communities. Washington summers are getting longer and hotter (WADOH) due to climate change. Studies show that worldwide, exposure to extreme heat is growing exponentially (WHO). Starting on June 21st this summer, unexpected heat waves across Europe began and the World Health Organization has attributed 1300 additional deaths to the soaring temperatures (BBC 2026). As the summer heat only grows, it is essential for nurses to anticipate and recognize summer concerns for health.

With rising temperatures, many public health departments are assisting communities with staying cool. One such example is the operation of “Cooling Centers”, air-conditioned locations where people can find a cooler indoors. Resources from the counties RONA serves can be found at the following webpages: Tacoma-Pierce County Health Department, Thurston County Public Health, Jefferson County Public Health, and Kitsap Public Health. Grays Harbor County Emergency Management appears to issue high heat warnings. No resources were found specific to summer or heat on Mason County webpages. Public health authorities generally share the same advice, summarized here: Seek shade, stay hydrated, and know the signs of heat cramps, heat exhaustion, and heat stroke. To keep indoors cooler even without air conditioning, try covering windows, staying on lower floors, and reduce oven or stove usage. Check in on your neighbors and community, especially the young and elderly, and before and after nighttime. The night can be a sneaky time for heat to become unsafe: resources like cooling centers are generally not open then, and so non-cooled indoor environments can exhaust a person with limited options of other places to be. Discuss with your patients how they anticipate caring for themselves during the hot summer months while considering unique factors such as mobility, access to services, fluid restrictions, and other individualized influences. 

Another significant element of summer is an increase in traumatic accidents and injuries: “Trauma Season”. It is both a perception among inpatient nurses and a statistical fact that with summer comes an increase in Emergency Department visits and traumatic admissions. A study examining pediatric trauma admissions found that “each degree increase in temperature increased the rate of trauma admissions by 4%” (PMC 2020). During the 2021 Pacific Northwest Heat Wave, a retrospective study on injury deaths in Washington state found an estimated total of 159 excess injury deaths … during the 3-week period (Am J Public Health 2023). Finally, increased heat exposure – temperatures in the 95th percentile – were strongly linked to “increased deaths from circulatory diseases as well as “external” causes of death associated with injuries and accidents, such as transport accidents, falls, and drowning.” (YSPH 2025). Discuss with patients what summer activities they enjoy, and focus on opportunities for both connection and personalized health promotion when they mention their pastimes. Do they enjoy swimming and boating? Promote safety tips for recreational water activities (WADOH) such as using floatation devices, avoiding any mind-altering substances such as alcohol or marijuana, and supervising all children and less strong swimmers. Avoid underestimating just how cold water can be or overestimating the safe depth of a body of water. Drowning is the second highest cause of death for ages 1-17 in Washington State (WADOH 2016). Hiking, biking, sporting, playing outside? Encourage having a safety plan, wearing appropriate gear, knowing your surroundings, and doing it with others. You can learn more at resources like Safety Essentials: A ToolKit for Hikers (WTA), Playground Safety During Warm Weather (WADOH 2026), and Summer Safety from the Harborview Injury Prevention & Research Center (HIPRC). Accidents and injuries can occur to even the most experienced, safest, and prepared people – but it is surely less likely for those who try their best!

With the summer sunshine, more people are basking in the sunny outdoors. Be on the lookout for an increase in sunburns for all ages and backgrounds! Unprotected sun exposure can not only obviously cause redness and pain, but can affect the body deeper than what can be seen and felt through damaging skin cells and increasing the risk of skin cancers. It is essential to make wise choices when basking in the sun, and focus on consistent sunscreen use, protective layers, and staying shaded when UV rays are the highest. It is also critical to remember that unprotected sun exposure can affect skin of all shades. In fact, research shows patients with darker skin tones are more likely to perceive less importance to sunscreen, while also having worse melanoma [skin cancer] clinical outcomes (CJMS 2023). Everyone should be practicing sun exposure safety! Learn more about Sunscreens and Sun Safety from the Washington State Department of Health. 

Now, health in the summer season is not all stressful. Lots of friends and family may also get together outdoors for different celebrations! With any outdoor events, it is important to consider food safety when eating in hotter weather. The temperature of the potluck pasta dish that sits out in the park shelter at your nephew’s birthday party can quickly rise and stay in the ‘danger zone’ temperature of 40 degrees fahrenheit (4degrees C) – 140 degrees fahrenheit (40 degrees C) (USDA 2023). It would spoil the fun to eat something spoiled! From the Washington State Department of Health, you can learn more about Food Safety Tips and specifically, tips for Barbecue and Picnic Food Safety (WADOH). And as always, practice hand hygiene when preparing and enjoying food by washing your hands for a minimum of 20 seconds, or using hand sanitizer and rubbing until dry (CDC 2024).

Finally, while the busy summer time may distract from some routine care, it is still vital to continue focusing on general safe and healthy behaviors. While it isn’t ‘flu season’, there are still plenty of opportunities for health promotion following recommended health practices around vaccination (WADOH), including for vaccines like Tdap, Hepatitis B, and more! Summer will eventually end, and with it, September and the school and flu season will arrive before we know it.

We are honored to celebrate Rainier Olympic Nurses Association 2026 nurse of the year, Kathleen Jabasa. Kat’s career began at age 19 in the Philippines, where she followed in her mothers and her grandmother‘s footsteps to become a nurse. 

In 2019 after starting at St. Joseph’s Medical Center in Tacoma, she served as a local unit bargaining team member and grievance officer. While precepting new nurses, Kat began to question why she was paid less than nurses with less experience. At that time, international nurses from countries, including the Philippines, were only having half of their work experience counted, which placed them on a lower salary step. Kat brought her concerns to her local unit leadership and Washington State Nurses Association who helped her fight to change the policy.

Even though the policy change was successful, the hospital resisted re-stepping all 31 nurses impacted. Once again Kat advocated for herself and her fellow nurses, insisting the situation be remedied without further delay. Reflecting on this fight for equity, Kat said, ‘the victory is more than financial, it is a restoration of dignity, our pride and our rightful place in the field of nursing”.

Evelyn‘s career in nursing began as an LPN working on MedSurg at St Clare Hospital, where she found that she could really make a difference in her patient’s lives. It was this realization that inspired her to return to school to obtain her RN.

After becoming RN and working at St Clare, Evelyn took on leadership roles, first with staffing and nurse, practice, committees, and then cochair of the local unit. From there she moved on to leadership roles at WSNA. She served on the E&GW cabinet, WSNF board and the WSNA board directors as well as a delegate for the ANA house of delegates.

After leaving St Clare Hospital, Evelyn worked at Capital Medical Center in Olympia, where she found a new passion sharing her knowledge by providing education to fellow nurses to ensure best practices were followed.

Evelyn said the most important aspect of nursing, is to make a difference in a patient’s life. The way to make a difference in your patient’s life is to first make a difference in your workplace. Making a difference in a nurses work life gives them the confidence and competence to provide excellent care to patients.

Evelyn also became active in PCNA leadership. She served several terms on the board as a Director as well as two terms as president. During her presidency, PCNA began to evolve. She worked closely with the executive director to professionalize the association, putting in place policies and procedures implementing a new pointing grid for awarding scholarships, bringing in a bookkeeper to provide detailed monthly financial reports and the long process of transitioning the association from a 501(c) six to a 501(c) three organization.

In addition to serving on the board, Evelyn has served on the scholarship committee, finance committee, banquet committee, and is currently working as our newsletter editor.

When asked why she steps up to lead and why she stays involved, she shared that it’s not only about supporting her fellow nurses, but also to have fellowship with peers and also “to laugh at the end of a hard day”.

Mike’s journey to nursing began in 1983 as a medic in the Army to see if he really wanted to pursue healthcare. In 1984 Mike began working on a step down ICU unit at the old mannequin Army Medical Center Hospital.

Mike eventually found his way to working at good Samaritan Hospital in Puyallup, where he served as a local unit leave leader through several contract negotiations and as a local unit chair. He also stepped up to leadership roles at WSNA, where he served as a delicate for the ANA House of delegates conventions. Mike also served on the WSNA economic and general Wheeler welfare cabinet, including multiple terms as chair of the cabinet. During this time, mike also became a leader at PCNA Pierce County Nurses Association.

Over two decades Mike served terms on the board as a director as well as two stents as president, each lasting 4 to 8 years. Even after stepping back from being on the board of directors, he continued to serve as a committee chair for the banquet committee, which requires a very strong leader.

Mike’s quiet, and steady leadership has made our annual celebrations successful.

Mike has attended countless presentations to nursing students across our region, sharing the story of his nursing career with young and future nurses. In his words, he wanted them to know that “nursing is big enough that you can do anything you want”.

I would be remiss not to pause and offer a heartfelt thank you to our outgoing president, Tami Green. Tami’s leadership has been a gift to this association—her steady guidance, tireless advocacy, and genuine care for our members have left a lasting mark on everything RONA is today. Her years of service on the board reflect a deep commitment to nursing and to this community that we do not take for granted. Tami, on behalf of the entire membership, thank you. We are better because of you, and we wish you all the best in the chapter ahead- looking forward to your ongoing engagement in RONA!