It’s 7:00 a.m., and Clara Bucio is clocking in for her shift as a charge nurse in the Emergency Department (ED) of a small hospital in central Washington. She’s one of just five registered nurses staffing a nonstop rural ED sitting on the edge of the Yakama Indian Reservation. Together, Bucio and her colleagues form the frontline of care for a community whose health needs far exceed the resources available to meet them.
Bucio’s path to becoming a highly skilled Emergency Room (ER) nurse and a caregiver was in the cards long before she took a Certified Nurse Assistant course during her senior year of high school and donned hospital scrubs.
“I took care of my mom when she passed away from cancer,” Bucio said in an interview. “I was a CNA at the time and I had already graduated high school, and she told me that I needed to continue.”
Bucio’s mother died before Bucio could enter nursing school, but that loss became her anchor. The ED—with its rapid-fire pace, acute problem-solving, and steady stream of patients carrying every kind of crisis imaginable—felt like the place where she could put that promise into action.
As part of a multi-story series highlighting the registered nurse—known as the backbone of America’s healthcare system—Bucio and rural nurses like herself represent the thin line between access and abandonment in communities across the country. The U.S. is facing a projected shortage of up to 450,000 nurses by 2025, with rural areas hit hardest as hospitals close, consolidate, or downsize their emergency departments. Nearly 70 percent of rural counties now lack adequate healthcare workforce coverage, and patients in these communities are more likely to rely on Medicaid, face higher rates of chronic disease, and travel farther for basic care.
That national trend meets reality in this corner of central Washington, where nearly half of residents depend on Medicaid or Medicare, the uninsured rate pushes close to 17 percent, the median age sits under 30, and poverty hovers around 16-18 percent. The majority Latino/Latina population with close proximity to the Yakama Nation adds layers of language, transportation and insurance barriers that compound everyday emergencies and health concerns, and turn them into life-altering events.
Chronic conditions like obesity and diabetes outpace state norms in these parts, while the health workforce remains startlingly thin. In many local hospitals, there are just a handful of dedicated registered nurses, many whom believe their work is more of a calling and their long hours part of a social justice mission. They shoulder volume and absorb the complexity of the community’s healthcare needs. Their stories reflect a national reckoning over what it takes to keep rural America alive and cared for amid federal government cuts and state and local deficits.
A couple of floors up from Bucio, Julia Barcott is also clocking in for her shift on the Intensive Care Unit (ICU). While there might be a few patients there, the volume of work and the emotional toll are almost the same.
The ICU, staffed by Barcott and four of her day shift colleagues, manages some of the hospital’s sickest patients–those in respiratory failure, septic shock, cardiac crisis, or recovering from major trauma. Monitoring every drip, rhythm and vital sign around the clock, these registered nurses are often caretakers for the patients and their families during very turbulent times.
“We give care to people who have no other option,” Barcott said. “We are taking care of people and entire generations that had no idea that they’re diabetic and their blood sugar has been running high.”
While it is their primary job to care for the patient lying in bed, for Barcrott and her colleagues, the community’s health disparities have changed how they show up every day.
“We don’t just care for the patient, we incorporate everyone in their care community, including their family and friends,” Barcott said. “We are part of providing care to the entire generation. So we try to do preventative stuff for younger generations in these families, so they don’t end up with the same disease pattern and processes and the same unfortunate outcomes.”
Before joining the nursing profession nearly 30 years ago, Barcott began her professional career as a music educator in the Washington State public school system. While with her husband on an assignment in Alaska, where he purchased fish from the Tlingit people, Barcott was hired at a rural, remote clinic. She caught the medical bug far from a hospital setting as she quickly learned to treat and stabilize various medical emergencies.
Upon returning to Washington State, Barcott enrolled in nursing school. While attending school, she served as an EMT and a medical tech in the ER. After spending time on different hospital floors, Barcott believes that working in the ICU is her calling.
“The ICU has a significant amount of people who are dying, and I have always been honored to take care of people who are very ill and dying,” Barcott said. “And I’m very honored and feel driven to help the patient and their family through the process so that they can look back on it with good thoughts and it not be so traumatic.”
She continued, “I feel birth and death are all the same and just I feel very fortunate when someone chooses me to be able to participate in their end-of-life care. I think it’s a blessing.”
For Barcott, caring for critically ill patients also means honoring the multi-racial, multi-ethnic community the hospital serves. In the ICU and its connected step-down unit, Barcott has helped ensure that care reflects patients’ cultural and spiritual practices —from coordinating visits with tribal medicine men to arranging Spanish-language ministry and other forms of spiritual support that are essential to a patient’s healing.
“It’s a whole process and that’s what nursing is all about,” Barcott added. “We’re very holistic about the whole process. We practice it every day, and that is our profession.”
For Barcott and Bucio, nursing looks nothing like it did before the COVID-19 pandemic. The long-brewing nursing shortage—more than 20 years in the making—has accelerated, shrinking staff even as patient needs grow more complex.
They’ve also been on the frontlines of a widening affordability crisis: more Americans losing employer-based coverage, more patients delaying care, and rising comorbidities that walk straight through their doors.
All of it lands directly on the bedside, reshaping how nurses deliver care and how communities experience the health system.
“Healthcare is shifting, I feel like it is not centered on patient care anymore versus making money,” Bucio said. “Now we are being pushed into this system of getting the patient seen and getting them out and trying to make the most money off the patient during that time period. And as a result, patient care is suffering.”
Nursing expert Britney Daniels echoed those sentiments in a recent book.
“I was part of a system that kicks us in the mouth and forces us to shallow our teeth, rips the rug right out from underneath us and walks away as our skulls smack that floor,” Daniels says in “Journal of a Black Queer Nurse.” “ I would rather not draw air than be complicit in the disappointment that is our healthcare system.”
During an interview with Forbes, Daniels urged new nurses entering the field to ensure that health equity was at the center of their work.
“Health equity can’t just be something we teach; it has to be a rhythm in your chest and vow in your work and a commitment to care for every voice that has ever been ignored,” she said.
Back in the ICU, Barcott has put that notion to practice.
“We are social justice warriors,” she exclaimed. “We’re the first line and the last line for our patients, their families, and our coworkers, because we don’t just discharge someone and say, ‘Okay, here’s your prescriptions.’ We also find out, do they even have money or the ability to pay for the prescriptions?”
In the fight for their patients, union nurses Barcott and Bucio have also benefited from the power and protection that comes with a collective bargaining agreement.
Through the Washington State Nurses Association, they’ve helped secure major wins at the hospital and state levels—from raising wages and improving staffing language in local contracts to driving legislative reforms in Olympia. Those statewide victories include stronger protections against workplace violence in healthcare settings, new unemployment eligibility for healthcare workers during strikes or lockouts, and meaningful oversight of hospital mergers and closures to prevent cuts that undercut staffing or compromise patient care.
The Washington State Nurses Association is a member of the AFT Nurses and Health Professionals, the nation’s second-largest union in the country representing members of the profession.
So far, Trump’s One Big Beautiful Big and its Medicaid cuts, while a year or so out, have already begun to affect nurses and patients in central Washington state’s ED.
“I’ve questioned whether I want to continue working in the emergency department. I’ve had, you know, thoughts of switching to maybe doing teaching or something else,” Bucio said. “Every time I feel like that, I just keep grounding myself in our patients and the knowledge that I am making a difference.”
Three years ago, the hospital shut down its OB/GYN and labor-and-delivery unit, forcing pregnant mothers and high-risk families to travel miles for basic reproductive care. The closure hasn’t stopped desperate families from showing up anyway.
Nurses like Bucio do what they can in the ED—but they’re not equipped to deliver a baby or manage neonatal emergencies.
“We see pregnant women all the time who come to us, but it does put that additional stress,” she said. “As soon as you see someone check in and they’re pregnant, your wheels start turning.”
Losing that floor also made something else unmistakably clear: if a core service like labor and delivery could disappear overnight, the entire hospital—this community’s main lifeline—could be next.
Given all of that, Julia Barcott and Clara Bucio are still clocking in day after day for their community and their patients. That may also be part of the definition of nursing: showing up when everyone else has decided to leave.
During the final moment of our interview, Barcott urged lawmakers to make sure that nurses had a seat at the table.
But it wasn’t how one would suspect:
“I know everybody’s busy, lawmakers are busy, but it would be nice to actually be asked and be invited to the table, because we know what needs to be changed, and we’re willing to step up and help.”