On the first day of a massive nurses’ strike across 16 hospitals in Minnesota, Emily Kniskern and her daughter arrived outside the hospital where she works, St. Luke’s Duluth, at 6:30 in the morning. Her daughter soon left to go to school, but after cross-country practice, she came back to rejoin the picket line. Other nurses brought their kids too. One had 4-month-old triplets in onesies emblazoned each with one of the unions’ three letters: MNA. Kniskern spotted children whose births she assisted. “Our kids get care there; this is the hospital that we go to when we are sick or when we are hurt,” she noted. The kids “are reminders of why we’re doing this.”

The nurses were joined by firefighters, teachers, retired nurses, even elected officials. Other unions pulled up with coolers full of food and water. Community members thanked the nurses for the care they’ve gotten at St. Luke’s. Bubbles, a pet goat, walked the line. Kniskern brought her pug and, when she got tired, put her in a red union tote bag. “I wouldn’t call it necessarily a celebratory atmosphere—we mean business,” she said. But “people are trying to keep each other’s spirits up.”

Kniskern said her whole unit of about 55 nurses walked the picket line. But the numbers run much deeper. For three days in mid-September, 15,000 nurses in the Twin Cities, Twin Ports, and Moose Lake areas of Minnesota represented by the Minnesota Nurses Association went on strike, making theirs the largest private-sector nurses’ strike in the country’s history. “It feels powerful,” Kniskern said. “It also feels sad to know that it’s this bad all over.”

Nurses in other parts of the country, including Michigan and New York, are ready to go on strike too. Across the different unions, one issue has pushed them to this point: understaffing and the extreme workload they face as a result. The problem predates the pandemic; understaffing has been a problem in American hospitals for decades. In a survey conducted just before the pandemic began, over half of nurses already said they were experiencing high levels of burnout. Once Covid began spreading, as hundreds of media stories reported at the time, hospitals were strained to the breaking point to care for the influx of acutely sick patients. But as hospitalization numbers have fallen, nurses say hospitals have only continued cutting. “We’re all facing the same issues of this intentional corporate choice to cut staffing to the bone and just reap these massive profits on the backs of nurses,” Kniskern said. “The whole system runs off us just giving more and more and more and chewing people up and spitting them out.”

Kniskern had never been on strike before, and even some of her colleagues with decades of experience hadn’t, either. It was not a decision she took lightly. She worried about the impact on her patients, and on her finances. She’s a single parent, and, through tears, said that when her daughter started high school the week before the strike, she couldn’t afford to buy her new shoes.

“Sometimes we need to make a sacrifice in order to win something better when the current conditions are not tolerable,” she said. “You strike so you don’t quit.”

Wages are also important to the nurses, especially with inflation eating away at their earnings and after two and a half years of watching hospitals pay a high premium to hire travel nurses to work alongside them. Pay is intimately tied to the staffing problems, they argue. If hospitals don’t keep wages competitive, experienced nurses will continue to seek travel contracts or leave the field altogether. Ali Marcanti, a nurse who went on strike at United Hospital in St. Paul, has talked to “plenty of nurses that have said, ‘I would go without a wage [increase] if you fix the staffing concerns,” she said.

After two and a half years of the pandemic, nurses also know their worth and want to be recognized and valued for their work. Brianna Hnath, who has worked for 15 years at North Memorial Health Hospital in Robbinsdale, Minn., was a nurse in an intensive care unit when the pandemic started. “We were right in the thick of it,” she said. She and her coworkers showed up every day, picked up extra shifts, and sometimes gave patients care without the right protective equipment. “Knowing we were the ones that were in these rooms, we were the ones being asked to use the same mask for 10 shifts in a row [has] played a pretty big role in how empowered we are feeling,” she said.

The pandemic has fueled an uptick in labor militancy among nurses. There were 76 strikes in the health care industry between January 2021 and mid-April 2022, including a nearly year-long one at St. Vincent Hospital in Massachusetts, which might have been the longest nursing strike in the past three decades. And yet hospitals are still failing to give nurses the support and resources they need to adequately care for patients.

Marcanti started working at United Hospital almost seven years ago after leaving a hospital in North Dakota. There, the non-union hospital forced her to take on extra patients when her unit was understaffed. When she started at United, supervisors would ask her whether she could take on an extra patient. “I was blown away,” she said.

But conditions have gradually declined since then. The hospital underwent a “benchmarking process” in 2019 in which it compared itself to other hospitals in the area, she said, and after that nurses’ workloads increased as staff slimmed down. “With Covid, it just kind of went off the rails,” she said. Her hospital has since undergone two more staff reductions. Nurses’ assignments went from eight or nine patients to a dozen.

A spokesperson for Allina Health, which owns United Hospital, said in a statement that “Our nurses provide an informed perspective, and their expertise is, and always has been, an integral part of our staffing and operations decisions. However, what they continue to ask for with their staffing proposals is veto power over staffing decisions. That is incompatible with our ability to manage the overall complex operations of hospitals and deliver care to our patients and communities.”

“I’m going on strike because I don’t trust them to hold the same standards that I do for patient care, because I’ve seen it lapse in front of my face,” Marcanti said, her voice hoarse from chanting alongside hundreds of other nurses on the first say of the strike.

The initial acute crisis of the pandemic has faded, but in many hospitals the practices that were adopted on an emergency basis haven’t gone away. When Hnath’s hospital was overwhelmed with acutely sick patients during the Delta surge, people were on ventilators and needing ICU care for far longer than normal. Before the crisis, a nurse would have been assigned to just one patient that sick, but the volume of patients meant that practice was “thrown out the window,” she said. Safer practices haven’t returned even though things are calmer. Almost every shift she works, the team is short staffed by anywhere from five to 10 nurses, and if those slots don’t get filled Hnath and the others are asked to take on an extra patient. (A spokesperson from North Memorial Health Hospital wrote that “Staffing challenges are the result of unplanned sick time, personal and medical leaves, and most importantly unfilled positions. Recruiting and retaining nursing talent is a top priority and one we are continually addressing with urgency.”)

Kniskern has had a similar experience. Her team in maternal child health is typically three or four nurses short each shift, leaving anywhere from three to 12 patients without an assigned nurse. Every day, she said, she gets multiple texts from the staffing office asking more nurses to come in, and there are only a handful of times each year when shifts are fully staffed. “It’s extra scary when you’re already drowning and you look around and all of your coworkers and drowning and there’s no one to help you,” she said. She herself has begged coworkers to come in or to stay after their shift is over, denying them time with their families or the sleep that ensures they can provide quality care.

Kniskern is also making tough decisions in order to triage patients with so little staff. If there’s a newborn in one room going through heroin withdrawal and screaming, but another in a different room struggling to breathe, she has to attend to the second baby and leave the other to wait. “But when multiple people are crashing,” she noted, “we miss things.” Things get so bad that sometimes her hospital has to shut down the pediatric in-patient unit, forcing kids to either wait in the ER, be cared for on the adult floors, or go to the birthing center where “women are wandering the halls leaking amniotic fluid,” she said.

The worst shift she’s ever worked as a nurse, she said, was on August 1, when she didn’t have enough staff to take care of the people already in labor at the hospital. She had to call up patients who had been scheduled to come in and have their labors induced and tell them not to come. “Women say, ‘But my doctor says the baby needs to be born,’ and I’m saying, ‘I’m sorry, I don’t have enough nurses,’” she recalled. Anyone high-risk or experiencing troubling symptoms was told to come in, but they could only be put in a hospital room and monitored without being induced. She felt, she said, “panicked and desperate in the face of this rising tide of patient need.”

The three-day strike ended on September 15 and nurses across Minnesota went back to work. There hasn’t been movement from management yet, according to the union, but talks resumed the following week.

But the threat of a strike in Michigan may have already moved hospital management. Anne Jackson, a nurse at Michigan Medicine in Ann Arbor, said she and her coworkers, 96 percent of whom voted on September 3 to authorize a strike, were motivated by the same issues as the nurses in Minnesota. Her hospital, although technically a nonprofit, started about a decade ago to implement corporate cost-cutting measures. “We can’t do what we know we’ve done in the past because all of our resources have been stripped away,” she said.

“This system was broken well before the pandemic, and the pandemic has just decimated it,” she said. The hospital and emergency room are both at or over capacity, and people are coming in sicker than before, with Covid complications or having neglected preventative care in the early pandemic. But every day, shifts are understaffed. “Hospital administrations have been able to take advantage of the fact that we’re still a predominantly female workforce. We will give and give and give and give until we get to the precipice of the cliff, and then we’ll fall off of it,” she said. It’s not that there aren’t enough nurses out there. “There aren’t any nurses willing to work in these conditions.”

The hospital’s management has insisted that it doesn’t have to, and won’t, bargain with the nurses over staffing and nurses’ workloads. So the nurses were ready to strike over an unfair labor practice allegation that the university isn’t bargaining in good faith and must by law negotiate with them over staffing levels. The authorization vote “was a pretty definite signal that nurses are not tolerant of what the working conditions in the hospital are and they want management to stop violating their rights and come to the bargaining table in good faith,” said Renee Curtis, president of the Michigan Nurses Association. The union has also sought a legal injunction forcing management to bargain over staff ratios. A hospital spokesperson declined to comment but pointed to a press release in which the hospital said it had offered an end to mandatory overtime, a 6 percent raise in the first year of the contract and 5 percent for the next three, and “expanded staffing guidelines to maintain our excellent, industry-leading staffing levels .”

On September 21, the Michigan Nurses Association announced that it had reached a tentative agreement with the hospital that includes “an improved mechanism for enforcing contractual workload ratios,” according to the union’s press release, as well as an end to mandatory overtime and “competitive” wages. The nurses will now review the details and vote on whether to ratify it.

These strikes are all connected—literally so. “We’re all talking to each other, are you kidding me?” Jackson said. The national union, National Nurses United, held a call the week before Minnesota’s strike between those workers, Jackson and her coworkers, those in Wisconsin at UW Health who were set to go on strike but reached a deal to avert it, and nurses at Kaleida Health in Buffalo who voted to authorize a strike on September 15. “Our issues are all the same,” Jackson said. “This affects everybody. We went from being heroes to we all feel like zeroes now. Nobody is willing to invest in us.”

“We are part of the larger movement,” Curtis said. “I think you hear the scream throughout not only our state, but the nation.”

The scream just echoed in Buffalo, where 96 percent of nurses and other workers at Kaleida Health voted to authorize the strike. They, too, are most concerned with staffing. “We are fighting for a fair contract that will make safe staffing in our hospitals a reality,” said Jim Scordato, 1199SEIU vice-president for WNY Hospitals, in a statement. “We will not settle for understaffed facilities, burnout, and exhaustion as the status quo.” More than 6,300 nurses will participate in the strike if it does indeed take place.

Nurses are striking not just to improve their own lives but also to save the industry from itself. “What we’re doing is to better patient care but also our profession as nurses going forward,” Hnath said. “Because we don’t feel like there’s really anything else we can do.”

“This is a really pivotal moment for our profession,” she added.

Editor’s Note: An earlier version of this piece said that St. Luke’s Duluth has restricted access to its pediatric ER when the hospital is short-staffed. In fact, it is the pediatric in-patient unit that has at times limited access.