Picket signs and strike chants rose precisely at 7 a.m. Monday outside 15 Twin Cities and Duluth hospitals, where as many as 15,000 nurses walked off their jobs for three days in protest over pay and staffing levels.

Early risers at the M Health Fairview Southdale Hospital in Edina were joined on picket lines by tired nurses in scrubs rotating off overnight shifts. Transition plans to separate the striking nurses fell apart in some cases, leaving them doing face-to-face handoffs of patients with their temporary replacements.

Veteran intensive care nurse Deb Shirley said it was unnerving, because her replacement was caring but didn't do a neurological assessment of a patient properly.

"I don't have a clue about what they do or don't know," she said.

The protest, which ends at 7 a.m. Thursday, involves nurses from Allina, Children's and Fairview hospitals in the Twin Cities along with HealthPartners' Methodist Hospital in St. Louis Park and North Memorial Health in Robbinsdale. Nurses are also on strike at St. Luke's and Essentia Health hospitals in Duluth and Superior, Wis.

The hospitals hired thousands of temporary nurses, often at double the usual wages or more, to maintain patient care during the strike. Twin Cities hospitals in a statement Monday asked for patience because it could take them longer to triage patients. However, they urged patients with emergency needs to call 911 or go to their nearest emergency department as usual.

The strike followed months of failed negotiations — with nurses asking for about 30% pay increases over three years to improve retention and prevent colleagues from quitting and leaving hospitals chronically understaffed.

Hospital systems responded with increases of about 10% over three years, noting that most of them are experiencing financial losses right now and that larger increases would be passed to patients through their health insurance.

"The union … held fast to wage demands that were unrealistic, unreasonable and unaffordable," said a statement from Twin Cities hospital systems other than Allina, which handles its strike communications separately.

Picketing nurses said wage hikes are important, but that more consistent staffing levels are key. Second-year nurse Madi Gay said she had reduced her nursing hours at Southdale over the stress and the threat to her livelihood of being asked to care for too many patients at once.

"How long can you keep this up?" she said. "My license is on the line."

The rate of nurses leaving hospital care has accelerated, said Larissa Hubbartt, an intensive care nurse at St. Luke's. "The trauma of working short, what we see on a daily basis, it adds up over time. There is no relief. We used to have a bad day now and then. Now, on a day when we have the appropriate staff, you feel guilty almost. Because you can take a lunch break."

Angie Nolle joined the Essentia picket line Monday after working for 16 hours in a behavioral health unit at St. Mary's Medical Center in Duluth. She was only scheduled for eight but picked up a second overnight shift when the unit was short two nurses.

"We do that to help our patients … and we are feeling the brunt of it," she said.

Negotiators for the Minnesota Nurses Association, the union representing the nurses, acknowledged that high wage demands could end up as a bargaining chip to gain staffing guarantees.

"We have very little interest in decreasing our offer any more until our hospital talks to us about staffing. That's what's important," said Melisa Koll, a nurse at Children's in St. Paul who is part of the negotiating team.

The nurses are working under old contracts that expired May 31 in the Twin Cities and June 30 in Duluth. First-year nurses with baccalaureate degrees are making about $36 per hour at Twin Cities hospitals, while those with 10 years of experience are making around $51.

No negotiation sessions are planned this week during the strike.

The strike is occurring amid relative stability for Minnesota hospitals. Federal data on Monday showed 9,337 staffed hospital beds in Minnesota that were filled by 7,955 patients, about average for the past month. The admissions included 437 adults with confirmed COVID-19, below the peak of 1,893 in October 2020.

Union leaders said staffing concerns predated COVID-19 but that the pandemic has influenced the strike in other ways. Hospital leaders said it forced them to become more nimble at training new nurses and adjusting to staff turnover, which is helping now.

Kate Zach, a Southdale intensive care nurse, said her decision to strike was influenced by the exhaustion of the pandemic. She recalled racing many times to don protective gear before going into rooms to try to save patients in cardiac arrest.

"I want to get paid for the hell of the last two years," she said.

Several suburban hospitals do not employ union nurses and are not involved. Allina's Abbott Northwestern, Mercy and United hospitals are under strike, but its Buffalo and Cambridge hospitals are not. M Health Fairview's Riverside campus of the University of Minnesota Medical Center is under strike along with Southdale and St. John's, but Ridges Hospital in Burnsville and Lakes Medical Center in Wyoming are not. North Memorial's Maple Grove Hospital also isn't under strike.

The major adult trauma center at North Memorial is the only one of three in the Twin Cities involved in the strike. Hennepin County Medical Center in Minneapolis and Regions Hospital in St. Paul had on-call staff available this week if patient demand increased.

The picket line was festive as the morning sun rose at North Memorial. One volunteer on the sidewalk flipped pancakes on a griddle. Another in a red tutu used a microphone to serve as music DJ, but also traffic cop if nurses spilled off the public sidewalk onto hospital property. The nurses said they hoped the collective strike by so many colleagues at once would motivate change.

MNA leaders have billed the labor action as the largest private sector nursing strike in U.S. history, though that is difficult to confirm. A federal database of strikes since 1993 showed one involving more than 15,000 nurses against Kaiser Permanente in California in 1997. However, news reports at that time showed smaller numbers of nurses involved. Experts at the Cornell University School of Industrial and Labor Relations were uncertain.

The addition of 2,500 nurses from Duluth makes it the largest such action in Minnesota, ahead of the one-day strike in 2010 by Twin Cities nurses. About 4,800 Allina nurses went on two strikes for a collective 44 days in 2016 over health benefits.