A strike by as many as 15,000 Twin Cities and Duluth hospital nurses might be days or weeks away, but the battle for public opinion is already underway.

Pickets and votes of no confidence in hospital leadership this summer have been part of the nurses' efforts to build support before they leave the bedside — a move that could leave hospitals understaffed and delay or jeopardize patient care.

"The public perception is just about everything," said Alan Benson, an assistant professor at the University of Minnesota's Carlson School of Management. "This union is asking its members to plant a sign on their doorstep and tell the world — tell their neighbors, tell anyone who will listen — that 'we are in the right here.' They're not going to do that if the public's not on their side."

The Minnesota Nurses Association (MNA) has yet to announce the start and duration of a strike against the Allina, Children's and Fairview hospital systems along with Methodist Hospital in St. Louis Park and North Memorial in Robbinsdale. Strikes also are looming against Essentia Health and St. Luke's in Duluth, with required 10-day notices being the next step.

The public's role will be indirect compared to strikes targeting restaurants such as Starbucks or retailers such as Amazon — when people can lend support to one side or another by what they buy. Patients can exert some influence by choosing whether to use hospitals under strike for elective surgeries, but mostly they go where ambulances take them, their doctors have operating privileges or insurers have in-network coverage.

Currying public support is even more important, because people won't tolerate prolonged disruptions to hospitals, said Kate Bronfenbrenner, director of labor education research at Cornell University's School of Industrial and Labor Relations in New York. Nurses and hospital leaders can expect strong opinions from neighbors and even friends and relatives.

"You're more likely to apply pressure," she said, if hospitals and nurses can't come to terms.

The hospitals and nurses remain far apart on terms of a new three-year contract — with the old one expiring May 31 for Twin Cities nurses and June 30 for Duluth nurses. The nurses have asked for more than 30% increases in compensation over three years to keep pace with inflation and incentivize burned-out colleagues to stay in the profession after an exhausting pandemic. Hospitals are offering to increase pay by more than 10%.

Nurse leaders believe they have the advantage, partly because of their sacrifices during the pandemic when so many patients depended on them. A March survey of Minnesotans found that 84% had favorable impressions of nurses. While only 55% had favorable impressions of the MNA, that was better than 11% for hospital executives, according to the union-funded poll.

Public support for labor in general increased after the pandemic — with Gallup polling finding that 68% of Americans approved of unions in 2021, up from 48% in 2009.

The MNA has seized on the timing, organizing the first-ever picket by Hennepin Healthcare nurses — who called for some of the same expansions in benefits and staffing that their colleagues at other Twin Cities' hospitals are seeking through contract negotiations. The union also organized a strike vote of 50 nurses in Moose Lake, Minn., who have been in a contract standoff for two years since Essentia Health took over their hospital.

Nurse Chris Rubesch said the timing is less about public polls and more about the need for changes before colleagues flee the profession and leave hospitals dangerously short-staffed. A poll this summer by the Illinois Economic Policy Institute found that more than half of hospital nurses are thinking of quitting in the next year.

"Nurses understand: if we don't address this crisis now, we might not have another chance," said Rubesch, a cardiac nurse at St. Marys in Duluth and an MNA vice president.

Negotiating hospitals haven't been as public yet with their arguments, but a spokesman said their case is equaling compelling to people struggling with inflation.

People should value nurses, but also the nonprofit health systems that are posting multimillion losses this year and can't afford large pay bumps without passing costs to patients, said Paul Omodt, a spokesperson for all the negotiating Twin Cities hospital systems other than Allina.

"If you look at nursing salaries in the country, Minnesota is always in the top 10. We're higher than any of our neighboring states and we intend to keep it that way," he said. "Our proposals already will keep us in the highest top 10. That's a strategy for recruiting nurses, retaining nurses."

Negotiation sessions are scheduled yet this month — with a strike no longer possible until after Labor Day. Hospitals have asked to bring in federal mediators to try to reach a compromise.

A strike usually results from a miscalculation by one side in the strength of its position, said the U's Benson, but in this case "it's really hard to tell who is making the miscalculation."

Strikes are costly for hospitals that have to hire replacement nurses at double the wages plus travel and training expenses. Allina reported $149 million in costs from nursing strikes over 44 days in 2016.

The MNA is planning to base the strikes on claims of unfair labor practices. If upheld by the National Labor Relations Board, those designations would compound costs for hospitals by requiring them to take back striking nurses and provide back pay for delays in returning them to their jobs. The union also is planning a time-limited strike of one or a few days, because it threatens the hospitals economically but limits the potential for patient harm, said Mary Turner, a North Memorial nurse and MNA president.

A 2010 study by the National Bureau of Economic Research found about a 19% increase in patient mortality and a nearly 7% increase in readmissions during nursing strikes.

Rubesch said the nurses would be striking in order to improve care long-term. The union has asked hospitals for changes in staffing levels to improve patient supervision and for furlough and educational benefits to help nurses cope with stress and avoid burnout.

The union has publicly demanded safer staffing levels before, including in 2010 when all of the Twin Cities nurses engaged in a one-day strike. Many of those demands were set aside, though, when the nurses agreed to a contract that preserved health and pension benefits.

Bronfenbrenner said a contract is just a first step and an effective union campaign can achieve more than those written terms. A French researcher found that workers who "lost" in protracted strikes ended up gaining benefits over time because employers quietly wanted to avoid future confrontations.

"If the union is doing a community campaign, the employer often makes changes that just don't get written in the contracts," she said "It's all dependent on the effectiveness of the campaign."