As coronavirus cases surge across the state and hospitalizations rise, 2,200 nurses across three hospitals in the Philadelphia region voted to authorize a strike if — among other issues — they couldn’t get their employers to commit to minimum staffing levels.

Another group of workers, the 260 nurses at Delaware County’s Mercy Fitzgerald Hospital, also authorized a strike but reached a deal with hospital owner Trinity Health. Nurses voted to ratify the contract Thursday evening. Details were not immediately available.

Nurses at three other hospitals — St. Mary Medical Center in Bucks County and Einstein Medical Center and St. Christopher’s Hospital for Children in Philadelphia — are still negotiating. The 800 nurses at St. Mary, who voted to join the nurses union PASNAP last year, will strike on Tuesday and Wednesday if they don’t reach a deal by then. Those at Einstein and St. Christopher’s have yet to send a 10-day strike notice to their employers.

Minimum staffing levels — limits on how many patients a nurse could be assigned during a shift — have been among the top issues for nurses around the state, including the roughly 4,000 nurses who unionized with PASNAP across the region in the last five years.

A coalition of nurses called the Nurses of Pennsylvania has been lobbying state lawmakers to pass a law mandating “safe patient limits," though the bill has yet to gain widespread support in the legislature. Now, the nurses at these four hospitals are seizing on a moment when health-care workers are not only in high demand but being called heroes.

Nurses say they have always dealt with staffing shortages, but the problems have gotten worse under COVID.

“Some of us were taking three patients at a time when we should never have more than two," Chelsea Rabena, a surgical and trauma ICU nurse at Einstein, said of her time working during the pandemic. “And sometimes these patients, they’re so sick, they’re meant to have one nurse.”

An Einstein spokesperson did not comment on staffing levels at the hospital. Einstein said in a statement that it is “committed to bargaining in good faith with PASNAP” and wants to reach an agreement without a strike, but that the hospital will remain “fully operational” and hire “licensed, experienced temporary replacement nurses” if a strike happens.

Trinity Health spokesperson Christy McCabe said St. Mary would also hire replacement nurses to stay open if nurses went on strike. The sticking point, she said, is not staffing, but wages.

“We are hearing concerns from our community that PASNAP, which has placed patient safety at the center of their platform, would choose this time — when the country and our local community contend with a COVID-19 surge — to exercise their right to strike,” McCabe said in a statement, adding that a two-day strike would actually last five days because it would take that long to transition from replacement nurses.

At St. Christopher’s, some children have been required to stay in its ICU and ER longer than they normally would because they’re waiting for a bed on a less acute floor — one that simply doesn’t have enough nurses to admit another patient, said Maria Plano, a pediatric ICU nurse and the vice president of the PASNAP nurses' local at the hospital.

“That’s dangerous, when you are running your staff really short — especially in the emergency department, you need those nurses ready,” Plano said.

A spokesperson for Tower Health said that the hospital follows staffing “principles” developed by the American Nurses Association and added that Tower Health believes staffing requirements “alone” in a collective bargaining agreement are “not an effective tool, since many variables impact effective staffing plans.”

Plano said she and her colleagues have been fighting for appropriate staffing levels since St. Christopher’s was bought by Tower Health and Drexel University last year. The nurses had won staffing standards in an earlier contract that was scrapped when the hospital was sold.

“If you have too many patients, you’re not able to give proper care,” she said.

That’s even more critical when caring for young children who may not understand why they’re in the hospital.

“With adults, I can reason with you — ‘Don’t pull your IV line out, don’t get out of bed,’” Plano said. “With a 4-year-old, that’s not going to work. Even for kids who aren’t super sick. It’s critical that we have enough nurses.”

Many of the issues in dispute, such as staffing problems and loss of sick time, existed before the COVID-19 pandemic hit, Plano said. But the pandemic has affected Tower’s finances to the point that the health conglomerate is now considering selling all its Philadelphia-area properties — exacerbating nurses' worry about staffing and budget cuts.

At Einstein, Rabena said nurses are asking for hazard pay for all nurses during the pandemic. During the first wave this spring, she said, only nurses who volunteered to work in COVID ICUs that the hospital set up were paid more. “Every nurse deserves that, because every nurse has dealt with this,” she said.

Rabena said voting for a strike had been a difficult decision for many Einstein nurses.

“None of us, truthfully, really, want to go on strike. We don’t want to do that to our community,” she said. “But we feel like there’s no other way of getting the administration to hear us and understand how we really feel about everything.”