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    Voters reject Question 1, which would have mandated nurse staffing levels

    CANTON — Massachusetts voters rejected a ballot measure Tuesday that would have set strict limits on the numbers of patients assigned to hospital nurses, following a bruising and costly campaign that pitted nurses against hospital administrators — and nurses against nurses.

    The ballot question was as passionately fought as it was difficult for many voters to decipher. The result was a blow to the Massachusetts Nurses Association, a labor union that sponsored the measure and had argued that limits were needed to ensure that patients were receiving safe care.

    A coalition led by the hospital industry fought Question 1, saying it was overly rigid and would come with enormous costs. Opponents warned that hospitals would have to scale back on important medical services — or perhaps, close altogether — if the question passed.

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    About 70 percent of voters rejected the ballot question, while 30 percent voted in favor.

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    “We are all disappointed by tonight’s results and the impact this will have on the patients we care for every day,” Donna Kelly-Williams, president of the nurses union, told reporters just after 9 p.m. in the group’s Canton headquarters, surrounded by dozens of nurses and other supporters.

    “We know that right now — as I speak to you here — there are nurses caring for too many patients, and those patients are unnecessarily being put in harm’s way. . . . The status quo is not a solution here,” Kelly-Williams said. She left the podium without taking questions.

    Some nurses teared up, and others hugged after Kelly-Williams spoke.

    In Burlington, Steve Walsh, president of the Massachusetts Health & Hospital Association, said, “What we won tonight was the ability to continue providing the best possible care for patients throughout Massachusetts.”

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    “All you ever win in an election is an opportunity,” Walsh said. “We may not agree on everything, but together we have made Massachusetts health care the best in the nation, and together we will make it even stronger tomorrow.”

    Opponents quickly started working toward reconciliation. As the votes appeared to be heading in their favor Tuesday night, campaign staff at the hospital association headquarters in Burlington pulled down signs imploring voters to vote “No on 1.” In their place, the workers paneled a wall with signs that said, “Working as 1 For Patients.”

    A few minutes later, a cheer erupted inside the room where campaign workers had gathered.

    Neither campaign wanted cameras in the rooms where staff and volunteers were meeting.

    The election result was not a complete surprise, as polls indicated that most voters opposed the measure.

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    An independent state watchdog agency, the Massachusetts Health Policy Commission, said in a report last month that Question 1 would require hospitals to hire as many as 3,101 additional nurses and could cost the state health care system more than $900 million a year.

    The controversial issue even divided nurses. Some believed mandated caseload limits would allow them to take better care of each patient. Others argued the ballot measure would strip them of the ability to use their professional judgment.

    Hospitals spent nearly $25 million to try to defeat the ballot measure, more than double the roughly $12 million spent by the union to promote the question. Much of that money was spent on television advertising. Hospitals ran several ads that warned Question 1 would cause delays for sick children and adults who go to the emergency room.

    Volunteers and staff for both campaigns spent the final days before the election making calls and knocking on doors to make their case to voters, including in Tuesday’s driving rain.

    Kate Norton, a spokeswoman for the “Yes” campaign, said earlier Tuesday that 1,850 volunteers were working to get out the vote. Campaign volunteers found that many voters were still undecided just before the election, Norton said.

    The “No on 1” campaign also dispatched volunteers to polling locations across the state on Tuesday.

    Each campaign said it distributed more than 30,000 lawn signs.

    The ballot question seemed to draw many voters to the polls.

    Framingham voter Nicole Gallagher said she opposed the measure.

    “You can’t regulate something as complicated as this,” said Gallagher, 34. “Health care’s not a factory.”

    Michelle Resendes, 46, a registered nurse at Norwood Hospital, wore a sticker on her shirt in support of Question 1 as she made her way to the polls at North Attleborough High School.

    “I think it’s the safest thing for patients,” she said.

    Brockton voter Windsor Lindor, 34, said the nurses issue was the hardest one on the ballot for him — and his wife is a nurse. After seeking input from her, he said, he voted no.

    “I just didn’t want to change the status quo,” Lindor said at the War Memorial building on West Elm Street.

    Many voters had felt confused about how to vote and wondered why such a complicated issue was on the ballot at all.

    The nurses union has pushed for legislation to set patient limits for two decades. In 2014, the union won a compromise: limits in intensive care units. ICU nurses are now restricted to one or two patients at a time. But Massachusetts lawmakers never backed a broader nurse staffing bill.

    Governor Charlie Baker opposed Question 1. Some Democrats in the Legislature also came out against the ballot question.

    Baker’s opponent, Democrat Jay Gonzalez, supported the ballot measure, as did other prominent Democrats including Boston Mayor Martin J. Walsh and Senator Elizabeth Warren.

    Hospital officials argued that they need flexibility to staff their units because it’s hard to predict when patient numbers are going to rise or fall — particularly in the emergency room. But union officials said nurses are routinely saddled with too many patients, increasing the likelihood of delays and errors.

    California is the only state that mandates patient limits, also known as nurse-to-patient ratios. The California law, implemented in 2004, is less strict than the Massachusetts ballot question, and studies about the effect of the law are mixed. Some studies found improvements in outcomes after the patient limits went into effect, while others did not.

    Question 1 would have required hospitals to adhere to patient limits at all times of day and night, including when nurses take meal breaks. Nurses taking care of medical and surgical patients would have been limited to four patients each.

    Correspondent Morgan Hughes contributed to this report. Priyanka Dayal McCluskey can be reached at priyanka.mccluskey@globe.com. Follow her on Twitter @priyanka_dayal. Andy Rosen can be reached at andy.rosen@globe.com. Follow him on Twitter @andyrosen.