Massachusetts Question 1, Nurse-Patient Assignment Limits Initiative (2018)

Elections in Massachusetts, 2018

* General election: Nov. 6
* Voter registration deadline: Oct. 17
* Early voting: Oct. 22 - Nov. 2
* Absentee voting deadline: Nov. 6

* Online registration: Yes
* Same-day registration: No
* Voter ID: No ID required generally
* Poll times: 7:00 a.m. to 8:00 p.m.

* * *

On the ballot: U.S. Senate • U.S. House • Governor • Attorney General • Secretary of State • State executive offices • State Senate • State House • Special state legislative • State ballot measures • Municipal • Democratic primaries • Republican primaries

Massachusetts Question 1

Election date
November 6, 2018
Topic
Healthcare
Status
d Defeated
Type
State statute| Origin
Citizens

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List of Massachusetts measuresMassachusetts Question 1Massachusetts Question 2Massachusetts Question 3Submit

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## Contents

* 1 Election results
* 2 Overview
* 2.1 What would Question 1 have changed?
* 2.2 Nurse assignment regulations in Massachusetts
* 2.3 Campaigns for and against Question 1
* 2.4 Past measures sponsored by the Massachusetts Nurses Association
* 3 Measure design
* 3.1 Patient assignment limits
* 3.2 Enforcement and penalties for violations
* 4 Text of measure
* 4.1 Ballot question
* 4.2 Ballot summary
* 4.3 Full text
* 4.4 Readability score
* 5 Support
* 5.1 Supporters
* 5.2 Arguments
* 5.2.1 Official argument
* 5.3 Campaign advertisements
* 6 Opposition
* 6.1 Opponents
* 6.1.1 Elected officials
* 6.1.2 Health and nursing organizations
* 6.1.3 Chambers of commerce
* 6.1.4 Massachusetts hospitals
* 6.1.5 Individuals
* 6.2 Arguments
* 6.2.1 Official argument
* 6.3 Campaign advertisements
* 7 Media editorials
* 7.1 Support
* 7.2 Opposition
* 7.2.1 Other opposing media editorials
* 8 Campaign finance
* 8.1 Support
* 8.1.1 Donors
* 8.2 Opposition
* 8.2.1 Donors
* 8.3 Methodology
* 9 Polls
* 10 Background
* 10.1 Nurse assignment limits in Massachusetts, 2014 initiatives
* 10.2 Nurse assignment limits in other states
* 10.2.1 Nurse staffing regulations in California
* 11 Reports and analyses
* 11.1 Massachusetts Health Policy Commission
* 11.2 Judith Shindul-Rothschild of Boston College
* 11.3 The Massachusetts Behavioral Health System
* 11.4 BW Research Partnership and Mass Insight Global Partnerships
* 11.5 Anderson Robbins Research (commissioned by MNA)
* 12 Path to the ballot
* 12.1 Details about this initiative
* 12.2 Lawsuit
* 13 See also
* 14 External links
* 14.1 Support
* 14.2 Opposition
* 15 Footnotes

Massachusetts Question 1, the Nurse-Patient Assignment Limits Initiative, was on the ballot in Massachusetts as an indirect initiated state statute on November 6, 2018. It was defeated.

|  A yes vote supported establishing patient assignment limits for registered nurses working in hospitals.

|

|  A no vote opposed this initiative to establish patient assignment limits for registered nurses working in hospitals, thereby leaving the existing laws and rules in place.

|

## Election results[edit]

Massachusetts Question 1

Result | Votes | Percentage
Yes | 787,511 | 29.76%

| 1,858,483 | 70.24%

Results are officially certified.
Source

## Overview[edit]

### What would Question 1 have changed?[edit]

Question 1 was designed to establish patient assignment limits for registered nurses working in hospitals. Limits would have been determined by the type of medical unit or patient with whom a nurse is working, and the maximum numbers of patients assigned determined by the limits would have applied at all times except during a public health emergency as declared by the state or federal government. The measure would have required these patient limits to be met without reducing staff levels, such as service staff, maintenance staff, or clerical staff.

The measure would have required the Massachusetts Health Policy Commission to write regulations to implement and enforce the initiative. Under the measure, the commission could have conducted inspections of facilities to ensure their staffing ratios comply with the initiative. The commission would have been required report violations to the office of the attorney general. The commission could have reported violations to the state attorney general. The office of the attorney general could have filed suit in superior court to obtain an injunction for compliance with the initiative and civil penalties of up to $25,000 per violation.

### Nurse assignment regulations in Massachusetts[edit]

Going into the election, the state of Massachusetts did not regulate the number of patients nurses can be assigned in private hospital emergency rooms, surgical units, maternity wards or psychiatric units, though the state did regulate the number of patients a nurse can be assigned in an intensive care unit. This requirement applies to all licensed intensive care units whether they are privately or publicly owned, or receive public funds.[1] In 2014, the Massachusetts legislature passed HB 4228, which stipulates that nurses in intensive care units can be assigned a maximum of two patients at one time.

### Campaigns for and against Question 1[edit]

Ballotpedia identified one ballot measure committee, the Committee to Ensure Safe Patient Care, registered in support of Question 1. The committee raised $12.04 million and spent the same. The committee was supported by the Massachusetts Nurses Association, which contributed $11.96 million (96.28 percent of the total contributions).

Ballotpedia identified one ballot measure committee, the Coalition to Protect Patient Safety, registered to oppose Question 1. The committee raised $26.48 million and spent $26.41 million. The committee was supported by the Massachusetts Health and Hospital Association, which contributed $25.18 million (93.53 percent of the total contributions).

According to state campaign finance officials The Coalition to Protect Patient Safety spent $24.7 million into efforts opposing Question 1, breaking a state record for ballot measure campaign spending. The Coalition to Protect Patient Safety beat the record $21.6 million spent by the Great Schools Massachusetts Committee, which supported an unsuccessful ballot question, Question 2 of 2016 to expand charter schools in Massachusetts.[2]

### Past measures sponsored by the Massachusetts Nurses Association[edit]

In 2014, the Massachusetts legislature passed HB 4228, which stipulates that nurses in intensive care units can be assigned a maximum of two patients at one time. The legislation was passed in response to two initiatives proposed that same year by the Massachusetts Nurses Association. One initiative would have placed more stringent caps on nurse-to-patient ratios in intensive care units. The other  initiative would have regulated the annual operating margins, chief executive officer compensation, and financial asset disclosures of hospitals and certain other health-care facilities that accepted public funds. The CEO compensation initiative was supported by the Massachusetts Nurses Association and opposed by the Massachusetts Health and Hospital Association, mirroring the support and opposition campaigns of Question 1. Both 2014 initiatives were withdrawn in response to a compromise that resulted in the legislature passing HB 4228.[3][1]

## Measure design[edit]

### Patient assignment limits[edit]

Question 1 was designed to establish patient assignment limits for registered nurses working in hospitals. Limits would have been determined by the type of medical unit or patient with whom a nurse is working, and the maximum numbers of patients assigned determined by the limits would have applied at all times except during a public health emergency as declared by the state or federal government. The measure would have required these patient limits to be met without reducing staff levels, such as service staff, maintenance staff, or clerical staff.[4][4][5]

The patient assignment limits under the measure would have been as follows:[4]

Patients allowed |  Types of patients

|

One patient per nurse  |

* caring for a patient under anesthesia
* in critical care or intensive care units (two patients in stable condition)
* caring for active labor patients, patients with intermittent auscultation for fetal assessment, and patients with medical or obstetrical complications
* caring for a patient during birth and up to two hours after birth
* caring for a baby during birth and up to two hours after birth

Two patients per nurse  |

* caring for post-anesthesia patients
* caring for urgent non-stable patients
* caring for babies in intermediate care or continuing care units

Three patients per nurse  |

* in step-down or intermediate care units
* caring for urgent stable patients

Four patients per nurse  |

* caring for pediatric patients
* in medical, surgical, and telemetry units
* in observational and outpatient units
* in units not otherwise listed above

Five patients per nurse  |

* caring for non-urgent stable patients
* caring for psychiatric patients
* in rehabilitation units

Six patients per nurse  |

* caring for uncomplicated mothers or babies postpartum;
* caring for well-baby patients.

### Enforcement and penalties for violations[edit]

The measure would have required the Massachusetts Health Policy Commission to write regulations to implement and enforce the initiative. As of 2018, the Health Policy Commission was an independent state agency established in 2012 with a mission to "provide data-driven policy recommendations regarding health care delivery and payment system reform and advance a more transparent, accountable, and innovative health care system through independent policy leadership and investment programs."

Under the measure, the commission would have been empowered to inspect of facilities to ensure their staffing ratios comply with the initiative. The commission would have been required to report violations to the office of the attorney general. The commission would have reported violations to the state attorney general. The office of the attorney general would have been authorized to file suit in superior court to obtain an injunction for compliance with the initiative and civil penalties of up to $25,000 per violation. Each day that a violation continued after a facility had been given notice of the violation would have been considered a separate and distinct violation subject to the same $25,000 penalty.[4]

Facilities covered by the initiative would have been required to post notices with language drafted by the commission with information about the patient limits. The notices would have been posted in all units, patient rooms, and patient areas. The commission would be required to set up a phone number and website for the submission of complaints about the violation of the initiative. A facility that refused to comply with the posting requirements would be subject to civil penalties of between $250 and $2,500 for each day of non-compliance.[4]

The enforcement of the initiative would have been suspended during a public health emergency as declared by the state or nationally.[4]

## Text of measure[edit]

### Ballot question[edit]

The ballot question was as follows:[6]

“  |

Do you approve of a law summarized below, on which no vote was taken by the Senate or the House of Representatives on or before May 2, 2018?[7]

|  ”

|
|

### Ballot summary[edit]

The ballot summary was as follows:[6]

This proposed law would limit how many patients could be assigned to each registered nurse in Massachusetts hospitals and certain other health care facilities. The maximum number of patients per registered nurse would vary by type of unit and level of care, as follows:

* In units with step-down/intermediate care patients: 3 patients per nurse;
* In units with post-anesthesia care or operating room patients: 1 patient under anesthesia per nurse; 2 patients post-anesthesia per nurse;
* In the emergency services department: 1 critical or intensive care patient per nurse (or 2 if the nurse has assessed each patient’s condition as stable); 2 urgent non-stable patients per nurse; 3 urgent stable patients per nurse; or 5 non-urgent stable patients per nurse;
* In units with maternity patients: (a) active labor patients: 1 patient per nurse; (b) during birth and for up to two hours immediately postpartum: 1 mother per nurse and 1 baby per nurse; (c) when the condition of the mother and baby are determined to be stable: 1 mother and her baby or babies per nurse; (d) postpartum: 6 patients per nurse; (e) intermediate care or continuing care babies: 2 babies per nurse; (f) well-babies: 6 babies per nurse;
* In units with pediatric, medical, surgical, telemetry, or observational/outpatient treatment patients, or any other unit: 4 patients per nurse; and
* In units with psychiatric or rehabilitation patients: 5 patients per nurse.

The proposed law would require a covered facility to comply with the patient assignment limits without reducing its level of nursing, service, maintenance, clerical, professional, and other staff.

The proposed law would also require every covered facility to develop a written patient acuity tool for each unit to evaluate the condition of each patient. This tool would be used by nurses in deciding whether patient limits should be lower than the limits of the proposed law at any given time.

The proposed law would not override any contract in effect on January 1, 2019, that set higher patient limits. The proposed law’s limits would take effect after any such contract expired.

The state Health Policy Commission would be required to promulgate regulations to implement the proposed law. The Commission could conduct inspections to ensure compliance with the law. Any facility receiving written notice from the Commission of a complaint or a violation would be required to submit a written compliance plan to the Commission. The Commission could report violations to the state Attorney General, who could file suit to obtain a civil penalty of up to $25,000 per violation as well as up to $25,000 for each day a violation continued after the Commission notified the covered facility of the violation. The Health Policy Commission would be required to establish a toll-free telephone number for complaints and a website where complaints, compliance plans, and violations would appear.

The proposed law would prohibit discipline or retaliation against any employee for complying with the patient assignment limits of the law. The proposed law would require every covered facility to post within each unit, patient room, and waiting area a notice explaining the patient limits and how to report violations. Each day of a facility’s non-compliance with the posting requirement would be punishable by a civil penalty between $250 and $2,500.

The proposed law’s requirements would be suspended during a state or nationally declared public health emergency.

The proposed law states that, if any of its parts were declared invalid, the other parts would stay in effect. The proposed law would take effect on January 1, 2019.

A YES VOTE would limit the number of patients that could be assigned to one registered nurse in hospitals and certain other health care facilities.

A NO VOTE would make no change in current laws relative to patient-to-nurse limits.

|

### Full text[edit]

The full text of the measure is as follows:[8]

SECTION 1. SECTIONS 2 through 4 below, along with section 231 of Chapter 111 of the General Laws, shall hereby be known as "The Patient Safety Act."

SECTION 2. Chapter 111 of the General Laws is hereby amended by adding the following sections after section 231:

Section 231 A. Definitions.

As used in sections 231 through 231J the following words shall have the following meanings:

"Patient assignment", a person admitted to a facility where a registered nurse accepts responsibility for the patient's direct nursing care. A patient must be assigned to a registered nurse at all times.

"Complaint", any oral or written communication by a patient, medical professional, facility or any of its employees that a facility has violated any term or condition of this act.

"Facility", a hospital licensed under section 51 of this chapter, the teaching hospital of the University of Massachusetts medical school, any licensed private or state-owned and state-operated general acute care hospital, an acute psychiatric hospital, an acute care specialty hospital, or any acute care unit within a state operated healthcare facility. This definition shall not include rehabilitation facilities or long-term care facilities.

"Health Care Workforce", personnel employed by or contracted to work at a facility that have an effect upon the delivery of quality care to patients, including but not limited to registered nurses, licensed practical nurses, unlicensed assistive personnel, service, maintenance, clerical, professional and technical workers, and all other health care workers.

"Nursing care", care which falls within the scope of practice as defined in Section SOB of Chapter 112 of the General Laws or is otherwise encompassed within recognized standards of nursing practice, including assessment, nursing diagnosis, planning, intervention, evaluation and patient advocacy.

"Violation", any failure by a facility to abide by a term or condition of this act.

"Written Implementation Plan", a written plan detailing both the maximum number of patients to be assigned at all times to a registered nurse in each of the units enumerated in section 231C as well as concurrently detailing the facility's plans to ensure that it will implement such limits without diminishing the staffing levels of its health care workforce.

Section 23IB: Concurrently with establishing and enforcing the maximum patient assignment limits enumerated in Section 231C below, each facility shall submit a written implementation plan to the Massachusetts Health Policy Commission certifying that it will implement the patient assignment limits without diminishing the staffing levels of its health care workforce.

Section 231C: It is the right of every patient in a facility to nursing care deemed safe by the registered nurse who has accepted responsibility for his or her care. It is the responsibility of each facility to provide the resources necessary to support the safe patient limits enumerated in this section. The maximum number of patients assigned at all times to a registered nurse in a facility shall not exceed the limits enumerated in this section. Nothing shall preclude a facility from assigning fewer patients to a registered nurse than the limits enumerated in this section; provided, however, that no such assignment shall result in a reduction in the staffing level of the health care workforce assigned to the facility's patients.

The patient assignment limits shall be as follows:

a. In all units with step-down/intermediate care patients, the maximum patient assignment of step-down/intermediate patients is three (3). Step-down/intermediate care patients are those patients that require an intermediate level of care between the intensive care unit and general medical surgical unit.

b. In all units with post anesthesia care (PACU) patients, the maximum patient assignment of PACU patients under anesthesia is one (1). The maximum patient assignment of PACU patients post anesthesia is two (2).

c. In all units with operating room (OR) patients, the maximum patient assignment of OR patients under anesthesia is one (1). The maximum patient assignment of OR patients post anesthesia is two (2).

d. In the Emergency Services Department:

(1) The maximum patient assignment of critical care or intensive care patients is one (1). A registered nurse may accept a second critical care or intensive care patient if that nurse assesses that each patient's condition is stable.

(2) The maximum patient assignment of urgent non-stable patients is two (2). A patient is in an urgent non-stable condition when prompt care of the patient is necessary within fifteen to sixty minutes.

(3) The maximum patient assignment of urgent stable patients is three (3). A patient is in an urgent stable condition when prompt care of the patient is necessary but can wait up to three hours if necessary.

(4) The maximum patient assignment of non-urgent stable patients is five (5). A patient is in a non-urgent stable condition when the patient has a condition or conditions that need attention, but time is not a critical factor.

e. In all units with maternal child care patients:

(1) The maximum patient assignment of active labor patients, patients with intermittent auscultation for fetal assessment, and patients with medical or obstetrical complications is one (1) patient.

(2) The maximum patient assignment during birth and for up to two (2) hours immediately postpartum is one (1) nurse responsible for the mother and, for each baby, one (1) nurse whose sole responsibility is the baby. When the condition of the mother and baby are determined to be stable and the critical elements are met, one (1) nurse may care for both the mother and the baby(ies).

(3) The maximum patient assignment during the postpartum period for uncomplicated mothers or babies is six (6), which shall be comprised of either six (6) mothers or babies, three (3) couplets of mothers and babies, or, in the case of multiple babies, not more than a total of six (6) patients. As used in this subsection, couplet shall mean one (1) mother and one (1) baby.

(4) The maximum patient assignment of intermediate care or continuing care babies is two (2) babies.

(5) The maximum patient assignment of well-baby patients is six (6) babies. f In all units with pediatric patients, the maximum patient assignment of pediatric patients is four (4).

g. In all units with psychiatric patients, the maximum patient assignment of psychiatric patients is five (5).

h. In all units with medical, surgical and telemetry patients, the maximum patient assignment of medical, surgical and telemetry patients is four (4).

i. In all units with observational/outpatient treatment patients, the maximum patient assignment of observational/outpatient treatment patients is four (4).

j. In all units with rehabilitation patients, the maximum patient assignment of rehabilitation patients is five (5).

k. in any unit not otherwise listed, the maximum patient assignment is four (4).

Section 23 ID: Each facility shall implement the patient assignment limits established by Section 231C. However, implementation of these limits shall not result in a reduction in the staffing levels of the health care workforce.

Section 23IE: The Massachusetts Health Policy Commission shall promulgate regulations governing and ensuring the implementation and operation of this act, including but not limited to regulations setting forth the contents and implementation of: (a) certification plans each facility must prepare for implementing the patient assignment limits enumerated in Section 231C, including the facility obligation that implementation of limits shall not result in a reduction in the staffing level of the health care workforce assigned to such patients; and (b) written compliance plans that shall be required for each facility out of compliance with the patient assignment limits. Notwithstanding the terms of this or any other section of this act, the Massachusetts Health Policy Commission shall not promulgate any regulation that directly or indirectly permits any delay, temporary or permanent waiver, or modification of the requirements set forth in sections 231C and 23 ID above.

Section 23 IF: Patient Acuity Tool. The patient acuity tool shall serve as an adjunct to the assessment of the registered nurse and shall be designed to promote and support the provision of safe nursing care for the patient(s); however, such tools are not to be utilized as a substitute for the assessment and clinical judgment of the registered nurse assigned to the patients. Each facility shall develop a patient acuity tool for each unit designated in Section 231C. The patient assessment and use of the patient acuity tool shall be performed by the nurse who has accepted the assignment for that patient(s). The patient acuity tool for each unit in a facility shall be developed by a committee, the majority of which is comprised of staff nurses assigned to the particular unit. The patient acuity tool shall be developed to determine if the maximum number of patients that may be assigned to a registered nurse(s) should be lower than the patient assignment limits specified in Section 231C, in which case that lower number will govern for those patients. The patient acuity tool shall be written so as to be readily used and understood by registered nurses, shall measure the acuity of patients not less frequently than each shift, upon admission of a patient, and upon significant change(s) in a patient's condition and shall consider criteria including but not limited to: (1) the need for specialized equipment and technology; (2) the intensity of nursing interventions required and the complexity of clinical nursing judgment needed to design, implement and evaluate each patient's nursing care plans consistent with professional standards of care; (3) the skill mix of members of the health care workforce necessary for the delivery of quality care for each patient; and (4) the proximity of patients to one another who are assigned to the same nurse, the proximity and availability of other healthcare resources, and facility design. A facility's patient acuity tool shall, prior to implementation, be certified by the Massachusetts Health Policy Commission as meeting the above criteria, and the Commission may issue regulations governing such tools, including their content and implementation. Such patient acuity tool and information contained and documented therein shall be part of the patient medical record.

Section 231G: This act shall not be construed to impair any collective bargaining agreement or any other contract in effect as of the effective date of this act, but shall have full force and effect upon the earliest expiration date of any such collective bargaining agreement or other contract. Nothing in this act shall prevent the validity or enforcement of terms in a collective bargaining agreement or other contract that provides for a lower number of patients assigned to a nurse than the number mandated by the patient assignment limits set forth in this act.

Section 231H: Enforcement. The Massachusetts Health Policy Commission may conduct inspections of facilities to ensure compliance with the terms of this act. A facility's failure to adhere to the patient assignment limits set forth in Section 231C, as adjusted per the requirements set forth in Sections 23 ID and 23IF, shall be reported by the Massachusetts Health Policy Commission to the Attorney General for enforcement. The Attorney General may bring a Superior Court action seeking injunctive relief and civil penalties in the amount of up to twenty-five thousand dollars per violation. A separate and distinct violation, for which the facility shall be subject to a civil penalty of up to twenty-five thousand dollars, shall be deemed to have been committed on each day during which a violation continues following notice to the facility. Upon written notice by the Health Policy Commission that a complaint has been made or a violation has occurred, a facility receiving such notice shall submit a written compliance plan to the Commission that demonstrates the manner in which the facility will ensure future compliance with all of the provisions of this act within the time frame required by the Commission. No employee shall be disciplined or retaliated against in any manner for complying with the patient limits set forth in section 231C above, and any such employee so disciplined or retaliated against shall be entitled to the remedies provided in section 185(d) of chapter 149 regardless of whether the employee satisfies any other terms or conditions set forth in section 185 of chapter 149. The requirements of this act, and its enforcement, shall be suspended during a state or nationally declared public health emergency.

Section 231I: Every facility shall post in a conspicuous place or places on its premises, including within each unit, patient room, and waiting areas, a notice to be prepared or approved by the Massachusetts Health Policy Commission that is easily readable in lay terms in English and in other languages determined by the commission setting forth excerpts of this act, including all of the patient assignment limits set forth in Section 231C, along with the manner in which to report violations and such other relevant information which the commission deems necessary to explain the requirements of this act. Any facility subject to this act which refuses to comply with the provisions of this section shall be punished by a civil penalty of not less than two hundred and fifty dollars and not more than two thousand five hundred dollars for each day the facility is not in compliance. The provisions of this section shall be enforced by the Attorney General.

Section 231 J: The Massachusetts Health Policy Commission shall establish a toll-free telephone number where complaints against facilities can be reported, and a public website where complaints, certification and compliance plans, and violations shall appear and be updated at least quarterly for each facility. The toll-free telephone number and website location shall be included in all notices prepared and posted pursuant to Section 231I above.

SECTION 2: Severability. The provisions of this act are severable, such that, if any clause, sentence, paragraph or section, or an application thereof, shall be adjudged by any court of competent jurisdiction to be invalid, such adjudication shall not affect, impair, or invalidate the remainder of any clause, sentence, paragraph or section thereof and shall be confined in its operation to such clause, sentence, paragraph, section or application adjudged invalid; provided further, that any such clause, sentence, paragraph, section or application deemed invalid shall be reformed and construed such that it would be valid to the maximum extent permitted.

SECTION 3: This act shall take effect on January 1, 2019.

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### Readability score[edit]

See also: Ballot measure readability scores, 2018
Using the Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) formulas, Ballotpedia scored the readability of the ballot title and summary for this measure. Readability scores are designed to indicate the reading difficulty of text. The Flesch-Kincaid formulas account for the number of words, syllables, and sentences in a text; they do not account for the difficulty of the ideas in the text. The secretary of the commonwealth[9] wrote the ballot language for this measure.

The FKGL for the ballot title is grade level 11, and the FRE is 60. The word count for the ballot title is 26, and the estimated reading time is 6 seconds. The FKGL for the ballot summary is grade level 14, and the FRE is 39. The word count for the ballot summary is 608, and the estimated reading time is 2 minutes and 42 seconds.

In 2018, for the 167 statewide measures on the ballot, the average ballot title or question was written at a level appropriate for those with between 19 and 20 years of U.S. formal education (graduate school-level of education), according to the FKGL formula. Read Ballotpedia's entire 2018 ballot language readability report here.

## Support[edit]

The Committee to Ensure Safe Patient Care led the campaign in support of Question 1.[10]

### Supporters[edit]

The following officials and organizations endorsed the Committee to Ensure Safe Patient Care or otherwise endorsed Question 1:[11]

Officials

* U.S. Sen. Bernie Sanders (I-VT)[12]
* U.S. Sen. Elizabeth Warren (D-MA)[13]
* U.S. Sen. Ed Markey (D-MA)
* Gubernatorial candidate Jay Gonzalez (D)[14]
* U.S. Rep. Michael Capuano (D-7)[13]
* U.S. Rep. Stephen Lynch (D-4)[13]
* U.S. Rep. Jim McGovern (D-2)
* U.S. Rep. Joseph Kennedy III (D-4)
* U.S. Rep. Katherine Clark (D-5)
* U.S. Congressional candidate (District 7) and Boston City Council member Ayanna Pressley (D)
* U.S. Congressional candidate (District 3) Lori Trahan (D)
* State Sen. Michael Brady (D-Second Plymouth and Bristol)
* State Sen. Harriette Changler (D-First Worcester)
* State Sen. Nick Collins (D-First Suffolk)
* State Sen. Brendan Crighton (D-Third Essex)
* State Sen. Julian Cyr (D-Cape and Islands)
* State Sen. James Eldridge (D-Middlesex and Worcester)
* State Sen. Paul Feeney (D-Bristol and Norfolk)
* State Sen. Anne Gobi (D-Worcester, Hampden, Hampshire and Middlesex)
* State Sen. John Keenan (D-Norfolk and Plymouth)
* State Sen. Barbara L'Italien (D-Second Essex and Middlesex)
* State Sen. Michael Moore (D-Second Worcester)
* State Sen. Patrick O'Connor (R-Plymouth and Norfolk)
* State Sen. Marc Pacheco (D-First Plymouth and Bristol)
* State Sen. Michael Rush (D-Norfolk and Suffolk)
* State Sen. Walter Timilty (D-Norfolk, Bristol and Plymouth)
* State Rep. Brian Ashe (D-Longmeadow)
* State Rep. Evandro Carvalho (D-Boston)
* State Rep. Tackey Chan (D-Quincy)
* State Rep. Mike Connolly (D-Cambridge)
* State Rep. Edward Coppinger (D-Boston)
* State Rep. Claire Cronin (D-Easton)
* State Rep. Josh Cutler (D-Duxbury)
* State Rep. Marjorie Decker (D-Cambridge)
* State Rep. Diana DiZoglio (D-Methuen)
* State Rep. Daniel Donahue (D-Worcester)
* State Rep. Sean Garballey (D-Arlington)
* State Rep. Denise Garlick (D-Needham)
* State Rep. Jim Hawkins (D-Attleboro)
* State Rep. Stephen Hay (D-Fitchburg)
* State Rep. Natalie Higgins (D-Leominster)
* State Rep. Mary Keefe (D-Worcester)
* State Rep. Jack Lewis (D-Framingham)
* State Rep. Paul Mark (D-Peru)
* State Rep. Joseph McGonagle (D-Everett)
* State Rep. Joan Meschino (D-Hull)
* State Rep. Harold Naughton (D-Clinton)
* State Rep. James O'Day (D-West Boylston)
* State Rep. Sarah Peake (D-Provincetown)
* State Rep. Denise Provost (D-Somerville)
* State Rep. Angelo Puppolo (D-Springfield)
* State Rep. Daniel Ryan (D-Charlestown)
* State Rep. Thomas Stanley (D-Waltham)
* State Rep. Timothy Whelan (R-Brewster)

Health care organizations

* Health Watch USA
* Independence House, Inc.
* Mass-Care
* Mass Health Professionals for Clean Energy (MHPCE)
* Massachusetts Nurses Association
* Massachusetts Student Nurses Association
* Show Me Your Stethoscope Foundation
* United Nurses & Allied Professionals
* Western Mass. Medicare for all
* Women’s Health Institute

Nurses associations

* California Nurses Association
* District of Columbia Nurses Association
* Haitian Nurses Association
* Michigan Nurses Association
* Minnesota Nurses Association
* National Nurses United
* National Union of Healthcare Workers
* Newfoundland and Labrador Association of Public and Private Employees (NAPE)
* New Brunswick Union
* New South Wales Nurses and Midwives Association Australia
* New York Professional Nurses Union
* New York State Nurses Association
* Northeast Nurses Association
* Nova Scotia Government and General Employees Union
* Ohio Nurses Association
* Pennsylvania Association of Staff Nurses & Allied Professionals
* Philippine Nurses Association of New England
* Prince Edward Island Union of Public Sector Employees'
* Queensland Nurses and Midwives' Union
* ANNF - Victoria Branch
* Law Enforcement Officers Security Unions LEOSU, LEOSPBA

Labor groups

* Berkshire Central Labor Council
* Greater Boston Labor Council
* Greater Southeastern Labor Council
* Hampshire Franklin Central Labor Council
* Norfolk County Central Labor Council
* North Shore Labor Council
* Pioneer Valley AFL-CIO
* Plymouth/Bristol Central Labor Council
* Worcester Community Labor Coalition
* AFSCME Local 944
* AFSCME Local 1526
* American Federation of Teachers Massachusetts
* Boston Metro Area Local 100, American Postal Workers Union, AFL-CIO
* Boston Teachers Union
* HPAE, New Jersey
* HPAE, Local 5118
* IATSE Local 11
* IBEW 104
* IBEW Local 2222
* Insulators Local 6
* International Association of Machinists and Aerospace Workers (IAMAW) Local 264
* International Union of Operating Engineers Local 877
* Ironworkers Local 7
* Local 4 Operating Engineers
* Massachusetts AFL-CIO
* Massachusetts Democratic Party
* Massachusetts State Council of Machinists
* Massachusetts Teachers Association
* Metro Boston Building Trades
* National Union of Public and General Employees
* New England Regional Council of Carpenters
* Pipefitters Local 537
* Professional Firefighters of Massachusetts
* Roofers & Waterproofers Union Local 33
* SEIU Local 888
* SEIU/NAGE
* Teamsters Local 25
* Teamsters Local 42
* Teamsters Local 170
* Teamsters Local 122
* UAW Local 2322 & 2324
* UAW Region 9 Massachusetts
* UNITE HERE, New England Joint Board
* UNITE HERE, Local 26
* United Food & Commercial Workers Local 1445 & 1459
* United Steel Workers Local 7912 & 9432
* Utility Workers Union of America Local 369

Democratic groups

* The Massachusetts Democratic Party
* Agawam Democratic Town Committee
* Barre Democratic Town Committee
* Brewster Democrats
* Braintree Democratic Town Committee
* Bridgewater Democratic Town Committee
* Chicopee Democratic City Committee
* Colrain Democratic Town Committee
* Dennis Democratic Town Committee
* Easthampton Democratic Town Committee
* East Longmeadow Democratic Town Committee
* Huntington Democratic Party
* Merrimack Valley Central Labor Council
* North Adams Democratic City Committee
* Northampton Democratic City Committee
* North Reading Democratic Town Committee
* Orleans Democratic Town Committee
* Princeton Democratic Town Committee
* Quincy Democratic City Committee
* Randolph Democratic Town Committee
* Sunderland Town Democratic Committee
* Shrewsbury Democratic Town Committee
* South Hadley Democratic Town Committee
* Truo Democratic Town Committee
* West Boylston Democratic Town Committee
* Westfield Democratic City Committee
* Winchendon Democratic Town Committee

Organizations

* Berkshire Democratic Brigades
* Boston Musicians Association
* Coalition for Social Justice
* Education Enterprises
* EPOCA (Ex-Prisoners and Prisoners Organizing for Community Advancement)
* Foundation for a Green Future
* Franklin County Continuing the Political Revolution
* Greater Worcester Humanists
* Jobs with Justice
* Mass Interfaith Worker Justice
* Mass Retirees
* Mass Senior Action Council
* Massachusetts Voter Table
* Massachusetts Coalition for Occupational Safety & Health
* Neighbor To Neighbor
* New England Jewish Labor Committee
* Our Revolution
* Our Revolution Massachusetts
* Pax Christi Boston
* Progressive Democrats of America
* Progressive Taunton
* Public Higher Education Network of Massachusetts (PHENOM)
* Resist the Pipeline
* Stop the West Roxbury Lateral Pipeline (SWRL)
* Socialist Alternative
* The Labor Guild, Archdiocese of Boston
* Women’s Institute for Leadership Development
* Worcester Interfaith
* Worcester Socialist Alternative

|

### Arguments[edit]

* The Committee to Ensure Safe Patient Care argued, "When RNs have too many patients to care for, we see a dramatic and dangerous impact on safety and patient outcomes. Study after study shows that there is an absolute need to set a maximum limit on the number of patients that can be assigned to each registered nurse in order to avoid serious complications, mistakes, and preventable readmissions. Recent studies have shown that patients in Massachusetts receive less time with their nurses, resulting in higher rates of complications and readmissions and longer wait times than in California."[15]

* U.S. Sen. Elizabeth Warren (D) said, "Nurses work hard to take care of all of us when it matters the most, and we should do the same for them by establishing standards to ensure they have the help they need to do their job safely. I stand with our nurses and support a yes vote on Question 1 in November."[13]

* Kate Norton, a spokesperson for the Committee to Ensure Safe Patient Care, stated, "Outside of ICU, there are no laws or standards in existence for the number of patients assigned to nurses, and there are no requirements for hospitals to provide an adequate level of nursing care in the emergency department, medical-surgical floors, maternity units or psychiatric units. That’s dangerous, pure and simple."[16]

* Donna Kelly-Williams, president of the Massachusetts Nurses Association, said, "Setting maximum patient limits will put patients before profits — where they belong. Right now, decisions about patient assignments are made by hospital executives focused solely on reducing costs and increasing profits. We’re going all the way to the November ballot. And we’re confident that the voters understand how important this issue is to public health.”[17] Kelly-Williams also said, "Hospital executives are the reason that we need safe patient limits in the first place. Hospital executives are the ones who have ignored nurses’ concerns, claiming a lack of resources for safe patient care, while pocketing seven-figure salaries."[18]

* President of the Massachusetts Teachers Association Merrie Najimy said, "Just as small class sizes allow teachers to give the necessary time and attention to each student, safe patient limits allow nurses to give the necessary time and attention to each and every patient so they can provide the critical care that their patients need."[19]

* Paul Jacques, a firefighter and officer in the Professional Firefighters of Massachusetts, said, "We are all potential patients, and this bill will make Massachusetts hospitals safer and its residents healthier. We gladly join the nurses in their struggle for safe staffing levels."[20]

* Democratic candidate for Massachusetts Governor, Jay Gonzalez, said, "We need to ensure that there isn't cost cutting going on that is compromising the health and safety of patients. I do think this is a worthwhile issue."[14]

#### Official argument[edit]

The following official argument was submitted by RN Donna Kelly-Williams, representing the Massachusetts Nurses Association, in favor of Question 1:[6]

“  |

I have worked as a bedside nurse for 40 years. I joined nurses from across Massachusetts to write this law and place safe patient limits on the ballot to improve the quality of patient care in Massachusetts hospitals. Independent scientific studies have consistently found that quality of care decreases dramatically when nurses are forced to care for too many patients at once, putting patients at increased risk for complications like pneumonia, medication errors, and more. This initiative establishes a safe maximum limit for the number of patients assigned to nurses in all hospital areas to ensure our patients receive the care and attention they need. It provides maximum flexibility, requiring hospitals to adjust Registered Nurse staffing levels based on the needs of patients and does so without reducing other members of the health care workforce. A recent survey found that 86% of Registered Nurses in Massachusetts favor this question.[7]

|  ”

|
|

### Campaign advertisements[edit]

The following videos were released by the Committee to Ensure Safe Patient Care:[21][22]

Title: "Nurses vs CEO Ad"

Title: "#NursesSayYESon1"

Title: "Execs vs. Us"

Title: "Bedside Nurses in TV Ad Supporting Safe Patient Limits and MA Question 1"

## Opposition[edit]

The Coalition to Protect Patient Safety led the campaign in opposition to the initiative.[23][16]

### Opponents[edit]

The following organizations and chambers of commerce have endorsed the Coalition to Protect Patient Safety or have otherwise indicated their opposition to Question 1:[24]

#### Elected officials

* Massachusetts Governor Charlie Baker (R)
* Mayor Jon Mitchell (New Bedford)
* Mayor Gail Infurna, RN (Melrose)
* Mayor Bob Hedlund (Weymouth)
* Mayor Donna Holaday (Newburyport)
* Mayor Mark Hawke (Gardner)
* Mayor Paul Heroux (Attleboro)
* Mayor Bill Martin (Greenfield)
* Jeanette McCarthy (Mayor of Waltham)
* Cambridge City Councilor and Vice Mayor Jan Devereux
* Quincy City Councilor Kirsten Hughes
* Chatham Selectman Peter Dykens

#### Health and nursing organizations

* American Nurses Association-Massachusetts
* Organization of Nurse Leaders
* Emergency Nurses Association – Massachusetts State Council
* Academy of Medical-Surgical Nurses
* Massachusetts Association of Colleges of Nursing (MACN)
* Western Massachusetts Nursing Collaborative
* Infusion Nurses Society
* Massachusetts Medical Society
* Massachusetts College of Emergency Physicians
* Home Care Alliance of Massachusetts
* Massachusetts Senior Care Association
* Massachusetts Assisted Living Association
* Massachusetts League of Community Health Centers
* Massachusetts Psychiatric Society
* Massachusetts Association of Behavioral Health Systems
* Massachusetts Ambulance Association
* American Academy of Pediatrics – Massachusetts Chapter
* Massachusetts Association for Mental Health
* Massachusetts Radiological Society
* Hospice & Palliative Care Federation of Massachusetts
* New England Quality Care Alliance
* Massachusetts Society for Respiratory Care
* Parent/Professional Advocacy League
* VNA Care
* Atrius Health
* Massachusetts Society of Anesthesiologists
* American College of Surgeons – Massachusetts Chapter
* Massachusetts Academy of Dermatology
* Massachusetts Pharmacists Association
* Massachusetts Independent Pharmacists Association
* Massachusetts Society of Eye Physicians and Surgeons
* Massachusetts Society of Health-System Pharmacists
* Massachusetts Orthopaedic Association
* Massachusetts Society of Otolaryngology/Head & Neck Surgery
* Massachusetts Association of Practicing Urologists
* Massachusetts Society of Pathologists
* Massachusetts Association for Medical Staff Services
* Partnership for Health in the Berkshires
* Beth Israel Deaconess Care Organization
* Beth Israel Deaconess HealthCare
* Physicians’ Organization at Boston Children’s
* Partners Community Physicians Organization
* Brigham and Women’s Physicians Organization
* Tufts Medical Center Community Care
* Tufts Medical Center Physicians Organization
* Tufts Medical Center Community Care
* Lowell General Physician Hospital Organization
* Harvard Medical Faculty Physicians
* UMass Memorial Medical Group
* UMass Memorial Accountable Care Organization
* South Shore Health System
* South Shore Physician Hospital Organization
* Southcoast Physicians Group
* Southcoast Health Network
* Mount Auburn Cambridge Independent Practice Association
* Northeast Physician Hospital Organization
* MetroWest Healthcare Alliance
* Signature Medical Group
* Merrimack Health Network
* Heywood Physician Hospital Organization
* Highland Healthcare Associates IPA
* Baycare Health Partners
* LeadingAge Massachusetts
* Reliant Medical Group
* Hallmark Health Physician Hospital Organization
* The Pointe Group
* Harrington HealthCare Provider Organization

#### Chambers of commerce

* Associated Industries of Massachusetts
* Bristol County Chamber of Commerce
* Burlington Area Chamber of Commerce
* Cape Cod Chamber of Commerce
* Cape Cod Canal Chamber of Commerce
* Central Mass South Chamber of Commerce
* Concord Chamber of Commerce
* Greater Boston Chamber of Commerce
* Greater Gardner Chamber of Commerce
* Greater Springfield Regional Chamber of Commerce
* Greater Westfield Chamber of Commerce
* Marlborough Regional Chamber of Commerce
* Massachusetts Business Roundtable
* Massachusetts Taxpayers Foundation
* Medford Chamber of Commerce
* NAIOP Massachusetts
* Nashoba Valley Chamber of Commerce
* Newton-Needham Regional Chamber of Commerce
* North Central Massachusetts Chamber of Commerce
* North Quabbin Chamber of Commerce[25]
* North Shore Chamber of Commerce
* Plymouth Area Chamber of Commerce
* SouthCoast Chamber of Commerce
* South Shore Chamber of Commerce
* United Regional Chamber of Commerce
* Wakefield Lynnfield Chamber of Commerce
* Woburn Business Association
* Worcester Regional Chamber of Commerce

#### Massachusetts hospitals

* AdCare Hospital
* Anna Jaques Hospital
* Arbour Hospital
* Athol Hospital
* Austen Riggs Center
* Bayridge Hospital
* Baystate Franklin Medical Center
* Baystate Medical Center
* Baystate Noble Hospital
* Baystate Wing Hospital
* Berkshire Medical Center
* Beth Israel Deaconess Hospital-Milton
* Beth Israel Deaconess Hospital-Needham
* Beth Israel Deaconess Hospital-Plymouth
* Beth Israel Deaconess Medical Center
* Beverly Hospital
* Boston Children’s Hospital
* Boston Medical Center
* Bournewood Hospital
* Brigham and Women’s Faulkner Hospital
* Brigham and Women’s Hospital
* Cape Cod Healthcare Inc.
* Cape Cod Hospital
* CareGroup, Inc.
* Carney Hospital
* Circle Health, Inc.
* Cooley Dickinson Health
* Curahealth Hospital Stoughton
* Dana-Farber Cancer Institute
* Emerson Hospital
* Fairlawn Rehabilitation Hospital
* Fairview Hospital
* Falmouth Hospital
* Franciscan Children’s
* Fuller Hospital
* Gosnold on Cape Cod
* Good Samaritan Medical Center
* Harrington Hospital
* HealthSouth Braintree Rehabilitation Hospital
* HealthSouth New England Rehabilitation Hospital
* HealthSouth Rehabilitation Hospital of Western MA
* Hebrew Rehabilitation Center
* Hebrew SeniorLife
* Heywood Healthcare
* Heywood Hospital
* High Point Hospital
* Holy Family Hospital – Haverhill
* Holy Family Hospital – Methuen
* Holyoke Medical Center
* HRI Hospital
* Lahey Hospital & Medical Center
* Lawrence General Hospital
* Leonard Morse Hospital
* Lowell General Hospital
* Martha’s Vineyard Hospital
* Massachusetts Eye and Ear Infirmary
* Massachusetts General Hospital
* McLean Hospital
* Melrose-Wakefield Hospital
* Mercy Medical Center
* MetroWest Medical Center
* Milford Regional Medical Center
* Morton Hospital
* Mount Auburn Hospital
* Nantucket Cottage Hospital
* Nashoba Valley Medical Center
* New England Baptist Hospital
* New England Sinai Hospital
* Newton-Wellesley Hospital
* North Shore Medical Center
* Norwood Hospital
* Partners Continuing Care
* Pembroke Hospital
* Providence Behavioral Health Hospital
* Quincy Community Care Network
* Saint Anne’s Hospital
* Saint Vincent Hospital
* Shriners Hospital for Children
* Shriners Hospital for Children-Boston
* Signature Healthcare
* Signature Healthcare Brockton Hospital
* Southcoast Behavioral Health
* South Shore Hospital
* Spaulding Hospital for Continuing Medical Care Cambridge
* Spaulding Rehabilitation Hospital
* Spaulding Rehabilitation Hospital Cape Cod
* St. Elizabeth’s Medical Center
* St. Luke’s Hospital
* Sturdy Memorial Hospital
* TaraVista Behavioral Health
* The Mercy Hospital
* Tobey Hospital
* Trinity Health Of New England
* Tufts Medical Center
* UMass Memorial HealthAlliance-Clinton Hospital
* UMass Memorial Marlborough Hospital
* UMass Memorial Medical Center
* Vibra Hospital of Southeastern Massachusetts
* Vibra Hospital of Western Massachusetts
* Walden Behavioral Care
* Westborough Behavioral Hospital
* Whittier Pavilion
* Winchester Hospital

#### Individuals

* Richard Birkhead, M.D., President of the Medical Staff at Lowell General Hospital[26]
* Wendy Mitchell, M.D. of Lowell General Hospital[26]

|

### Arguments[edit]

* Massachusetts Governor Charlie Baker (R) said, "Based on the results of that report, I'm going to vote no on Question 1. I'm going to vote no because the Health Policy Commission report raised three issues that I was, frankly, not aware of... many community hospitals and some nursing homes and even some rehab hospitals would have their operational future put in jeopardy if that law were to pass."[27]

* Amanda Stefancyk Oberlies, CEO of the Organization of Nurse Leaders, stated, "Make no mistake: this proposal threatens the high quality of care we provide patients. It will force many hospitals to reduce critical services and will dramatically increase emergency room wait times. This measure will prevent nurses and doctors from being able to use their best judgment in times of crisis."[16]

* Diane Hanley, president of the board of directors for the Massachusetts ANA, said in a statement from the organization that the initiative "undermines the flexibility and decision-making authority of nurses and puts rigid mandates above patient safety, clinical nurse input, nurse manager's discretion, and every other consideration in a hospital."[28]

* Conor Yunits, a spokesman for the Coalition to Protect Patient Safety, said, "Community hospitals would have to cut back on services they offer to comply with this mandate. Ultimately that will put patients’ health and safety at risk.”[17]

* Holly Chaffee, CEO of VNA Care, said the initiative would "contribute to the shortage of seasoned nurses."[29]

* Pat Keheller, director of the Home Care Alliance of Massachusetts, said, "If hospitals across Massachusetts need to hire more than 5,000 new nurses, I fear it will pull nurses away from the home health community."[29]

* Mark Wright, executive director of the North Quabbin Chamber of Commerce, said, "The proposal is poorly conceived and ill-advised, and would transfer critical decision-making out of the hands of healthcare professionals and into inflexible government formulas. This ballot question would likely result in a decreased ability for hospitals to serve their communities, threatening the quality of care for our citizens."[25]

* Elizabeth Lydstone, a nurse on the Massachusetts Perinatal Team, wrote "We strive to staff according to the AWHONN (Association of Women's Health, Obstetric and Neonatal Nurses) staffing guidelines specific to labor and delivery and all of maternal child health, and in dire situations we need all hands on deck. This law would hinder our ability to navigate a crisis. If we violate the ratios in favor of safety, our organization will be charged a huge fee. Instead of focusing on the needs and acuity of our patients, we would need to be fixated on achieving an arbitrary staffing number dictated by law. Nurses will second-guess themselves when alarms sound; instead of jumping into action, and there may be delays."[30]

#### Official argument[edit]

The following official argument was submitted by RN Amanda S. Oberlies, representing the Coalition to Protect Patient Safety, in opposition to Question 1:[6]

“  |

Nurses are asking you to Vote No on Question 1.

Massachusetts hospitals rank among the best in the nation, but Question 1 will put that patient care quality and safety at risk. It forces rigid, government-imposed nurse staffing ratios at every hospital, overriding the professional judgment of nurses and doctors.

Question 1 would create a massive unfunded government mandate costing more than one billion dollars in higher healthcare costs annually, causing community hospitals to close and forcing others to reduce emergency, addiction and behavioral health services. Question 1 has been called “the most irresponsible approach to healthcare”.

There is no scientific evidence that these rigid ratios improve patient care.

Question 1: higher costs, rigid mandates, and one-size-fits-all healthcare.

Nurses and over one hundred healthcare organizations, including American Nurses Association Massachusetts, Massachusetts Medical Society, Massachusetts College of Emergency Physicians, and every Massachusetts hospital urge: Vote NO on Question 1.[7]

|  ”

|
|

### Campaign advertisements[edit]

The following videos were released by the Coalition to Protect Patient Safety:[31]

Title: "Consequences"

Title: "Teamwork"

Title: "Rooms"

Title: "Irresponsible"

## Media editorials[edit]

See also: 2018 ballot measure media endorsements

### Support[edit]

Ballotpedia did not identify any media editorials in support of Question 1. If you are aware of one, please send an email with a link to editor@ballotpedia.org.

### Opposition[edit]

* The Boston Globe wrote: "The Globe endorses the no side on Question 1 — and not because of the dire warnings from hospital executives who predict it will cause patients to die, force pregnant women to trek to Connecticut to deliver babies, or provoke an immediate staffing crisis."[32]

* MassLive wrote: "What the ballot approach ignores is that most voters will not have the time or resources to review an extremely complex subject that affects not just medical care but medical cost and hospital efficiency. Nurse staffing is a vital issue, but it's not one the voters of Massachusetts are equipped to determine in a fact-based, informed fashion. Not every important decision should be tossed onto the laps of the voters, even in a democratic republic such as ours. This is one such example that demands time and study by people who were elected to serve us, and who have staff members to help with the research. In fact, when it comes to referendum questions, this might be the best example yet of when not to use it."[33]

* The Wall Street Journal wrote: "To meet the new mandate, Massachusetts hospitals would have to add up to 3,101 additional full-time nurses, according to the Health Policy Commission. The ratios would create an artificial scarcity of nurses, driving up wages and overtime. Higher medical bills would be one outcome, though another way to meet the ratios would be to limit patients. Voters—future patients nearly all—have every reason to reject Question 1."[34]

* The Bay State Banner wrote: "This proposal, if enacted, would ultimately shift the cost to patients and health insurance customers. This proposal seems to be a union ploy to frighten the public into paying more for health care. The purpose of Question 1 is to enable nurses to get a bigger piece of the spiraling cost of health care. VOTE NO ON QUESTION 1!!!"[35]

* The Crimson wrote: "The effects of this ballot measure could be large and numerous, so are its complexities. Healthcare is one of this country’s most complex and controversial issues. Although we are calling for voters to vote no on this ballot measure, we are not calling for the dismissal of this issue, but rather that it be given more careful consideration by legislators — who can improve and amend it. Because of the complexity of healthcare issues, the general public is not able to make a well-informed decision."[36]

* The New Bedford Standard-Times (South Coast Today) wrote: "Nursing staff levels is a complicated issue that deserves continued examination for beneficial medical outcomes, patient safety, and the well-being of nurses. Adequate nursing levels deserve input from all involved — hospital administrators, nurses, and union leaders — and should be negotiated with support from the Legislature, the way mandated ratios for intensive care units were in 2014. It is not one that voters should be deciding."[37]

* The Falmouth Enterprise wrote: "Managing hospitals and health care requires specific expertise, and voters overwhelmingly do not have it. Massachusetts hospitals are required by the state to have a patient care assessment program and that program must be approved by the state Board of Registration in Medicine. Further, there is the Massachusetts Health Policy Commission, an independent board that, in addition to monitoring healthcare costs, provides policy recommendations for healthcare delivery If the entities that oversee hospitals and patient care are not doing their job, then they should be the target of reform. And that is something voters can address by sending a message to their elected representatives."[38]

* The Cape Cod Times wrote: "Depending on whom you believe, the measure will either provide a desperately needed enhanced level of nursing care, or it will create a cataclysmic situation that will force hospitals to lay off hundreds of employees or, in some cases, to close altogether. However, after weighing all of the factors, we recommend a no vote on Question 1. Although the intent behind the question has merit – who does not want a more personalized level of care when getting medical treatment? – the one-size-fits-all approach to this measure seems roughly akin to using a chainsaw to trim hedges; it will get the job done, but you could easily end up doing more harm than good."[39]

Note: This editorial was republished as an opinion piece in the MetroWest Daily News, Newburyport Wicked Local, and the NewsChamber of Massachusetts.

#### Other opposing media editorials[edit]

The following editorial boards have also endorsed a no vote on Question 1:

* The Berskhire Eagle[40]
* The Republican[41]
* The Daily Hampshire Gazette[42]
* The Daily Free Press[43]
* The Telegram & Gazette[44]

## Campaign finance[edit]

See also: Campaign finance requirements for Massachusetts ballot measures
Total campaign contributions:

Support: |  $12,044,919.81
Opposition: |  $24,808,566.78

Ballotpedia identified one ballot measure committee, the Committee to Ensure Safe Patient Care, registered in support of Question 1. The committee raised $12.04 million and spent the same. The committee was supported by the Massachusetts Nurses Association, which contributed $11.96 million (96.28 percent of the total contributions).[45][46]

Ballotpedia identified one ballot measure committee, the Coalition to Protect Patient Safety, registered to oppose Question 1. The committee raised $26.48 million and spent $26.41 million. The committee was supported by the Massachusetts Health and Hospital Association, which contributed $25.18 million (93.53 percent of the total contributions).[46][47]

### Support[edit]

| Committees in support of Question 1, Nurse-Patient Assignment Limits Initiative

Supporting committees| Cash contributions| In-kind services| Cash expenditures
Committee to Ensure Safe Patient Care| $12,044,919.81| $374,701.38| $12,044,919.81
Total| $12,044,919.81| $374,701.38| $12,044,919.81
| Totals in support

Total raised:| $12,419,621.19
Total spent:| $12,419,621.19

#### Donors[edit]

According to the most current reports available, the donors who had given $50,000 or more to the committee were as follows:[45]

Donor  |  Cash  |  In-kind  |  Total

|
|
|

Massachusetts Nurses Association |  $11,600,278.46  |  $357,020.26  |  $11,957,298.72
California Nurses Association |  $150,000.00  |  $0.00  |  $150,000.00
American Federation of Teachers  |  $50,000.00  |  $1,000.00  |  $51,000.00
Massachusetts Teachers Association  |  $50,000.00  |  $0.00  |  $50,000.00

### Opposition[edit]

| Committees in opposition to Question 1, Nurse-Patient Assignment Limits Initiative

Opposing committees| Cash contributions| In-kind services| Cash expenditures
Coalition to Protect Patient Safety| $24,808,566.78| $2,114,484.70| $24,733,966.35
Total| $24,808,566.78| $2,114,484.70| $24,733,966.35
| Totals in opposition

Total raised:| $26,923,051.48
Total spent:| $26,848,451.05

#### Donors[edit]

According to the most current reports available, the top five donors in opposition to this initiative were as follows:[47]

Donor  |  Cash  |  In-kind  |  Total

|
|
|

Massachusetts Health & Hospital Association  |  $24,573,500.00  |  $606,698.84  |  $25,180,198.84
Organization of Nurse Leaders, Inc.  |  $1,000.00  |  $43,059.28  |  $44,059.28
Spaulding Rehabilitation Hospital  |  $0.00  |  $104,253.34  |  $104,253.34
Boston Medical Center  |  $0.00 |  $84,961.15  |  $84,961.15
Steward Healthcare System LLC  |  $225,000.00  |  $0.00  |  $225,000.00

### Methodology[edit]

To read Ballotpedia's methodology for covering ballot measure campaign finance information, click here.

## Polls[edit]

See also: Ballotpedia's approach to covering polls and 2018 ballot measure polls

Shown below are poll results for Massachusetts Question 1. Also displayed are who conducted the poll, the dates the poll took place, the number of respondents, and the margin of error.

Massachusetts Question 1

Poll | Support | Oppose| Undecided| Margin of error| Sample size
WBUR News/MassInc Polling Group poll
10/25/18 - 10/28/18 | 31.0%| 58.0%| 10.0%| +/-4.4| 500
Suffolk University/Boston Globe poll
10/24/18 - 10/27/18 | 32.0%| 59.0%| 9.0%| +/-4.4| 500
Boston Globe/UMass Lowell poll
10/1/18 - 10/7/18 | 46.0%| 48.0%| 7.0%| +/-4.4| 791
WBUR News/MassInc Polling Group poll
9/17/18 - 9/21/18 | 44.0%| 44.0%| 12.0%| +/-4.4| 506
Suffolk University/Boston Globe poll
9/13/18 - 9/17/18 | 52.0%| 33.0%| 15.0%| +/-4.4| 500
AVERAGES|  41%|  48.4%|  10.6%|  +/-4.4|  559.4
Note: The polls above may not reflect all polls that have been conducted in this race. Those displayed are a random sampling chosen by Ballotpedia staff. If you would like to nominate another poll for inclusion in the table, send an email to editor@ballotpedia.org.
Further explanations of the poll results can be expanded here

* A WBUR News/MassInc Polling Group poll of 500 Massachusetts registered nurses conducted October 5-10, 2018, found that nurses were split on how to vote on Question 1: 48 percent of nurses said they supported the measure, 45 percent said they opposed it, and 8 percent were undecided.[48]

* A Boston Globe/UMass Lowell poll conducted October 1-7, 2018, found that 46 percent of respondents said they would vote yes on the measure, 48 percent would vote no, and 7 percent were undecided.

* A WBUR News/MassInc Polling Group poll conducted September 17-21, 2018, found that respondents were evenly split on how to vote on Question 1 while 12 percent remained undecided.

* A poll conducted by Suffolk University and the Boston Globe from September 13-17, 2018, found that 52 percent of respondents supported the measure to establish nurse-patient limits while 33 percent opposed it. Fifteen percent of respondents were undecided.

## Background[edit]

### Nurse assignment limits in Massachusetts, 2014 initiatives[edit]

As of 2018, the state of Massachusetts did not regulate the number of patients nurses can be assigned in private hospital emergency rooms, surgical units, maternity wards or psychiatric units. As of 2018, the state did regulate the number of patients a nurse can be assigned in an intensive care unit. This requirement applies to all licensed intensive care units whether they are privately or publicly owned, or receive public funds.[1]

In 2014, the Massachusetts legislature passed HB 4228, which stipulates that nurses in intensive care units can be assigned a maximum of two patients at one time. The legislation was passed in response to two initiatives that were proposed that same year. One initiative would have placed more stringent caps on nurse-to-patient ratios in intensive care units. The other  initiative would have regulated the annual operating margins, chief executive officer compensation and financial asset disclosures of hospitals and certain other health-care facilities that accepted public funds. The initiative was supported by the Massachusetts Nurses Association and opposed by the Massachusetts Health and Hospital Association, mirroring the support and opposition campaigns of Question 1. Both 2014 initiatives were withdrawn in response to a compromise that resulted in the legislature passing HB 4228.[49][1]

### Nurse assignment limits in other states[edit]

As of December 2015, 14 states had enacted legislation or adopted regulations addressing nurse staffing. Of those states, seven states (CT, IL, NV, OH, OR, TX, WA) required hospitals to have committees responsible for staffing policy and five states (IL, NJ, NY, RI, VT) required disclosure or public reporting of staffing. Massachusetts enacted legislation for nurse-to-patient ratios specifically for ICU nurses in 2014, and California enacted limits on nurse assignments in 1999.[50]

#### Nurse staffing regulations in California[edit]

California became the first state to establish patient assignment limits for nurses hospitals in 1999. Hospitals were required to meet the staffing ratios by January 1, 2004. In California, the required ratio of nurses to patients (as of 2018) was as follows:[51]

Patients allowed |  California |  MA Question 1

|
|

One patient per nurse  |

* Operating room
* Trauma patients in the ER

* Patient under anesthesia
* Critical care or intensive care units (two patients in stable condition)
* Active labor patients, patients with medical or obstetrical complications
* During birth and up to two hours after birth
* Baby during birth and up to two hours after birth

Two patients per nurse  |

* ICU or critical care
* Neo-natal Intensive care
* Post-anesthesia recovery
* Labor and delivery
* ICU patients in the ER

* Post-anesthesia patients
* Urgent non-stable patients
* Babies in intermediate care or continuing care units

Three patients per nurse  |

* In step-down

* In step-down or intermediate care units
* Urgent stable patients

Four patients per nurse  |

* Emergency room
* Telemetry
* Other specialty care

* Pediatric patients
* Medical, surgical, and telemetry units
* Observational and outpatient units
* Units not otherwise listed

Five patients per nurse  |

* Medical/Surgical

* Non-urgent stable patients
* Psychiatric patients
* Rehabilitation units

Six patients per nurse  |

* Psychiatric
* Post-partum women

* Uncomplicated mothers or babies postpartum;
* Well-baby patients

## Reports and analyses[edit]

Note: The inclusion of a report, white page, or study concerning a ballot measure in this article does not indicate that Ballotpedia agrees with the conclusions of that study or that Ballotpedia necessarily considers the study to have a sound methodology, accurate conclusions, or a neutral basis. To read a full explanation of Ballotpedia's policy on the inclusion of reports and analyses, please click here.

### Massachusetts Health Policy Commission[edit]

Research Presentation: Analysis of Potential Cost Impact of Mandated Nurse-to-Patient Staffing Ratios in Massachusetts

On October 3, 2018, the Massachusetts Health Policy Commission (HPC) released a report analyzing the potential cost impact of implementing Question 1. The report was led by David Auerbach, Ph.D., health economist and director of research and cost trends at the HPC, and Joanne Spetz, Ph.D., a professor at the Institute for Health Policy Studies at the University of California. The report concluded that, once fully implemented, the provisions created by Question 1 would cost $676 to $949 million annually.[52]

Key findings of the report can be expanded here

* Mandated nurse staffing ratios under Question 1 would result in annual increased costs of $676 to $949 million once fully implemented
* These costs could also lead to higher commercial prices for hospital care and higher insurance premiums
* Hospitals would need to hire 2,286 to 3,101 additional full-time equivalent registered nurses (FTE RNs)
* The required increase of RN hospital staff would likely increase the demand for RNs in Massachusetts, leading to an increase in RN earnings over time
* There would be an estimated potential savings of $34 to $47 million with the hiring of additional RNs due to savings from reduced length of hospital stays and reduced adverse events (in other words, savings would amount to about $15,000 per additional FTE RN hired)

A spokesman for the Coalition to Protect Patient Safety (opponents of Question 1) said, "The Health Policy Commission's analysis confirms that the negative consequences are too great and the costs are too high for rigid, government-mandated nurse staffing ratios in the Commonwealth."[53] The executive director of the Massachusetts Nurses Association (supporters of Question 1) said, "This guess on costs by the HPC is irresponsible and inconsistent and resembles nothing that the HPC has ever done before. This estimates a cost of $300,000 per nurse (full-time equivalent), per year, and — like the inflated numbers distributed by hospital executives — there is no independent data source or transparency in these cost estimates."[53][54]

The full report can be read here.

### Judith Shindul-Rothschild of Boston College[edit]

Estimated Massachusetts Hospital Costs

Judith Shindul-Rothschild, an associate professor at the William F. Connell School of Nursing at Boston College, released a report on the estimated costs of implementing Question 1. Supporters of the measure, the Committee to Ensure Safe Patient Care wrote, "The study shows a total cost for Massachusetts acute care hospitals to implement the law of under $47 million, which is a fraction of than the $1.3 billion figure posited by the opponents of Question 1."[55]

The executive summary of the report can be expanded here

|  “  |

My analysis estimates the cost of implementing Question 1 ranges from a moderate cost of $35,070,376 with a starting average RN hourly wage to a high cost of $46,830,087.08 with an average RN hourly wage. If there is a reallocation of the proportion of RNs to total hospital personnel by 3% to match the proportion in California, costs to implement Question 1 would decline to $23,618,869.33. Based on my calculations, Question 1 would add 128 RNs per day or between 539 and 1,617 full-time RNs annually to the 24,544 full-time RNs currently employed in the 67 Massachusetts acute-care hospitals cited in this report. This represents an increase in RNs employed in Massachusetts hospitals ranging from 2% - 7%.[7]

|  ”

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The full report can be read here.

### The Massachusetts Behavioral Health System[edit]

Implications of Mandated Nurse Staffing Ratios

In August 2018, opponents of the measure, the Massachusetts Behavior Health System, released a report titled "Implications of Mandated Nurse Staffing Ratios." The report concluded that mandated nurse staffing ratios would result in a decreased capacity to care for patients, decreased access to behavioral health services, increased costs for patients, and increased costs for hospitals to comply with staffing regulations.

The executive summary of the report can be expanded here

|  “  |

An affirmative vote on Question 1, proposed by the Massachusetts Nurses Association’s (MNA) and appearing on this November’s ballot, would impose nurse staffing mandates on a Massachusetts behavioral health system that is already chronically underfunded and overburdened with higher demand than availability. Running counter to behavioral health clinical standards of care, mandated ratios will not improve patient outcomes and will lead to the loss of more than 1,000 behavioral health beds, increased emergency department wait times, and the loss of recovery services that are turning the tide against the opioid crisis. [7]

|  ”

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The full report can be read here.

### BW Research Partnership and Mass Insight Global Partnerships[edit]

Protecting the Best Patient Care in the Country: Local Choices v. Statewide Mandates in Massachusetts

On April 30, 2018, BW Research Partnership and Mass Insight Global Partnerships released a study commissioned by the Massachusetts Health and Hospital Association (MHA) titled "Protecting the Best Patient Care in the Country: Local Choices v. Statewide Mandates in Massachusetts," an analysis of the proposed measure which would mandate a certain nurse to patient ratio. The report concluded that the approval of this initiative could cost the healthcare system $1.31 billion in the first year and $900 million annually thereafter due to nurse salaries, wage inflation, and technology. The study also concluded that implementation of the initiative would "reduce quality of care and increase inequality in care provision."[56]

The executive summary described by the report as its key findings can be expanded here

|  “  |

The following study conducted by BW Research Partnership and Mass Insight addresses three main areas of questioning with regards to the proposed Mandated Nurse Staffing Ratios, or MNSRs: (1) what are the costs and other financial impacts of the proposed MNSR ballot initiative, (2) to what extent is the MNSR feasible to implement across all hospitals in Massachusetts, and (c) how will the MNSR impact care at both hospital and non-hospital healthcare facilities across the Commonwealth. The research team examined impacts to staffing, wage inflation, recruitment and turnover costs, employer competition, as well as additional costs to education and training using a mixed methodology approach that synthesized data across several sources—PatientCareLink, the Bureau of Labor Statistics (BLS), and Economic Modeling Specialists Intl (Emsi), and comprehensive surveys and interviews with healthcare leaders in Massachusetts.

Massachusetts’ healthcare system is powered by the most talented professionals in the nation and is home to some of the highest rated hospitals. Implementation of MNSRs would disrupt this successful approach by limiting flexibility and limiting the ability of providers to hire the most qualified candidates available, at a time when the state is lowering the cap on healthcare spending for 2018 and the federal budget will lead to significant cuts to healthcare programs. Some estimates suggest that Massachusetts could lose more than $12.5 billion in Medicaid funding each year if the Trump Administration’s FY 2019 budget is approved as drafted.

The data suggest that a one-size-fits-all statewide implementation will be a costly and poor allocation of resources, leading to greater inequity in the provision of care, less local access to healthcare, and reduced patient choice. Furthermore, hospitals may be forced to hire less experienced and educated RNs, which would likely offset any quality and safety improvements that the proposal’s sponsors believe would follow from MNSR adoption. Where staffing challenges exist, an approach in which local care teams craft solutions in the context of available resources would likely be more efficient and cost-effective than a one-size-fits-all mandate that might produce lower qualified and inexperienced RN staffing. Doctors and nurses at the bedside are best able to tailor solutions to local needs, which best protects and supports patients as well as critical healthcare programs, achieving the goal of improved healthcare at lower costs.[7]

|  ”

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The full study can be read here.

### Anderson Robbins Research (commissioned by MNA)[edit]

The State of Patient Care in Massachusetts

A survey of nurses conducted by Anderson Robbins Research and commissioned by the Massachusetts Nurses Association (MNA) was released in May 2018. The survey questions were asked between April 9 and April 25, 2018. The survey polled nurses, many of whom were members of the MNA. Among the nurses surveyed, the following results were reported:[57]

The survey results can be expanded here

* 90% of nurses polled said that they lacked time to properly comfort and assist patients and families
* this compared to 87% in 2017, 86% in 2015, and 82% in 2014
* 86% of nurses polled said that they lacked time to provide adequate discharge planning/education to patients
* this compared to 83% in 2017, 81% in 2015, and 68% in 2014
* 78% reported complications or other problems for a patient related to the ratio of nurses to patients
* this compared to 75% in 2017, 61% in 2015, and 59% in 2014
* 77% reported medical errors
* this compared to 73% in 2017, 61% in 2015, and 57% in 2014
* 72% reported readmission for patients
* this compared to 71% in 2017, 56% in 2015, and 56% in 2014
* 66% reported longer hospital stays related to the ratio of nurses to patients
* this compared to 62% in 2017, 50% in 2015, and 51% in 2014
* 64% reported injury or harm to a patient
* this compared to 63% in 2017, 50% in 2015, and 46% in 2014
* 36% reported death for a patient
* this compared to 29% in 2017, 25% in 2015, and 23% in 2014

When asked about the challenges faced by bedside nurses, the following responses were given:[57]

* 65% reported not enough time to attend to patients
* 61% reported having to care for too many patients at the same time
* 36% reported inadequate pay or benefits
* 35% reported insurance and reimbursement policies
* 30% reported increased mandatory overtime

* 28% reported the replacement of registered nurses with part-time staff
* 26% reported workplace violence or abuse
* 25% reported workplace injurises
* 17% reported the implementation of new technology
* 16% reported a lack in safety from infectious diseases

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To read a full summary of the nurse survey, click here.

## Path to the ballot[edit]

See also: Laws governing the initiative process in Massachusetts

In Massachusetts, the number of signatures required to place an indirect initiated state statute on the ballot is equal to 3.5 percent of votes cast for governor in the most recent gubernatorial election. The first 3 percent is collected in order to refer the indirect initiative to the Massachusetts General Court. If members of the General Court pass and the governor signs the initiative, then the initiative becomes law. If the legislature declines to act on an initiative or the governor vetoes it, sponsors of the initiative need to collect additional signatures equal to 0.5 percent of the votes cast for governor.

To make the 2018 ballot, sponsors of an initiative needed to collect the first round of 64,750 signatures between September 20, 2017, and November 22, 2017. If the General Court failed to act on the initiative by May 2, 2018, then an additional 10,792 signatures were required by July 4, 2018.

Cost of signature collection:
Sponsors of the measure hired JEF Associates to collect signatures for the petition to qualify this measure for the ballot. A total of $570,518.17 was spent to collect the 75,542 valid signatures required to put this measure before voters, resulting in a total cost per required signature (CPRS) of $7.55.

### Details about this initiative[edit]

* Sponsors filed two versions of the initiative. On September 6, 2017, Attorney General Maura Healey (D) approved one version, Initiative 17-07, for signature gathering. A second version, Initiative 17-08, was initially rejected as containing "subjects that are not related or mutually dependent." Reports, however, indicated that signatures were submitted for both versions.[58]

* The proponents of this initiative reported turning in about 100,000 signatures to the office of the secretary of the commonwealth by the deadline on December 6, 2017. The office of the secretary of the commonwealth confirmed that signature petitions for this initiative were submitted. Prior to submission to state officials, the signatures were submitted to local registrars of voters by a deadline on November 22, 2017, and verified by the local registrars. Petitions were submitted for both versions of this initiative—17-07 and 17-08.[59][60]

* On December 21, 2017, the secretary of the commonwealth said that a sufficient number of signatures had been submitted and certified two versions of the measure to move forward in the process. The measure then went before the Massachusetts General Court.[61] Since the General Court failed to act on the initiative by May 2, 2018, an additional 10,792 signatures were required by July 4, 2018.

* On July 3, 2018, the secretary of the commonwealth's office confirmed to Ballotpedia that signatures had been submitted for the initiative.[62]

* On July 9, 2018, the Massachusetts Secretary of State assigned the measure an official ballot question number, meaning the measure was certified for the ballot.[63]

### Lawsuit[edit]

Lawsuit overview

Issue: Single-subject rule; whether the provision requiring certain patient assignment limits and the provision prohibiting reduced staffing are unrelated.
Court: Massachusetts Supreme Judicial Court
Ruling: Ruled in favor of defendants, the initiative may appear on November ballot
Plaintiff(s): Four Massachusetts voters backed by the Steward Health Care System LLC| Defendant(s): Attorney General Maura Healey
Plaintiff argument:
The initiative's provision concerning nurse-patient assignment limits and the provision prohibiting reduced staffing are unrelated and violate the constitutional requirement that initiatives concern only one subject. | Defendant argument:
The initiative was designed to establish a system of related regulations and meets the constitutional requirement.
Source: Boston Herald

A lawsuit was filed by four Massachusetts voters against Attorney General Maura Healey in the Massachusetts Supreme Judicial Court seeking to block the initiative from the ballot. The lawsuit was backed by the Steward Health Care System LLC which argued that Healey should not have certified the initiative for circulation because it violated the state's single-subject rule. The supreme court heard arguments in the case on April 3, 2018.[64]

Thaddeus A. Heuer, an attorney for the Steward Health Care System LLC, said, “This appeal is about upholding the ability of Massachusetts voters to make clear, uniform public policy choices through the initiative petition process." Attorney Elissa Flynn-Poppey said, “Voters who might favor mandatory nurse-patient ratios cannot register their preference without also supporting the enactment of a costly, unfunded and overbroad workforce retention mandate."[64]

Healey’s office said it would defend the initiative and that it contained an “integrated regulatory scheme” that meets the constitutional requirements. The Committee to Ensure Safe Patient Care stated, “we are pleased that the Attorney General approved the language we put forth for the Patient Safety Act and we believe that decision will stand up to any challenge.”[64]

On June 18, 2018, the Supreme Court ruled that the measure's provisions were related and therefore that the measure could appear on the November 2018 ballot.[65]

## See also[edit]

2018 measures

* 2018 ballot measures
* Healthcare on the ballot
* 2018 legislative sessions

Massachusetts

* Massachusetts ballot measures
* Massachusetts ballot measure laws

News and analysis

* Ballot measure lawsuits
* Ballot measure readability
* Ballot measure polls

|
|

## External links[edit]

* 2018 Ballot Questions
* 2018 Citizen's Initiative Review statement on Question 1
* Massachusetts 2018 Information for Voters

### Support[edit]

* Committee to Ensure Safe Patient Care website
* Committee to Ensure Safe Patient Care Facebook
* Committee to Ensure Safe Patient Care Twitter
* Committee to Ensure Safe Patient Care Instagram

### Opposition[edit]

* Coalition to Protect Patient Safety website
* Coalition to Protect Patient Safety Facebook
* Coalition to Protect Patient Safety Twitter

|

## Footnotes[edit]

1. ↑ 1.0 1.1 1.2 1.3 ‘’The Salem News’’, “Nurses press for patient ratio limit,” September 14, 2017
2. ↑ Boston Globe, "A ballot initiative campaign last fall broke the state record for spending," accessed February 28, 2019
3. ↑ ‘’The General Court of the Commonwealth of Massachusetts’’, “Bill H.4228,” accessed December 30, 2017
4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Massachusetts Secretary of State, "Initiative 17-07," accessed August 2, 2017
5. ↑ WBUR News, "3 Mass. Ballot Qs Set: Keeping Transgender Protections, Citizens United, Nurse-To-Patient Ratios," accessed July 9, 2018
6. ↑ 6.0 6.1 6.2 6.3 Massachusetts Secretary of the Commonwealth, "2018 Information For Voters," accessed October 5, 2018
7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Note: This text is quoted verbatim from the original source. Any inconsistencies are attributable to the original source.
8. ↑ Massachusetts Government, "Question 1 full text," accessed September 28, 2018
9. ↑ The ballot language is written by the secretary of the commonwelath, but it requires approval by the attorney general.
10. ↑ Committee to Ensure Safe Patient Care, "Homepage," accessed December 26, 2017
11. ↑ Safe Patient Limits, "Who we are," accessed September 27, 2018
12. ↑ Mass Live, "U.S. Sen. Bernie Sanders endorses nurse staffing ballot question," accessed October 29, 2018
13. ↑ 13.0 13.1 13.2 13.3 WBUR, "Sen. Warren Endorses Ballot Initiative On Patient-To-Nurse Ratios," accessed September 26, 2018
14. ↑ 14.0 14.1 Mass Live, "Baker waiting for Question 1 analysis; Gonzalez supports nurse staff plan" accessed October 1, 2018
15. ↑ Safe Patient Limits, "What we stand for," accessed September 15, 2018
16. ↑ 16.0 16.1 16.2 Cite error: Invalid `<ref>` tag; no text was provided for refs named `story1`
17. ↑ 17.0 17.1 Newbury Port News, "Nurses to voters: set patient limits," accessed May 7, 2018
18. ↑ Boston Globe, "Nurses rally for ballot initiative on staffing, target hospital execs," accessed August 23, 2018
19. ↑ PatientSafetyMA on Twitter, "he Mass Teachers Association says #YESon1!," accessed September 28, 2018
20. ↑ The Sun Chronicle, "Firefighters support Question 1 on nurse staffing," accessed September 28, 2018
21. ↑ YouTube, "Massachusetts Nurses Association Channel on YouTube," accessed October 25, 2018
22. ↑ YouTube, "Safe Patients YouTube Channel," accessed October 25, 2018
23. ↑ Coalition to Protect Patient Safety, "Supporters," accessed September 27, 2018
24. ↑ Protect Patient Safety, "Coalition Supporters," accessed October 25, 2018
25. ↑ 25.0 25.1 Greenfield Recorder, "North Quabbin Chamber opposes nurses referendum," accessed May 23, 2018
26. ↑ 26.0 26.1 Lowell Sun, "LGH medical chiefs oppose Question 1," accessed October 25, 2018
27. ↑ WCVB, "Gov. Baker says he'll vote 'no' on Question 1," accessed October 11, 2018
28. ↑ Cite error: Invalid `<ref>` tag; no text was provided for refs named `ANA`
29. ↑ 29.0 29.1 Cite error: Invalid `<ref>` tag; no text was provided for refs named `newsoppo`
30. ↑ Lowell Sun, "Nurse staffing initiative is 'harmful' plan," accessed June 28, 2018
31. ↑ YouTube, "Coalition to Protect Patient Safety YouTube Channel, accessed September 27, 2018
32. ↑ Boston Globe, "Editorial endorsement on Question 1," accessed October 23, 2018
33. ↑ Mass Live, "Nurse staffing by referendum is a bad idea (Editorial)," accessed September 27, 2018
34. ↑ Wall Street Journal, "Bad Bedside Manner in Massachusetts," accessed October 29, 2018
35. ↑ The Bay State Banner, "Vote ‘no’ on 1," accessed October 29, 2018
36. ↑ The Crimson, "Vote No on Ballot Question One," accessed October 29, 2018
37. ↑ South Coast Today, "We want to help nurses, but this isn’t the way," accessed October 29, 2018
38. ↑ Cape News, the Falmouth Enterprise, "No On Question 1 - Editorial," accessed October 29, 2018
39. ↑ Cape Cod Times, "Editorial: Vote no on Question 1," accessed October 13, 2018
40. ↑ Berkshire Eagle, "Our Opinion: No on Question 1," accessed October 30, 2018
41. ↑ Mass Live, "The Republican endorses 'no' on Question 1 (Editorial)," accessed November 2, 2018
42. ↑ Daily Hampshire Gazette, "Editorial: Nurses need more support, but Question 1 is not the solution," accessed November 3, 2018
43. ↑ The Daily Free Press, "FreeP’s endorsements on the Massachusetts ballot measures," accessed November 4, 2018
44. ↑ Telegram.com, "Vote ‘No’ on Question 1 – Stark scenarios on Registered Nurse staffing, an overheated campaign, and an issue far too complex and fraught to be thrown to voters to decide," accessed November 4, 2018
45. ↑ 45.0 45.1 Massachusetts Office of Campaign and Political Finance, "Committee to Ensure Safe Patient Care," accessed September 7, 2018
46. ↑ 46.0 46.1 Massachusetts Office of Campaign and Political Finance, "Ballot Question Committee Schedule," accessed January 22, 2019
47. ↑ 47.0 47.1 Massachusetts Office of Campaign and Political Finance, "Coalition to Protect Patient Safety," accessed September 7, 2018
48. ↑ Sentinel and Enterprise, "Mass. nurses divided over Question 1, satisfied with their jobs," accessed October 15, 2018
49. ↑ ‘’The General Court of the Commonwealth of Massachusetts’’, “Bill H.4228,” accessed December 30, 2017
50. ↑ American Nurses Association, "Nurse Staffing," accessed September 28, 2018
51. ↑ Connecticut General Assembly Legislative Research Report, "California RN Staffing Ratio Law," accessed September 28, 2018
52. ↑ Massachusetts Government, "Health Policy Commission Research Presentation: Analysis of Potential Cost Impact of Mandated Nurse-to-Patient Staffing Ratios in Massachusetts," accessed October 4, 2018
53. ↑ 53.0 53.1 Mass Live, "Health Policy Commission: Nurse staffing ballot question would cost $674 to $949 million," accessed October 4, 2018
54. ↑ Biz Journals, "State's health care watchdog sides with hospitals on nurse ballot cost," accessed October 4, 2018
55. ↑ Safe Patient Limits, "NEW STUDY FINDS HOSPITAL EXECUTIVES GROSSLY EXAGGERATING COST OF QUESTION 1," accessed September 18, 2018
56. ↑ Mass Insight Global Partnerships and BW Research Partnership, "Protecting the Best Patient Care in the County," accessed May 1, 2018
57. ↑ 57.0 57.1 Cision PR Newswire, "MNA: 'State of Patient Care in Massachusetts' Survey Released for National Nurses Week Finds Nurses Sounding the Alarm Over Deteriorating Conditions for Hospitalized Patients and Need for Safe Patient Limits," May 8, 2018
58. ↑ Cite error: Invalid `<ref>` tag; no text was provided for refs named `ag`
59. ↑ The Patriot Ledger, "7 question submitted for 2018 state election," December 7, 2017
60. ↑ Ballotpedia Staff Writer, "Telephone correspondence with the office of the secretary of the commonwealth," December 8, 2017
61. ↑ US News, "6 Initiative Petitions Advance, Could Reach November Ballot," December 21, 2017
62. ↑ Jackie Mitchell, Telephone communication with Massachusetts Secretary of State's Office, Elections Division," July 3, 2018]
63. ↑ WBUR News, "3 Mass. Ballot Qs Set: Keeping Transgender Protections, Citizens United, Nurse-To-Patient Ratios," accessed July 9, 2018
64. ↑ 64.0 64.1 64.2 Boston Herald, "SJC to consider ballot question affecting nursing assignments," March 20, 2018
65. ↑ Beckers Hospital Review, "Massachusetts high court rules nurse staffing initiative clear for ballot," accessed June 18, 2018

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