BOSTON — Julie Garza has seen a barrage of TV ads that support or oppose the nurse staffing ballot question but doesn't know how she'll vote in November.
"It's totally confusing," said Garza, 34, a hair stylist from Lynn. "Both sides are saying nurses are for or against it. You really don't know who to believe."
Question 1 would limit the number of patients a single nurse can be assigned at a time and impose a $25,000 fine on hospitals that violate the rules.
The staffing ratios, if approved by voters, would vary by hospital department. Emergency room nurses, for example, would be limited to treating 1 to 5 patients at a time, depending upon the patients’ conditions. In psychiatric wards, a nurse would be allowed to care for up to four children or five adults.
Supporters of the referendum, who are backed mostly by nurses unions, say the initiative would mean increased safety and better overall outcomes for patients. The question’s opponents, backed largely by the hospital industry, argue that it would result in longer wait times at emergency rooms and increased health care costs.
Both sides accuse the other of misleading voters with their campaign ads, which is making it difficult for voters such as Garza to decide.
"One of the biggest problems is that citizens really don't have a lot of information or well-formed opinions about nurse staffing levels," said John Cluverius, associate director of the Center for Public Opinion at the University of Massachusetts at Lowell. "So, it's hard for either side to convince voters it's a fight they need to be involved in."
Because of the issue’s complexity, both campaigns frame the debate around whether nurses support or oppose the question, which makes it more tangible, he said.
"When you go to a hospital, the person you're most likely to engage with is a nurse, so people feel good about nurses," Cluverius said. "If they're put to a vote, they want to be on the side of nurses."
While there are nursing groups on either side of the question, he said it is primarily "a battle between the unionized nurses and the hospital and health care provider associations."
Unlike other questions on the November ballot, which ask voters to uphold or reject protections for transgender individuals and limit corporate campaign contributions, Cluverius said "there's no platform in either party's plank about what staffing limits should be.”
“It isn't a common discussion point in party politics," he said.
For weeks, supporters and opponents have traded barbs over contrasting ads, cost-benefit studies and even lawn signs claiming nurses are for or against Question 1.
Earlier this week, the Committee to Ensure Safe Patient Care, which supports Question 1, wrote a letter to local TV stations demanding that they stop running ads from the opposition claiming the proposed changes would violate state law. The group blasted the claims as "false" and "blatantly misleading."
"It is absolutely unconscionable for hospital executives to continue to threaten people on this ballot question and to attempt to deceive the voters, straight to their faces," said Kate Norton, the group's spokeswoman. "This opposition campaign has been funded by deep-pocketed hospital executives who throw a grenade of deception in hopes that people will latch on to their fear-mongering without fact-checking their claims."
Meanwhile, opponents of the measure accuse supporters of spreading disinformation with the most recent ad — "Don't be THAT nurse" — which claims that a majority of nurses support the ballot question. It also suggests that a nurse who appeared in opposition ads was actually a Partners HealthCare executive "dressed in scrubs."
Nurses Association President Donna Kelly-Williams later walked back the claims after news surfaced that the nurse in the ad wasn't actually a health care executive.
"We saw exactly what the union means when they warn somebody not to be THAT nurse," said Nicole Caravella, a spokesperson for the Coalition to Protect Patient Safety, which opposes Question 1. "It means they will make false claims about you, belittle your decades of experience caring for patients, and try to disparage you on television."
Both sides of the issue have touted studies that buttress arguments for and against mandated staffing limits. The conflicting data also muddies the waters.
A report commissioned by the Hospital Association estimated the change would cost health care providers $1.3 billion the first year and $900 million annually thereafter.
But a competing study released by the Massachusetts Nurses Association reported the cost of adopting staffing ratios would be far lower — about $46 million per year.
To date, supporters and opponents have poured nearly $12 million combined into their respective campaigns, making it the most expensive question on the November ballot so far.
A Suffolk University/Boston Globe poll released Wednesday showed 52 percent of 500 registered voters surveyed said they would vote yes on Question 1.
About 33 percent of those surveyed said they would vote no, while 15 percent were undecided, according to the survey.
Secretary of State Bill Galvin this week urged voters who may be confused by the competing claims to do their homework before Election Day.
His office has produced a 2018 election guide, mailed to voters this week, that contains additional information on the ballot question, explaining what a "yes" or "no" vote means.
"And on the ballot there will be a one-sentence statement that will make it clear what it does," he said. "So you should make sure that you read that before you cast a ballot."
Christian M. Wade covers the Massachusetts Statehouse for North of Boston Media Group’s newspapers and websites. Email him at firstname.lastname@example.org.