For a summary of November's most important ballot measures, click here.

Voters this fall could make Massachusetts only the second state in the country to limit the number of patients that hospital nurses can help at one time.

Question 1 would create legal ratios based on the type of patients that nurses are dealing with. Nurses aiding women during birth and up to two hours after, for instance, would be limited to one patient. If they're working with children, they could see four patients at once. In the psychiatric ward, nurses could help up to five patients.

While nurses unions and progressive political groups back the ballot measure, most medical groups -- including the Massachusetts chapter of the American Nurses Association and the state's Health and Hospital Association -- oppose it.

The ballot measure's supporters argue that not regulating this negatively impacts patient care and overall health outcomes.

“There is overwhelming evidence when you look at studies and talk to nurses that when there are limits, there are better health outcomes,” says Kate Norton, campaign spokewoman for the Committee to Ensure Safe Patient Care, which is the official campaign for the ballot measure.

2011 study in the journal Health Affairs found that nurse-patient ratios in California resulted in decreased mortality rates after surgery and an additional half-hour of care for patients overall. 

Seven states have laws that require hospitals to have committees that address staffing issues, but California is the only state with a cap on the number of patients a nurse can see during one shift. Advocates have struggled to gain support for ratio laws elsewhere, in part because the hospital industry doesn't believe there's enough evidence to support them.

California's regulations were drafted by the state’s department of health and have been in effect since 2004. There was some fear at the time that hospitals would be forced to hire more nurses with less education in order to comply with the ratios. But according to the 2011 study, that didn't happen.

Opponents of Massachusetts' measure also worry that it would force hospitals “to make deep cuts to critical programs, such as opioid treatment and mental health services. Many community hospitals will not be able to absorb the added cost and will be forced to close.” 

In California's experience, those fears are likely overblown. 

Research by the California Healthcare Foundation in 2009 shows that while “leaders reported difficulties in absorbing the costs of the ratios, and many had to reduce budgets, reduce services or employ other cost-saving measures,” the impact of the ratios was not discernible on hospital finances.

Research further shows that hiring levels only increased slightly after the mandate. But California is expected to have a nursing shortage of more than 44,000 by 2030. It's not clear how big a role, if any, the staffing ratios play in this shortage.

In Massachusetts, opponents of the measure argue that it would worsen the existing nurse shortage there. Right now the vacancy rate for registered nurses in Massachusetts hospitals is 6.4 percent. 

“If it passes, the estimates are that hospitals will have to hire 6,000 more nurses [according to a study led by the opposition camp]. Where will they get them?” says Jake Krilovich, director of policy and public affairs for the Home Care Alliance of Massachusetts, which opposes the measure.

But according to data from the U.S. Department of Health and Human Services, the state is projected to have a surplus of nurses by 2030. 

Although well-financed organizations like the Massachusetts Business Roundtable, Massachusetts Health and Hospital Association and 11 local chamber of commerces oppose the measure, the supporting campaign has much more cash on hand: $1 million to just over $11,000 in the opposition camp.

There hasn’t been any formal polling done on the measure.

For a summary of November's most important ballot measures, click here.