Massachusetts voters on Tuesday rejected a proposal to put more nurses on duty in hospitals, affirmed a 2016 transgender anti-discrimination law and agreed to form a commission to make campaign finance recommendations to the federal government.

Question 1, which called for limits on the number of patients assigned to nurses, failed on the heels of expensive ad campaigns in which the Massachusetts Nurses Association pushed for the initiative petition and a coalition of hospital industry and other health care groups argued against staffing mandates.

With nurses themselves divided over the proposal, many voters were torn over which side to take, but ultimately agreed with opponents who argued staffing requirements should not be set by a voter law and hospitals and other facilities are best run when managers have flexibility in assigning nurses as needed.

"We are certainly grateful tonight," said Massachusetts Health and Hospital Association President Steven Walsh. "Thank you to the voters of Massachusetts for a vote to protect the best health care system in the nation. Thank you to our team of nurses, doctors and every patient-centered health care organization in the Commonwealth. Your tireless efforts to help educate the electorate on the dangers of Question 1 have made all the difference."

The Massachusetts Health Policy Commission influenced the election with the release, during the height of the campaign, of a report warning that health care costs could rise by $950 million and as many as 3,100 nurses would need to be hired to meet the proposal's requirements. Commission officials said the study was not intended to make a case for or against the ballot question, but it was cited as influential by many opponents, including Gov. Charlie Baker.

"I know you have given your hearts and your souls to this campaign and I'm so incredibly proud and beyond grateful for everything that you have done," Donna Kelly-Williams, Massachusetts Nurses Association president, said in a concession speech Tuesday night, surrounded by nurses. "We're all very disappointed by tonight's results and the impact that this will have on our patients that we care for every day."

The hospital sector spent $27 million "in an attempt to drown out the voices of bedside nurses calling for help," Kelly-Williams said. She added, "These tactics rooted in fear and confusion seem to have worked and the voters deserved better."

Walsh said voters in rejecting Question 1 had "endorsed the high quality of care at our hospitals," but added that the proposal "forced some difficult and necessary discussions about the future of our health care and the future of our workforce going forward." The "incredibly important conversations" will continue at bargaining sessions, legislative debates, and meeting rooms, he said.

With nearly 28 percent of the vote in, Question 1 supporters accounted for about 29 percent of the vote, compared to 71 percent for opponents.

The Yes on 3 campaign declared victory just before 10 p.m., describing Massachusetts as the first state in the nation "to successfully defend transgender rights by popular vote." The question was leading 68 percent to 32 percent with nearly 28 percent of the vote counted just after 10 p.m.

"Massachusetts made history tonight, both for our transgender neighbors who call this state home and for transgender people across this nation," said Kasey Suffredini, Yes on 3 Campaign co-chair and President of Strategy at Freedom for All Americans, in a statement. "From the very early days of our campaign, we have been clear that this is about dignity and respect for all people. Together, we have shattered broken stereotypes of what it means to be transgender and debunked the myth – once and for all – that protecting transgender people compromises the safety of others."

The 2016 transgender rights law features legal protections against discrimination in public places like restaurants, retail shops and hospitals, and allows transgender individuals to use sex-segregated facilities that correspond with their gender identity regardless of their assigned sex at birth.

The law's opponents asserted it poses safety risks because it could allow criminals to gain access to a shower or locker room of the opposite sex. Backers of the law said there's no evidence that anyone has used the law in that manner and argued that anyone who did could be prosecuted under other laws.

Question 2, which is largely advisory in nature, was on a path to victory Tuesday night with 71 percent in favor and 29 percent against.

It will require state government officials to create a 15-member, unpaid commission to recommend potential amendments to the U.S. Constitution "to establish that corporations do not have the same Constitutional rights as human beings and that campaign contributions and expenditures may be regulated."

The law requires the governor, secretary of state, attorney general, House speaker, and Senate president to each appoint three members to the commission. The commission would be subject to the state's open meeting and public records laws, and its first report is due Dec. 31, 2019.