224 JONA • Vol. 33, No. 4 • April 2003 JONA Volume 33, Number 4, pp 224–234 ©2003, Lippincott Williams & Wilkins, Inc. DFN Objective: To test a causal model of the impact of (a) nursing unit context on professional nursing prac- tice; (b) professional practice on selected organiza- tional (nurses’ work satisfaction, nursing turnover, average length of patient stay) and patient outcomes (patient satisfaction, rate of reported medication er- rors, and falls); and (c) nursing unit context on these same organizational and patient outcomes. Summary Background Data: Professional nursing practice has been linked to positive outcomes for both nurses and patients. In contrast to other stud- ies, this study focuses on professional nursing prac- tice specifically at the nursing unit level, and uses a new analytic technique that permits examination of the simultaneous effects of professional nursing practice on both organizational and patient out- comes. Methods: Data were collected from 1682 registered nurses, and 1326 patients on 124 general medical- surgical nursing units in 64 general short-term acute care hospitals in the southeast. Multilevel structural equation modeling was used to analyze the data. Results: We found that professional nursing practice had consistent effects across model levels on nurs- ing satisfaction, but very limited effects on other out- comes. Important differences in the hospital- and nursing unit level models support continued use of multilevel modeling techniques in the study of orga- nizational and patient outcomes. There is an accumulating body of evidence suggest- ing that “professional nursing practice”—defined as “a system that supports registered nurse control over the delivery of nursing care and the environ- ment in which care is delivered” 1, p 354 —contributes to improved outcomes for the organization and its patients. 2 Professional nursing practice is character- ized by decentralization of nurses’ clinical decision- making, enhanced autonomy, and collaborative rela- tionships with physicians. For example, Havens and Aiken 3 report that nurses’ job satisfaction is signifi- cantly higher, 4-6 and patient mortality significantly lower, 7 in hospitals enacting professional nursing practice. Lower mortality on dedicated AIDS units that promote professional nursing practice has also been documented. 8 In addition, less emotional ex- haustion, safer work environments, 9 and lower rates of needlestick injuries 10 have been reported in hos- pitals engaging in professional nursing practice. However,most research in this area has focused either on the individual nurse, and relies predomi- nantly on primary data, or on the hospital, and relies on secondary data.Yet, it is likely that variability in nursing unit organization can best be seen, and the relationship of nursing unit organization to out- comes understood most clearly, at the nursing unit level. Second, since organizations produce multiple, concurrent outcomes, it is important to use an ana- lytic technique that permits investigation of several outcomes simultaneously. Finally, because a nursing unit’s behavior is partly determined by the hospital in which it is located, a multilevel perspective allows examination of this important interplay. To address these issues, in the Outcomes Re- search in Nursing Administration Project (ORNA), we used a long-established theoretical framework, focused on the nursing unit as the focal unit of analy- sis, and used multilevel structural equation modeling Professional Nursing Practice Impact on Organizational and Patient Outcomes Barbara A. Mark, PhD, RN, FAAN Jeanne Salyer, PhD, RN Thomas T.H. Wan, PhD Authors’ affiliations: The University of North Carolina at Chapel Hill, Chapel Hill, NC (Dr Mark); Virginia Commonwealth University,Richmond,Va (Drs Salyer and Wan). Corresponding author: Barbara A. Mark, PhD, RN, FAAN, Sarah Frances Russell Distinguished Professor,The University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall CB#7460, Chapel Hill, NC 27599-7460 (b_mark@unc.edu).