Professional Nursing Practice Environment Research Articles

Professional Nursing Practice Environment and Work Engagement: The Mediating Roles of Self-Efficacy and Achievement Motivation.

The shortage of nurses is a global problem. Increasing the level of work engagement is known to effectively reduce turnover rate among nursing staff. Strategies to improve work engagement based on the job demands-resources model may effectively improve nurses' job satisfaction and reduce staff turnover. A job demands-resources model was used in this study to test the hypothesis that work engagement is affected by both external resources (professional nursing practice environment) and internal resources (self-efficacy and achievement motivation). In addition, the mediating role of self-efficacy and achievement motivation in the relationship between professional nursing practice environment and work engagement was also verified. A cross-sectional survey employing a convenience sampling design was implemented. Five hundred fifteen registered nurses were recruited from four tertiary hospitals in Chengdu, China, from January to June 2020. The Practice Environment Scale of the Nursing Work Index, General Self-Efficacy Scale, Achievement Motive Scale, and Utrecht Work Engagement Scale were used to measure the four variables. The results of the structural equation model showed that the degree of fit for each index model was good, indicating that all of the three variables, including professional nursing practice environment, self-efficacy, and achievement motivation, directly affected work engagement. In addition, the variable professional nursing practice environment was found to indirectly influence work engagement through the partial mediation of self-efficacy and achievement motivation. The results may be used to guide health policymakers and nurse managers attempting to enhance the work engagement of nurses by providing a supportive working environment, improving the welfare mechanism, formulating a talent training plan, and fostering appropriate empowerment to improve the working environment, self-efficacy, and motivation in nurses.

Working Conditions Among Chinese Nurses Employed in Japan: A Cross-Sectional Survey-Based Study.

Although the number of Chinese nurses employed in Japan is increasing, the situation regarding their work conditions has not been clarified. It is necessary to understand such conditions to consider support for Chinese nurses in Japan. This study examined the professional nursing practice environment, occupational career, and work engagement of Chinese nurses in Japan. Using a cross-sectional study design, 640 paper questionnaires were mailed to 58 Japanese hospitals that employed Chinese nurses and included a QR code for online responses. A survey request form and URL were sent to the Wechat app, where Chinese nurses in Japan communicate. The contents include attribute-related questions, the Practice Environment Scale of the Nursing Work Index (PES-NWI), Occupational Career Scale, and Utrecht Work Engagement Scale. Either Wilcoxon's rank-sum or the Kruskal-Wallis test was performed to compare scores of the study variables between subgroups. A total of 199 valid responses were obtained, of which 92.5% were female, and 69.3% had a university degree or higher. The PES-NWI score was 2.74, and the work engagement score was 3.10. The group with a university degree or higher had significantly lower scores on PES-NWI and work engagement than those with diplomas. Regarding the subscale of occupational career, scores of forming and coordinating interpersonal relationships, self-development, and accumulating a variety of experience were 3.80, 2.58, and 2.71, respectively. The scores were significantly higher with more than 6 years of nursing experience in Japan than those with 0-3 years or 3-6 years. Most participants had university degrees or higher, and their scores of PES-NWI and work engagement tended to be lower than those with diploma degrees. Participants showed low self-ratings in self-development and lacked a variety of experience. Understanding Chinese nurses' work conditions in Japan enables hospital administrators to develop measures for continuing education and support.

Analysis of the Work Environment and Burnout among Nurses, Technicians and Nursing Assistants in Brazilian Institutions

In addition to causing damage to the health of patients, the Covid 19 pandemic has brought a greater burden to health systems directly affecting professionals, leading many to physical and emotional exhaustion. The present study aims to demonstrate the perceptions of the professional practice environment of nurses, technicians and nursing assistants through the use of the Environment of Professional Practice research (Practice Environment Scale of the Nursing Work Index – PES/NWI) and the Maslach Burnout Inventory (MBI), in addition to comparing them. The researches were applied in private and public administrative institutions in four Brazilian states, these being Amazonas (AM), Minas Gerais (MG), Mato Grosso do Sul (MS) and Rio de Janeiro (RJ) that are part of the IQG Nursing Certification, from December 2020 to June 2021, with the participation of 1484 professionals from the six invited institutions. The nursing team-physician relationships are identified as the most favorable characteristics of the work environment in the PES/NWI, and the foundations for nursing practice, however, identified as unfavorable to the participation of nursing in hospital affairs and adequacy of personnel and resources. Regarding the dimensions of the MBI research the best results are related to emotional exhaustion. However, the rates of low professional fulfillment were 69.1%. There are impacts on burnout related to emotional exhaustion and professional fulfillment related to the work environment, more frequently in the group of nurses. The analysis showed differences in the perceptions of nurses when compared to nursing assistants and technicians, with attention to inter-professional working relationships and the availability of resources. Therefore, the importance of guiding actions aimed at the management of these health resources is portrayed, with attention to the risk to the quality and safety of care, but also to the health of these professionals. The role of the leader, represented by the nurse, needs more attention and preparation, given its potential in guiding the best practices, professional engagement and promoting changes in the environment of professional practice.

Examination of Factors Affecting Therapeutic Attitude and Empowerment of Perianesthesia Nurses Who Care for Patients With Opioid Use Disorder

Patients with opioid use disorder (OUD) and associated complexities are presenting to hospitals in increasing numbers. Preparation of perianesthesia nurses caring for this patient population has lagged, with noted deficits in continuing education, resources, and role support. Previous research found education without considering therapeutic attitude (TA), empowerment and factors that influence nursing practice does not translate into feelings of competence in nursing care. The purpose of this study was to identify correlates and predictors that affect TA and empowerment among perianesthesia nurses caring for patients with OUD. A cross-sectional, correlation design was used to identify correlates and predictors of TA and empowerment in a national sample of perianesthesia nurses (N=215) METHODS: A national survey collected data from perianesthesia nurses. The Perianesthesia Nurse Empowerment and Therapeutic Attitude Model was the guiding framework. Pearson product-moment correlation and hierarchical multiple regression analyses were used to examine relationships between personal factors, the professional practice environment and societal factors of perianesthesia nurses. The standardized regression coefficients indicated the professional practice environment (β=-0.28), drug user stigma (β=0.27), access to a pain specialist (β=0.25), and exposure to drug users (β=0.25) were the strongest predictors of TA. Access to a pain specialist (β=-0.15) and the professional practice environment (β=0.72) were the strongest predictors of empowerment. The professional practice environment directly influenced the degree of empowerment and TA reported by perianesthesia nurses. Exposure to persons with OUD and personal stigmatization of persons who misuse drugs decreased TA but had no association with empowerment. Access to a pain specialist was moderately predictive of empowerment and negatively associated with TA suggesting a lack of role legitimacy and the need for further research into perianesthesia nurses' perceptions of their role when caring for this population.

Leadership, adequate staffing and material resources, and collegial nurse-physician relationships promote better patients, professionals and institutions outcomes.

To test a theoretical model aiming to understand which characteristics of the professional nursing practice environment most affect patients, professionals and institution outcomes. A cross-sectional and correlational study, using a structural equation model. One thousand seven hundred and seventy-three staff nurses were recruited using convenience sampling in five Brazilian hospitals from November 2017 to July 2018. Structural equation modelling was used to assess the relationship between the characteristics of the nursing work environment and patients (climate of safety and quality of care), nursing professionals (job satisfaction and emotional exhaustion) and institutions (intention to leave the job) outcomes. The model was tested using the partial least squares method, considering the bootstrapping technique to estimate the results. The path coefficients and their respective 95% confidence intervals were calculated. The quality of fit of the structural model was assessed by calculating the coefficient of determination (R2 ), the predictive validity coefficient (Q2 ) and the effect size (f2 ). The characteristics that most affected the outcomes for patients were Nurse manager ability, leadership and support of nurses (λ=0.27), and Staffing and resource adequacy (λ=0.26); for nursing professionals, Staffing and resource adequacy (λ=-0.19), and Collegial nurse-physician relations (λ=0.19); and for institutions, Nurse manager ability, leadership and support of nurses (λ=-0.10), and Collegial nurse-physician relations (λ=-0.10). The characteristics of the professional nursing practice environment that most contribute to achieving better outcomes include nurse manager ability, leadership and support of nurses, staffing and resource adequacy, and collegial nurse-physician relations. This study allowed us to assess which strategies should be prioritized in the professional nursing practice environment to achieve better results. Thus, investment in the training of leadership, in the adequacy of resources, and in physician-nurse relations will bring better results for patients, nursing professionals, and institutions.

Quality improvement programs and the professional nursing practice environment: an integrative review.

to analyze the knowledge produced regarding the practice environment in hospitals with quality improvement programs. integrative literature review performed in the Latin American and Caribbean Literature in Health Sciences databases, US National Library of Medicine/National Institutes of Health, Web of Science, Scopus and CINAHL, consisting in 10 articles. data were presented and discussed using categories: Measures for the professional nursing practice environment; Hospital accreditation as an improvement program; Nursing autonomy, interpersonal relationship between nurse and doctor and the nurse as a manager and leader. it was possible to analyze that the influence of quality improvement programs can be considered as favorable in the professional nursing practice environment. The survey also brings contributions to administration in implementing strategies aiming at continuous improvement in the environment characteristics.

Quality and Safety in Health Care, Part LXXX: The National Database for Nursing Quality Indicators and the Practice Environment Scale of the Nursing Work Index.

The National Database for Nursing Quality Indicators is an important source of information used to benchmark nursing by unit category in multiple areas related to not only structure and process but also outcome. It also provides some information regarding best practices and the cost to achieve certain results. The Practice Environment Scale of the Nursing Work Index is a frequently used way to measure the professional practice environment of nurses and the relationship of the latter to quality, safety, and other outcomes.

The Impact of Shared Governance Over Time in a Small Community Hospital.

This study examined the impact of shared governance (SG) on the professional nursing practice environment of a small community hospital over time. Shared governance has been shown to empower nurses in direct patient care to make decisions about their practice and improve job satisfaction. No research has been found that examined the progression of SG over time in a small community hospital. Questionnaires pertaining to the professional practice environment, perception of nursing leadership, nurse empowerment, nurse satisfaction, risk of practice errors, and comfort with evidence-based practice were administered to all nurses employed at a 149-bed community hospital in central North Carolina for 5 consecutive years. Results showed that nursing leadership and SG explained 90% of the variance in the nursing professional practice environment. This relationship held true for 5 years. All variables showed continued improvement for 4 years, until year 5 when the organization experienced disruptive change. Even during this year, the results did not return to baseline. In order to improve the professional practice environment of nurses, hospitals should focus on strong nursing leadership and a sound SG infrastructure.

Professional practice environment and burnout among nurses

Objective: to evaluate the professional practice environment of nurses, their relationship with burnout syndrome and thedifferences among three institutions. Methods: a cross-sectional study developed at one secondary and two tertiary hospitals,with 278 nurses, who filled the Nursing Work Index Revised – Brazilian Version and the Maslach Burnout Inventory. Results:most of these nurses showed job satisfaction and good quality of health care, while few informed intentions to leave theirjobs. When comparing the institutions, the secondary level one had more autonomy in nursing practice, more control overthe work environment, better relationship with physicians, and lower levels of emotional exhaustion. Conclusion: thesefindings contribute for the implementation of changes to improve the nursing professional practice, enabling to achieve thesatisfaction of those involved in the process, such as patients, professionals, and institutions.

Work and personal well-being of nurses in Queensland: Does rurality make a difference?

This study aims to ascertain if differences exist in the perception of the professional practice environment and personal well-being of nurses across different geographical areas in Queensland. This paper was performed on a prospective, self-report cross-sectional on-line survey. The study was conducted among the nurses employed in public and private health care settings: acute hospitals, community health and aged care in Queensland, Australia. Participants of this study were 1608 registered and enrolled nurses and assistants in nursing, current members of the Queensland Nurses Union in 2013 and who provided a workplace postcode. One thousand eight of these participants worked in major cities, while 382 in rural locations and 238 in remote areas. None. Scores of well-being as determined by the following scales: the Depression, Anxiety and Stress Scale, the Professional Quality of Life Scale version 5, the Connor-Davidson Resilience Scale and of the Professional Practice Environment using the Practice Environment Scale - Nursing Work Index Revised. Nurses employed in major cities perceived 'nursing foundations for quality care' more favourably than those from other settings. Remote area nurses had lower levels of secondary traumatic stress than nurses in major cities and rural areas. There was no difference between nurses across their geographical locations for stress, anxiety, depression, compassion satisfaction, burnout, resilience and the four other measures of the Practice Environment Scale. The study findings provide new data suggesting that, with the exception of secondary traumatic stress, the personal well-being of nurses does not differ across geographical settings. Similarly, with the exception of the subscale of 'nursing foundations for quality care' there was no difference in perceptions of the professional practice environment. As secondary traumatic stress is associated with burnout, this finding needs to be investigated further.

The influence of empowerment, authentic leadership, and professional practice environments on nurses' perceived interprofessional collaboration.

The aim of this study was to examine the influence of structural empowerment, authentic leadership and professional nursing practice environments on experienced nurses' perceptions of interprofessional collaboration. Enhanced interprofessional collaboration (IPC) is seen as one means of transforming the health-care system and addressing concerns about shortages of health-care workers. Organizational supports and resources are suggested as key to promoting IPC. A predictive non-experimental design was used to test the effects of structural empowerment, authentic leadership and professional nursing practice environments on perceived interprofessional collaboration. A random sample of experienced registered nurses (n=220) in Ontario, Canada completed a mailed questionnaire. Hierarchical multiple regression analysis was used. Higher perceived structural empowerment, authentic leadership, and professional practice environments explained 45% of the variance in perceived IPC (Adj. R²=0.452, F=59.40, P<0.001). Results suggest that structural empowerment, authentic leadership and a professional nursing practice environment may enhance IPC. Nurse leaders who ensure access to resources such as knowledge of IPC, embody authenticity and build trust among nurses, and support the presence of a professional nursing practice environment can contribute to enhanced IPC.

Differences in nursing practice environment among US acute care unit types: A descriptive study

BackgroundThe hospital nursing practice environment has been found to be crucial for better nurse and patient outcomes. Yet little is known about the professional nursing practice environment at the unit level where nurses provide 24-hour bedside care to patients. ObjectivesTo examine differences in nursing practice environments among 11 unit types (critical care, step-down, medical, surgical, combined medical–surgical, obstetric, neonatal, pediatric, psychiatric, perioperative, and emergency) and by Magnet status overall, as well as four specific aspects of the practice environment. DesignCross-sectional study. Settings5322 nursing units in 519 US acute care hospitals. MethodsThe nursing practice environment was measured by the Practice Environment Scale of the Nursing Work Index. The Practice Environment Scale of the Nursing Work Index mean composite and four subscale scores were computed at the unit level. Two statistical approaches (one-way analysis of covariance and multivariate analysis of covariance analysis) were employed with a Tukey-Kramer post hoc test. ResultsIn general, the nursing practice environment was favorable in all unit types. There were significant differences in the nursing practice environment among the 11 unit types and by Magnet status. Pediatric units had the most favorable practice environment and medical–surgical units had the least favorable. A consistent finding across all unit types except neonatal units was that the staffing and resource adequacy subscale scored the lowest compared with all other Practice Environment Scale of the Nursing Work Index subscales (nursing foundations for quality of care, nurse manager ability, leadership, and support, and nurse–physician relations). Unit nursing practice environments were more favorable in Magnet than non-Magnet hospitals. ConclusionsFindings indicate that there are significant variations in unit nursing practice environments among 11 unit types and by hospital Magnet status. Both hospital-level and unit-specific strategies should be considered to achieve an excellent nursing practice environment in all hospital units.

Nurse burnout: Personal and environmental factors as predictors

The aim of this study is to investigate the level of burnout of clinical nurses and to examine the influence of personal and environmental factors on nurse burnout. A total of 717 full-time nurses from six hospitals in Tianjin, China, completed five questionnaires: a demographic questionnaire, the Maslach Burnout Inventory, the General Self-Efficacy Scale, the Practice Environment Scale of the Nursing Work Index and the Nurse Job Stressor Scale. The participants had moderate levels of emotional exhaustion (mean score 23.95 ± 11.11) and depersonalization (mean score 7.90 ± 6.58) and a high level of reduced personal accomplishment (mean score 27.51 ± 10.96). Both personal and environmental factors were correlated with nurse burnout; however, personal factors played bigger roles in predicting personal accomplishment, whereas environmental factors played bigger roles in predicting emotional exhaustion and depersonalization. In order to reduce nurse job burnout effectively, administrators should pay more attention to the improvement of nurses' self-efficacy and professional nursing practice environment and the reduction of stressors.

Impact of professional nursing practice environment and psychological empowerment on nurses' work engagement: test of structural equation modelling

This study aimed to investigate the influence of professional nursing practice environment and psychological empowerment on nurses' work engagement. Previous researchers have acknowledged the positive influence that nurse work environment and psychological empowerment have on engagement. However, less is known about the mechanisms that explain the links between them. A predictive, non-experimental design was used to test the model in a random sample of 300 clinical nurses from two tertiary first class hospitals of Tianjin, China. The Utrecht Work Engagement Scale, the Practice Environment Scale of the Nursing Work Index and the Psychological Empowerment Scale were used to measure the study variables. Structural equation modelling revealed a good fit of the model to the data based on various fit indices (P = 0.371, χ(2) /df = 1.056, goodness of fit index = 0.967), which indicated that both professional practice environment and psychological empowerment could positively influence work engagement directly, and professional practice environment could also indirectly influence work engagement through the mediation of psychological empowerment. The study hypotheses were supported. Psychological empowerment was found to mediate the relationship between practice environments and work engagement. Administrators should provide a professional nursing practice environment and empower nurses psychologically to increase nurse engagement.

Professional nursing practice: environment and emotional exhaustion among intensive care nurses

to evaluate the characteristics of the professional nursing practice environment and its relationship with burnout, perception of quality of care, job satisfaction and the intention to leave the job in the next 12 months. cross-sectional study with a quantitative approach to data. The sample was composed of 129 nurses working in adult Intensive Care Units from a region in the interior of São Paulo, Brazil. The structural equation modeling, using path analysis, revealed that characteristics of the environment influence job satisfaction, perception of quality of care, and having an intention to leave their job, when mediated by emotional exhaustion. Nurses with limited autonomy, poor control over their practice, and poor relationships with physicians, experience a greater level of emotional exhaustion, which can negatively influence their perception of quality of care, job satisfaction and an intention to abandon their jobs. the mediating role of emotional exhaustion may negatively influence care delivery. Therefore, there is a need to adopt strategies to minimize this condition among nurses.

Correlation and regression analysis on nurse's job burnout, self-efficacy and work environment

Objective To investigate the status of job burnout of clinical nurses, and to analyze its relationship with self-efficacy and the environmental factors. Methods Maslach Burnout Inventory, General Self-Efficacy Scale, Nursing Work Index-Revised and Nurses' Job Stressor Scale were used to investigate 239 clinical nurses from 2 tertiary first-class hospitals of Lianyungang City. Correlation and regression analysis were used to analyze the relationship between all the dimensions of nurse burnout, self-efficacy, professional nursing practice environment and job stressor. Results The scores of emotional exhaustion and depersonalization were (23.95±11.11) and (7.90±6.58) respectively, indicating medium level of burnout. The score of decreased personal accomplishment was reverse coded, and the score was (27.51±10.96), indicating a high level of burnout. Both work environment and self-efficacy were related to job burnout (P<0.05 or P<0.01). Environment played bigger roles in influencing emotional exhaustion and depersonalization, and self-efficacy influenced personal accomplishment more significantly. Conclusion More attention should be paid to the improvement of nurses' self-efficacy and work environment in order ot reduce nurses’ job burnout. Key words: Job burnout; Nurse; Self-efficacy; Environment

The professional nursing practice environment and nurse‐reported job outcomes in two European countries: a survey of nurses in Finland and the Netherlands

The working environment of nurses is receiving international interest, because there is a growing consensus that identifying opportunities for improving working conditions in hospitals is essential to maintain adequate staffing, high-quality care, nurses' job satisfaction and hence their retention. Thus, the aim of this study was to investigate the relationship between nurse work environment characteristics and nurse-reported job outcomes in hospital settings in Finland and the Netherlands and to compare these results. A comparative cross-sectional nurse survey was conducted. Data were collected from the two countries randomly sampling the countries' National Nurses Association' membership databases. In this paper, the results from Registered Nurses working in hospital settings are used. In total, 869 hospital nurses participated: 535 from Finland and 334 from the Netherlands with the response rate of 44.9 and 33.4%, respectively. Fifty-five items from the Nursing Work Index-Revised were used as a main tool for the practice environment. Exploratory factor analysis was used to identify a set of internally consistent subscales. Further, logistic regression analysis and T-tests were used. Three practice environment characteristics were identified: adequacy of resources, supportiveness of management and assurance of care quality via collaborative relationships. Favourable evaluations of the adequacy of resources and supportiveness of management were positively correlated with nurse-assessed quality of care and job-related positive feelings and negatively correlated with intentions to leave a unit, organization or the entire profession. In neither of the participating countries were adverse incidents affecting nurses related to nurses' evaluations of their current professional practice environment. Compared with Finland, in the Netherlands, RN appears to evaluate the majority of work environment characteristics more positively; nevertheless, to some extent, the results were uniform as adequacy of resources and supportiveness of management were main predictors for nurse-reported job outcomes considered.

Validation of the Brazilian version of the Nursing Work Index‐Revised (B‐NWI‐R)

The goal of this paper was to evaluate the reliability and validity of the Nursing Work Index-Revised-Brazilian version (B-NWI-R). Some instruments evaluate the presence of certain characteristics in the professional practice environment of nurses. Among them, the B-NWI-R, often cited in the literature and which is examined in the present study. This instrument is composed of 57 items and four subscales: autonomy, control over the work environment, nurse-physician relationships and organisational support. A cross-sectional research design was carried out in three public university hospitals in the State of São Paulo, Brazil. The sample was composed of 278 nurses. The reliability of the instrument was evaluated through its homogeneity, using the Cronbach's alpha coefficient. The validity of the subscales of the B-NWI-R was evaluated through divergent construct validity and criterion-related validity. For the divergent construct validity, the Brazilian version of the Maslach Burnout Inventory (MBI) was employed, while for the criterion-related validity, variables such as 'satisfaction at work', 'perception of quality of care' and 'nurses' intention to leave work in the following year' were considered. The results showed satisfactory consistency for the total of the items (α=0·95) and for the subscales of the B-NWI-R: 'control over practice settings' (α=0·75); 'nurse-physician relationships' (α=0·75); 'organisational support' (α=0·75) and 'autonomy' (α=0·63). The divergent validity resulted in significant correlation between the adapted instrument subscales and those of the MBI. In addition, a significant correlation was obtained between the subscales of the B-NWI-R and the variables 'perception of quality of care', 'satisfaction at work' and 'intention to leave work in the following year'. The reliability and validity of the B-NWI-R have been established. The B-NWI-R subscales can be used to assess the nurses' perceptions of the work environment.

Validation of the Professional Practice Environment Scale in Australian General Practice

To validate the Professional Practice Environment Scale (PPE) in Australian general practice. The PPE was modified slightly for appropriateness for the practice setting and administered to a sample of 342 Australian general practice nurses via an online survey tool. The factor structure of the 38-item PPE was examined using principal components analysis with Varimax rotation. An eight-factor solution accounted for 71.6% of the variance. Low factor loading (<0.3) or cross-component loadings were detected in eight items. A comparison of Cronbach's alpha values demonstrated little change in the deletion of eight items from four of the eight related components. Findings demonstrated that a 30-item version of the PPE was reliable and valid for use to assess the professional practice environment of nurses working in Australian general practice. A tool to measure the professional practice environment in general practice is important as it will assist in monitoring the impact of the work environment on the recruitment, retention, and satisfaction of nurses in this setting.

Public health nurses’ perceptions of the professional practice environment in New Zealand

BackgroundThe professional practice environment of hospital-based nurses has been the focus of considerable attention over the last few decades. More recently, attention has been paid to the community nursing environment, and this study considers the context of public health nursing in New Zealand.AimThe purpose of the study was to identify the organizational attributes that public health nurses consider important, and those that are considered less important, for professional practice and to rate the presence of these attributes within the public health nurses’ work environment.MethodIn all, 167 public health nurses across New Zealand assessed the importance and presence of 48 organizational attributes in the nursing work environment using the Nursing Work Index-Revised (NWI-R). This instrument was developed from work with Magnet hospitals in the US and is designed to measure attributes of the professional nursing environment. Frequency distributions and difference scores were calculated using SPSS-PC.FindingsResults showed that there was strong agreement that most NWI-R attributes were considered important for professional practice, the most highly endorsed relating to support from the organization, education/orientation and staffing. However, agreement that these attributes were actually present in the current work environment was much less strong. Participants also generated additional ideas for attributes considered important for public health nursing practice and these were categorized under four headings concerning specialty practice, resources, networking and education/research.