대한응급의학회지제 30 권제 3 호 Volume 30, Number 3, June, 2019 원 저 Education 구글행아웃을이용하여원격화상회의로진행한응급의학과전공의교육경험 한상길 홍주영 황윤정 박인철 정성필 조준호 연세대학교의과대학응급의학교실 The experience of remote videoconferencing to enhance emergency resident education using Google Hangouts Sang Gil Han, Ju-young Hong, Yoong Jung Hwang, Incheol Park, Sung Phil Chung, Junho Cho Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea Objective: It is difficult for emergency residents to attend all the lectures that are required because of the limited labor time. The Google Hangouts program for has been used as a remote videoconference to overcome the limit to provide equal opportunities and reduce the time and costs since 2015. This article reports the authors experiences of running a residency education program using Google Hangouts. Methods: From 2015, topics on the emergency radiology were lectured to emergency residents in three different hospitals connected by Google Hangouts. From 2017, electrocardiography analysis, emergency radiology, ventilator application, and journal review were selected for the remote videoconference. The residents' self-assessment score, and a posteducation satisfaction questionnaire were surveyed. Results: Twenty-nine emergency residents responded to the questionnaire after using the Google Hangouts. The number of participants before and after Hangout increased significantly in other two hospitals. All the residents answered that the score on achieving the learning goal increased before and after the videoconference lectures. All the residents answered that the training program is more satisfactory after using the Google Hangouts than before. Conclusion: All emergency residents were satisfied and were more confident after the remote videoconference education using the Google Hangouts than before. Keywords: Videoconferencing; Emergency medicine; Education; Hangout 서론응급의학과전공의교육에있어저널클럽, 증례토의, 토픽발표등은꼭필요하다. 이는의사가알아야할여러가지지식을비판적으로평가하고간접적으로라도환자경험을통해전문가로성장하는데중요한교육방법이기때문이다. 2013년에 Annals of Emergency Medicine과 Academic Life in Emergency Medicine (ALiEM) 은공 동으로 social media based global emergency medicine journal club을시작하였다. 1 이는의사가저널을평가하는능력을갖는것이매우중요한데이런교육을받을수없는상황의의사에게여러곳에서동시에화상연결프로그램을이용하여교육을진행하고자하는목적으로시도하였다. 이와같이공간과시간의제약을뛰어넘는교육이의사와간호사를대상으로다양하게시도되고있다. 2-6 행아웃은 2011년구글에서만들어발표한화상채팅과메시지를할수있는플랫폼이다. 이기술은참가자들이다른장 책임저자 : 조준호서울특별시서대문구연세로 50-1 연세대학교의과대학응급의학교실 Tel: 02-2228-2460, Fax: 02-2227-7908, E-mail: emjh@yuhs.ac 접수일 : 2018년 9월 6일, 1차교정일 : 2018년 10월 1일, 게재승인일 : 2018년 10월 10일 224
Emergency resident education using Google Hangouts / 225 Capsule Summary What is already known in the previous study Videoconference education has already been applied to various fields, such as nursing and rehabilitation. What is new in the current study The videoconference education using the Google Hangouts is a good tool to overcome the limit to provide equal opportunities and reduce the time and costs. 소에서화상회의를할수있고개인화면을공유할수있으며문자대화도가능하고동시에문서들을편집할수있다. 7 이러한프로그램을이용하여전공의교육을시도하고있다. 8 구글행아웃을이용하면실시간토론이나문답이가능하기때문에저널클럽에서학습자와저자가논문결과해석등에대해직접실시간문답을할수있다. 9 예를들어지주막하뇌출혈환자에대한임상결정, 저체온요법에관한논문을주제로저자와실시간문답하는것을찾아볼수있다. 본병원응급의학과전공의 29명은수련병원 3곳에서순환근무를하고있다. 이병원들은각각 1시간이상교통시간이걸리는곳에위치해있기때문에전공의를한곳에모아교육하는것은전공의개인으로보면시간낭비가많다. 또한전공의숫자가늘어나고, 근무병원순환, 그리고특히응급의학과는근무시간이 24시간, 365일이기때문에전공의가모든교육에동시에참석하기가어려운현실이다. 학회조차도근무스케줄때문에참석못하는전공의가많아서유명석학의한번뿐인강의는못듣는전공의가발생하게된다. 더구나각병원으로오는질환군도다르고근무시간대에따라오는환자특성도다르기때문에응급의학과전공의교육은균등한기회제공이매우힘들다. 최근에는전공의특별법으로인해주당근무시간과교육시간도엄격히제한하고있기때문에전공의교육이더욱어려워졌다. 이와같은상황은응급의학과전공의를수련하는병원에서비슷하게겪는어려움일것이다. 이에전공의수련에있어교육기회를균등하게제공하고투입하는시간과기회비용을줄이고자본병원에서행아웃을이용하여원격으로전공의수련프로그램을운영한경험을보고하고자한다. 방법본병원은각년차마다 8명전공의를수련병원 3곳에서순환근무를하여교육을하고있다. 수련교육프로그램은 진료, 전공의블록활동 (resident block activity), 저널클럽, 증례토의, 토픽발표, 각종워크샵참석등으로이루어져있다. 이가운데토픽발표는영상해석, 인공호흡기, 심전도를주제로전공의가준비하여발표하였는데, 3개병원가운데 2개병원에서각각다른전공의가진행하였다. 저널클럽도각병원에서진행하였다. 이과정에서근무나휴가로인해참석하지못하는전공의가발생하였고같은주제라도발표하는전공의에따라내용이달랐다. 이를해결하기위해 2015년부터 3개병원에서행아웃을통해교육내용을공유하는방안을채택하였다. 행아웃연결을위해각병원회의실에이미설치되어있는컴퓨터에웹캠과마이크를설치한뒤행아웃프로그램작동을연습하였다. 여러명이동시에접속하여도작동에문제가없음을확인한뒤일주일에두번씩한병원에서발표를진행하면다른병원의전공의들도행아웃을통해참여할수있도록하였다. 처음단계에서는한병원에서발표하는내용을다른두병원에출근한전공의들이행아웃에연결하여듣는방식으로진행을하였다. 영상해석이이와같은강의에적절한주제로생각하여이를시작으로점차익숙해짐에따라주제를확대하여심전도, 독성학, 연구방법론등에대해교육을진행하였다. 교육은매주화요일과목요일아침 8시 30분부터한주제당 15분정도로진행하였고내용및진도는전공의가자율적으로준비하도록하였다. 휴가중이거나근무가아니어서병원에출근하지않은전공의들도교육내용에관심이있을때는핸드폰등으로도접속할수있도록하였다. 2016년에는행아웃의교육주제를확대하여저녁시간교실에서주도하는전공의를대상으로한 resident block activity에도적용하였고신입예비전공의교육에도적용하였다. 한병원에서발생한진료과정문제도다른병원전공의와공유할수있었다. 행아웃을통해교육이지속되면서너무다양한주제가다뤄지고주로글로이루어진슬라이드를보면서진행하는강의는집중도가떨어지는문제점이있어 2017년부터는행아웃을통한교육에적합한주제를선별하여심전도분석, 영상해석, 인공호흡기적용, 논문리뷰를주제로정하였다 (Table 1-3). 교육내용과시간은한달전미리전공의들에게공지하였다. 또한전공의발표위주로진행하던것을각주제당한명의전문의가함께내용을준비하도록하였고각주제당교육시간은 20분으로하여한주에 3 개주제를목요일아침 7시 30분부터 1시간에걸쳐교육을진행하였다. 29명의전공의가운데근무자를제외한 18-20명정도의전공의와 6명이상의전문의가아침교육에참석하였다. 2017년현재전공의 29명을대상으로설문조사를시행하였다. 행아웃을이용한교육에참여한횟수, 교육참여에필요한시간, 각주제별교육전후자가평가점수, 행아웃
226 / 한상길외 Table 1. Curriculum of residency education program (emergency radiology) using Google Hangouts Week Topic 01 Brain CT: normal finding, skull fracture, brain hemorrhage, etc. 02 Chest X-ray: normal finding, rib fracture, pneumonia, etc. 03 Basic of lung ultrasound 04 Basic of emergency echocardiography: pulmonary thromboembolism, aorta dissection, etc. 05 Chest CT (1): normal finding, pneumonia, lung abscess, pulmonary thromboembolism, etc. 06 Chest CT (2): rib fracture, pneumo-hemothorax, esophageal rupture, etc. 07 Hand, wrist X-ray: normal finding, fracture, etc. 08 Elbow, humerus X-ray 09 Shoulder, clavicle, scapula X-ray 10 Foot, ankle X-ray 11 Pelvis, femur, knee X-ray 12 Cervical spine, thoracolumbar spine X-ray 13 Abdomen pelvis CT (1): normal finding, appendicitis, diverticulitis 14 Abdomen pelvis CT (2): pneumatosis of intestine, superior mesenteric artery occlusion, ischemic bowel disease 15 Abdomen pelvis CT (3): cholecystitis, cholangiohepatitis, liver abscess, pancreatitis 16 Abdomen pelvis CT (4): acute pyelonephritis, renal abscess, renal infarction 17 Abdomen pelvis CT (5): pelvic inflammatory disease, tubo-ovarian abscess, ovarian torsion, hemoperitoneum 18 Brain CT perfusion: technique, normal and ischemic perfusion patterns 19 Brain MR systemic reading (1): normal finding, artifact, acute ischemic stroke, hemorrhage 20 Brain MR systemic reading (2): herpes encephalitis, carbon monoxide poisoning, acute hypertensive encephalopathy 21 Brain MR systemic reading (3): diffuse axonal injury, dural sinus thrombosis, cortical venous thrombosis, Wernicke encephalopathy 22 Spine MR systemic reading (1): normal finding, artifact, space occupying lesion (epidural abscess, spinal mass, epidural hemorrhage) 23 Spine MR systemic reading (2): spinal cord injury, myelitis, spinal cord infarction 24 Obstetrics-gynecology, Urology disease: CT, ultrasound, scrotal ultrasound 25 Pregnancy related image: MRI appendicitis 26 Lung sonography (Blue protocol) 27 RUSH protocol 28 Echocardiography and Culprit artery CT, computed tomography; MR, magnetic resonance; MRI, magnetic resonance imaging. Table 2. Curriculum of residency education program (electrocardiography) using Google Hangouts Week Detail topic 01 Basic interpretation of electrocardiography: Axis, Lead 02 STEMI: Basic outline 03 STEMI: Culprit artery I LAD 04 STEMI: Culprit artery II LCx, RCA 05 STEMI in Bundle Branch Block, Pacemaker rhythm 06 STEMI equivalent 07 Wellens syndrome 08 Atrial fibrillation, atrial flutter 09 Atrioventricular block, Junctional arrhythmia and bradycardia 10 PSVT:AVRT, Wolff-Parkinson-White syndrome, AVNRT 11 Ventricular tachycardia: RVOT, LVOT, Brugada syndrome 12 PSVT vs. ventricular tachycardia, Brugada criteria 13 Bundle branch block 14 Electrolyte imbalance, drug intoxication 15 Hypothermia, intracranial hemorrhage STEMI, ST-segment elevation myocardial infarction; LAD, left anterior descending coronary artery; LCx, left circumflex coronary artery; RCA, right coronary artery; PSVT, paroxysmal supraventricular tachycardia; AVRT, atrioventricular reentrant tachycardia; AVNRT, atrioventricular nodal reentry tachycardia; RVOT, right ventricular outflow tract; LVOT, left ventricular outflow tract.
Emergency resident education using Google Hangouts / 227 전후만족도도조사하였다. 각주제별교육전후자가평가점수및행아웃전후만족도는최소 1점, 최대 10점으로 1 점단위로배정하였다. 29명전공의중 11명은행아웃을이용한교육적용이전고식적강의와행아웃을이용한교육을경험한전공의로이들을대상으로교육참여횟수와투입시간을행아웃교육적용전후로나누어비교하였다. 통계분석은 R ver. 3.2.2 (The R Foundation for Statistical Computing, Vienna, Austria) 를이용하였다. 평가점수비교는 Wilcoxon rank sum test를, 빈도비교는 chi 제곱검정법과 Fisher exact test 검정법을사용하 였으며 P값 0.05 이하를통계학적으로의미있다고정의하였다. 결과 29명의전공의가설문에응답하였다. 행아웃을이용한교육이후한달평균교육참여횟수는세병원에서각각 2.3회, 2.7회, 3.2회였으며참여를못하는이유는모두근무스케줄때문이었다. 교육참여에투입되는월평균시간은 Table 3. Curriculum of residency education program (ventilator apply) using Google Hangouts Week Topic 01 Principles of mechanical ventilation 02 Ventilator setting in special situation: head/chest trauma 03 Ventilator setting in special situation: obstructive lung disease/heart failure 04 Ventilator setting in special situation: burn and inhaled injury/acute respiratory distress syndrome 05 Monitoring during mechanical ventilation 06 Trouble shooting Table 4. The average number of participations in education Hospital No. of participations P-value A 1.5±1.0 2.1±1.0 0.131 B 1.9±0.7 2.8±1.0 0.034 C 2.2±1.3 3.5±1.8 0.041 Table 5. The average time to participate in education Hospital Time to participate (hour) P-value A 1.7±1.0 1.5±0.9 0.157 B 2.0±1.3 2.0±1.1 0.564 C 1.8±1.2 1.5±1.2 0.564 Table 6. The self-assessment score about the learning goal before and after the training using Hangout (emergency radiology) Emergency radiology Self-assessment score P value How to read X-ray; to know sign that suggests a fracture 5.6±1.9 7.4±1.7 <0.001 Basic findings of brain CT 6.1±1.6 7.8±1.1 <0.001 Findings of acute abdomen: abdomen-pelvic CT 6.1±1.5 7.6±1.0 <0.001 Imaging findings of fatal disease in chest CT 5.8±1.5 7.4±1.0 <0.001 CT, computed tomography
228 / 한상길외 각각 A병원 1.5시간 (±1, P=0.131), B병원 1.9시간 (± 0.7, P=0.034), C병원 1.4시간 (±1.3, P=0.041) 이었다. 행아웃을적용하기이전과이후의교육참여횟수와투입시간비교는두시기를경험한 11명의전공의설문을비교하였다. 교육참여횟수는 B, C 병원에서유의미하게증가하였다 (Table 4). 교육에투자되는시간도평균수치는감소하였지만통계적의의는없었다 (Table 5). 1. 각학습목표에관한자가점수측정 29명모든전공의가교육을받은후가교육을받기전보다학습목표에대한자가측정점수가높아졌다고응답하였으며모두통계적의의를가졌다 (Table 6-9). 2. 전공의만족도행아웃을이용한교육에얼마나만족하는지에대한설문에 29명모두행아웃을이용한교육을받았을때더만족스럽다고응답하였다 (Fig. 1). 고찰이번연구에서설문에참여한응급의학과전공의 29명은행아웃을이용한교육방법에만족한다고답변하였으며스스로평가한학습목표에대한자가측정점수도교육이전보다이후가높았다. 행아웃을이용하기전을경험한전공의 11명을대상으로추가적으로분석한결과행아웃을이용하기전보다이용한후교육참여횟수가유의미하게증가하였으며, 이는이전발표되었던아래논문들과비슷한결과를보인다. Chipps 등 10 은 1990년부터 2011년까지의사와간호사교육에있어화상회의기반원격교육효과를기존대면강의와비교한논문을조사하여, 비록분석한 5개논문이연구방법론의한계가있으나그효과가비슷하여이런교육방식을추천한다고하였다. 치과의사를대상으로미리녹화된 25개의세미나를시청하고미국오하이오와북캐롤라이나에있는학생과교수가화상회의를통해토론하는수업에참여하였는데 256명전공의와 42명교수들이이런수업방식이효과적이고즐거웠다고대답하였다. 4 브라질 Fig. 1. Satisfaction survey. The higher score is the better satisfaction. All scores after Hangout lectures are increased significantly (P<0.05). Question 1: Overall, it was a useful lecture; Question 2: I got a lot of knowledge through this lecture; Question 3: I participated actively in this lecture; Question 4: Allocation of lecture time was appropriate; Question 5: The difficulty of the lecture was appropriate; Question 6: I fully understood the content of the education through this lecture; Question 7: This lecture was enough to draw my interest and interest; Question 8: I would like to recommend this class to another student.
Emergency resident education using Google Hangouts / 229 에서간호대생을대상으로화상회의기술을이용하여원격으로근육주사놓는방법을교육한뒤마네킹에실습을하는교육에대하여도참가자들은집중할수있었고 (93%), 배움에도움이되었다 (87%) 라고응답하였다. 3 캐나다에서 200 km 떨어진두병원에서화상회의장비를이용하여비뇨기과의사를대상으로소아비뇨기과내용을주제로 4주간 60분가량의 4개강의를진행하고이런교육의효과, 장비사용에있어쉬움, 추후이와같은세미나를또참여할지에대한설문에 5점만점에 4.5를주었으며특이하게도같은강의를대면으로진행했다고해서더나아지지않았을것이라고모두대답하였다. 5 브라질에서도최대 2,660 km 떨어진두장소에서다리절단환자와허리통증환자재활치료교육에화상회의, 인터넷기반교육, 화상회의기반워크샵, 인터넷을통한토론수업을진행한경우에도무리없이진행할수있었다고보고하였다. 2 미국과우간다에서마취과전공의를대상으로 Skype 를통해강의를진행하고전후시험점수를비교해보니대면강의를들은군과화상회의를통해강의를들은군모두강의후점수가통계적으로유의미하게상승하였다. 6 하지만이런교육방법이성공하려면다음과같은전략과제한점을고려하여야할것이다. 7 우선강의자가이와같은인터넷기반교육방법에노출된지얼마안되어교육에이런기술을도입하는데주저하게된다. 그로인해이러한기술이가지고있는잠재적교육효과를얻지못하고있다. 이의극복을위해구글행아웃과같은프로그램을교육에도입하기전교육자와피교육자를대상으로워크샵을시행해볼수있다. 전공의들이개인노트북이나스마트폰을이용하는경우딴짓을하거나강사가이런전공의들의모습을보면서자기강의에집중하지못한다고오해하는경우도발생한다. 하지만이는기존강의방법에서도마찬가지로인터넷을이용한교육에만국한된문제라고는볼수없다. Table 7. The self-assessment score about the learning goal before and after the training using Hangout (electrocardiography) Electrocardiography Self-assessment score P-value Analysis of waveform (P, Q, R, S, T) in electrocardiography 6.5±2.0 7.6±1.5 0.003 To predict the culprit artery based on electrocardiography 5.7±2.0 7.8±1.5 0.000 To know STEMI equivalents and STEMI mimics 5.8±2.1 7.8±1.4 0.000 To distinguish cause of wide QRS tachycardia 5.2±2.0 6.8±1.7 0.000 To distinguish cause of narrow QRS tachycardia 5.3±2.0 6.8±1.7 0.000 STEMI, ST-segment elevation myocardial infarction; QRS, QRS complex. Table 8. The self-assessment score about the learning goal before and after the training using Hangout (ventilator apply) Ventilator apply Self-assessment score P-value How to apply the initial ventilator settings 4.9±2.3 6.3±1.8 <0.002 To know the key points of ventilator setting for each disease like ARDS, PTE, etc. 4.6±2.3 6.8±1.8 <0.001 Interpretation of ventilator waveforms 4.8±2.2 6.6±1.6 <0.001 How to fix and know the cause when ventilator alarms on 4.6±2.4 6.5±1.8 <0.000 ARDS, acute respiratory distress syndrome; PTE, pulmonary thromboembolism. Table 9. The self-assessment score about the learning goal before and after the training using Hangout (journal club) Journal club Self-assessment score P-value To know the basic structure of the article 4.6±2.3 5.7±2.0 <0.001 Understanding the basic medical statistics to interpret articles 4.2±2.1 5.5±1.7 <0.001 To note considerations when set a hypothesis 4.0±2.0 5.4±1.8 <0.001 Try to design your own research 3.8±2.0 5.0±1.7 <0.001
230 / 한상길외 또한기존교육방법에비해학습주제도공평하게다뤄지지않을가능성이높다. 인터넷과소셜미디어에적합한주제만선택하게될수있다. 연구자들도처음주제를정할때심전도를정한이유가그것이다. 그러므로모든교육을이새로운방법만으로고집해서는안될것이다. 마지막으로환자정보를공유하는데있어개인권리침해문제가발생할여지가있다. 현재기술에서도쌍방향대화가가능하기는하지만, 더욱활발할대화가이뤄지도록채팅창을적극적으로활용해야할것이고이를위해모든참가자들이노트북이나스마트폰을가지고수업에참여할수있어야할것이다. 그렇게된다면교수자의일방적인수업진행보다는교수자와학습자가모두강의에참여하는수업을만들어나갈수있을것이다. 8 화상회의기술을사용하여교육을진행할때에는아래와같은실수를피하여야한다. 첫째, 발표자가레이저포인터로슬라이드의특정부분을강조하는경우무의식적으로 여기, 저기 등지시대명사를사용하는경우가있는데원격지에있는청중은발표자모습과레이저포인터가가리키는부분이어디인지알수없기때문에설명을따라가지못하고집중도가떨어진다. 둘째, 동영상이나파워포인트슬라이드에서사용하는애니메이션기능등슬라이드화면에움직임이있는경우인터넷속도에따라끊김현상혹은작동이잘안되어강의자가기대하는효과를얻을수없다. 셋째, 원격지에서여러명이듣는경우개인헤드셋을사용하지않고스피커와마이크를사용하는경우하울링현상이발생한다. 원격지에서는마이크를꺼놓고강의를듣다질문이나할말이있는경우에만마이크를켜서사용하여야이런현상을피할수있다. 마지막으로 2018년우리병원은보안문제로외부인터넷망과내부인터넷망구별을엄격하게하여원내망을이용하여구글행아웃을사용할수없게만들었다. 원내망과는별도의인터넷을사용해야한다. 본연구는전공의 80시간근무제한으로인해전공의교육시간확보에어려움을겪는응급의학과수련에해결책을제시할수있는첫단초를제공한다는장점이있다. 또한화상회의기술이각병원과지역특성때문에발생할수밖에없는교육기회의불균등을해결할수있는방법이될수있다는가능성을제시하였다. 또한특별한장치가필요없이인터넷에연결된컴퓨터와카메라, 마이크만있으면일반적인수련병원에서도충분히시도해볼수있는교육방법이다. 미래에는페이스북라이브등녹화기능을이용하여근무로인해듣지못하는전공의에게도기회를제공하고, 수련취약병원의전공의들에게도교육기회를넓힐수있으며, 대한응급의학회차원에서도전국응급의학과전공의수련에꼭필요한주제등을전달할수있을것이다. 또한현재소규모연구회활동이활발하게진행되고있 고그수준이점차높아지고있지만이또한거리, 시간, 비용문제로모든전공의에게균등한교육기회가주어지지않는현실을극복할수있을것이다. 이번연구의제한점으로교육에참여한전공의수가적은점, 교육효과를객관적으로비교하지못한점이있다. 이는앞으로이교육을진행하고확대적용하여많은전공의가참여하게하고학회인트레이닝시험점수나병원에서시행하는시험점수를비교해볼수있겠다. 마지막으로기존에행하던고식적인강의방식과행아웃을이용한방식을직접적으로비교하지못하였다. 기존고식적인교육방법에대한자료도없을뿐만아니라, 두교육방법을비교하기위하여는전향적무작위배당연구가필요하다. 요약하자면, 연구자는구글행아웃이라는프로그램을이용하여전공의교육을시도해보았고, 학습자가스스로생각하기에교육목표달성이나교육주제에관한자신감은기존강의방법보다나쁘지는않았다고하였다. 향후교육효과를객관적자료를바탕으로평가할필요가있다. ORCID Sang Gil Han (https://orcid.org/0000-0002-0893-6271) Ju-young Hong (https://orcid.org/0000-0003-3416-3054) Yoon Jung Hwang (https://orcid.org/0000-0001-7286-7699) Incheol Park (https://orcid.org/0000-0001-7033-766x) Sung Phil Chung (https://orcid.org/0000-0002-3074-011x) Junho Cho (https://orcid.org/0000-0003-2240-3989) CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. REFERENCES 01. Radecki RP, Rezaie SR, Lin M. Annals of Emergency Medicine Journal Club. Global Emergency Medicine Journal Club: Social media responses to the November 2013 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2014;63:490-4. 02. Kavamoto CA, Wen CL, Battistella LR, Bohm GM. A Brazilian model of distance education in physical medicine and rehabilitation based on videoconferencing and Internet learning. J Telemed Telecare 2005;11 Suppl 1:80-2. 03. de Godoy S, Costa Mendes IA, Hayashida M, Nogueira MS, Marchi Alves LM. In-service nursing education
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