ePULab

An Adaptive e-Learning Tool for Pressure Ulcer Evaluation

Laura Morente

and Francisco J. Veredas

Escuela Universitaria de Enfermer´ıa, Diputaci´on Provincial de M´alaga, M´alaga, Spain

Dpto. Lenguajes y Ciencias de la Computaci´on, Universidad de M´alaga, Bulevar de Louis Pasteur s/n, M´alaga, Spain

Keywords:

Pressure Ulcer, e-Learning, Adaptive Tutorial Systems, Image Processing, Computational Intelligence,

Nursing Informatics.

Abstract:

Pressure ulcers (PrU) are considered as one of the most challenging problems that Nursing professionals

have to deal with in their daily practice. Nowadays, the education on PrUs is manly based on traditional

lecturing, seminars and face-to-face instruction, sometimes with the support of photographs of wounds being

used as teaching material. This traditional educational methodology suffers from some important limitations,

which could affect the efﬁcacy of the learning process. This current study has been designed to introduce

information and communication technologies (ICT) in the education on PrU for undergraduate students, with

the main objective of evaluating the advantages an disadvantages of using ICT, by comparing the learning

results obtained from using an e-learning tool with those from a traditional teaching methodology. In order to

meet this major objective, a web-based learning system named ePULab has been designed and developed as

an adaptive e-learning tool for the autonomous acquisition of knowledge on PrU evaluation. In this article, the

ePULab software is described in details and the general results from an experimental educational validation

study are also presented and analysed.

1 INTRODUCTION

The European Pressure Ulcer Advisory Panel

(EPUAP) deﬁnes a pressure ulcer (PU) as an area of

localized damage to the skin and underlying tissue

caused by pressure, shear, friction and or a combi-

nation of these (European Pressure Ulcer Advisory

Panel (EPUAP), 1999; Gawlitta et al., 2007). The

pressure ulcers (PrU) are considered as one of the

most challenging problems for Nursing profession-

als in their daily practice, whatever is the assistance

speciality they are working on. The PrU care usu-

ally suffers from a high variability and uncertainty in

decision-making tasks carried out by nurses, not only

when dealing with preventionstrategies but also when

considering the evaluation of the wound and the phar-

macological treatment to be administered (Demarre

et al., 2011; Revello and Fields, 2012). All these as-

pects are on the basis of the interests that Nursing

professionals pursue when they are proposed to en-

rol an education activity to improve their skills in PrU

evaluation and wound care-taking. On the other hand,

getting a better education on PrU diagnosis and treat-

ment, not only by professionals but also by undergra-

duate students, could become the most effective strat-

egy to reduce the use of pharmacological products

with non-yet-demonstrated beneﬁts, and also to ho-

mogenize the clinical interventions and increase the

efﬁciency of decision-making protocols for PrUs.

Nowadays, the education on PrUs for undergradu-

ate students is mainly based on traditional on-campus

learning, with face-to-face classes and the common

use of real PrU photographsas teaching aid. The most

frequent educational objectivesare usually focused on

two main aspects: 1) to facilitate the comprehension

of the risk factors related to PrU incidence and pre-

vention; and 2) to provide the students with the nec-

essary knowledge to identify accurately and classify

correctly each one of the different types of wounds,

on the basis of the four classical PrU evolution stages

proposed in USA in 1989 by the NPUAP (National

Pressure Ulcer Advisory Panel), and adapted with mi-

nor changes in 1.999 by the EPUAP (The European

Pressure Ulcer Advisory Panel) in Europe (Deﬂoor

and Schoonhoven, 2004). Furthermore, that theo-

retical education is usually complemented with other

practical activities, which the students can carry out

when attending the practical clinical sessions in which

155

Morente L. and J. Veredas F..

ePULab - An Adaptive e-Learning Tool for Pressure Ulcer Evaluation.

DOI: 10.5220/0004187901550160

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2013), pages 155-160

ISBN: 978-989-8565-37-2

 2013 SCITEPRESS (Science and Technology Publications, Lda.)

they are able to observe PrU wounds in a real clinical

context and try the therapeutic criteria they learned

at the classroom. Nevertheless, this traditional ed-

ucation suffers from some important limitations that

could compromise the efﬁcacy of the learning pro-

cess: on one hand, in traditional education schemes

the students behave usually as passive subjects dur-

ing their learning process, as the classical teaching

methodology is difﬁcult to arouse their motivation

and interest; on the other hand, a high variability in

the learning process is generated during the clinical

sessions, so that it is not possible to control the en-

tire educational environment —its ﬁnal conﬁguration

depends on the eventual existence or absence of PrU

wounds in the clinical unit in which each student is

temporary practising, as well as on the offer of oppor-

tunities for the student to get involved in the care of

the existing PrUs of that clinical unit. Having all these

aspects into account, it is not possible to guarantee

that all the students can observe and care PrUs and,

furthermore, the number of PrUs that each student can

observe is limited and different to that of their class-

mates; ﬁnally different evolution stages and high vari-

able treatments could be found by each student when

dealing with the PrUs of patients in the clinical unit

they are involved in during their practical sessions.

To conclude, the traditional education on PrUs makes

difﬁcult to homogenize the acquisition of knowledge

and practice by the undergraduate students, while it

does not guarantee yet the learning of the same con-

cepts and the enjoyment of the same education op-

portunities on PrUs evaluation. This fact could also

determine the subsequent variability of the PrU care

carried out by the Nursing professionals when the join

ﬁnally the Health system. Moreover, the continuing

education on PrUs of these Nursing professionals usu-

ally suffers from the same limitations as the under-

graduate education above, as it is difﬁcult to arouse

the motivation and participation of these Health work-

ers in their own education on PrU diagnosis and treat-

ment.

With the aforementioned problems, this current

study has been designed to introduce the information

and communication technologies (ICT) in the educa-

tion on PrUs for undergraduate students, and evaluate

its advantages by comparing the results from this e-

learning strategy with those obtained with traditional

teaching methods. Many studies have appeared in the

last decade which show the impact of ICT on Nursing

education (see (Bloomﬁeld et al., 2008) and (Ains-

ley and Brown, 2009) as two conclusive reviews on

this particular subject). However, although the meth-

ods based on e-learning have gained an increasing

popularity in the last few years and become effective

strategies constituted as a real alternativeto traditional

teaching tools, some authors have recently pointed to

the necessity of improving the validity of the studies

which evaluate the effectiveness of e-learning tools,

advancing by this way to the optimization of the

methodological design of those studies (Bloomﬁeld

et al., 2008).

2 ePULab E-LEARNING TOOL

The design of the ePULab (educational-Pressure Ul-

cer Laboratory)software has been focused on the reg-

istering of PrU photographs, their automatic segmen-

tation, the computer-assisted labelling of all the tis-

sues present in the PrU images by using artiﬁcial vi-

sion techniques (Veredas et al., 2010), and the col-

laborative work for mutual evaluation of PrUs done

by Nursing professionals and other clinical experts.

On one hand, the speciﬁcation the ePULab system

includes the design of some modules to manage the

different educational levels of the students. These

modules adapt the educational level of the system to

the learning necessities of each student during their

evolutionary learning cycle. On the other hand, the

design of the ePULab system has been oriented to

allow the monitoring of the progresses made by the

students, while giving also support to the teachers

to analyse the learning objectives that their students

achieve, therefore making possible the subsequent

generation of reports and statistics on the progresses

and marks obtained by the students. The ePULab sys-

tem allows the users to have both an on-line or an off-

line learning, therefore making the time consumed by

the learning process more ﬂexible and adaptable.

2.1 ePULab Teacher’s Interface

The so-called teacher’s interface (Figure 1) allows

the lecturer to insert new PrU cases in the system,

as well as edit their clinical information —which in-

cludes the possibility of uploading PrU photographs

and their image segmentation maps— and all the rel-

evant information about the PrU evaluation: local fea-

tures such as classiﬁcation, PUSH (Pressure Ulcer

Scale for Healing) index, presence of infection signs

or smell, state of the surrounding skin, depth, pres-

ence of cavitation, amount of exudate existing in the

wound, etc.; treatment information such as dressing

type and treatment, handling of bacterial load, posi-

tion changes to be provided, support devices used by

the patient, etc.; and patient’s general information on

their health state, such as patient’s Pfeiffer and Braden

indexes, patient’s sex and age, informal carer’s in-

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156

terest, education and motivation, patient’s nutritional

status, etc.

The login page of the teacher’s interface allows

them to have access to the system by using an au-

thenticated connection which counts on the SSL en-

crypting protocol, with a

https

URL, to get a secure

connection to the data. The design of the login page is

similar for both interfaces, i.e. the teacher’s one and

the student’s one, although those two separated inter-

faces are independent and located at different URLs.

Once a user with teacher proﬁle has been granted

access to the system, an operating interface is shown,

which consists of several frames with speciﬁc func-

tionality. The main page of this teacher’s interface is

structured in three different sections (ﬁgure 1):

• The list of PrUs: it is located in the upper left

frame (Figure 1) and consists of the list of all the

PrUs available in the system. From this frame,

the information on the evaluation of each PrU is

accessible for edition and query.

• The list of training/evaluation tests for students:

it is located in the lower left frame of the

teacher’s interface (Figure 1), and allows the

user with teacher proﬁle to create and edit train-

ing/evaluation tests, i.e. a set of PrU cases that

have been evaluated by the teacher and grouped

together to be available to the students for their

practice on PrU evaluation (by using the ePULab

student’s interface). Consequently, these train-

ing/evaluation tests have to be designed by the

teacher with two main objectives: to allow their

students the learning of the principles of PrU di-

agnosis and treatment (at three different complex-

ity levels that the teacher is able to select), and

to evaluate and monitor the progresses that their

students achieve during their learning phases.

• The central frame of the interface, in which the

forms, ﬁelds, panels and data of each PrUs stored

in the system are shown for query or edition (Fig-

ure 1). These data consist of information on

the evaluation of each PrU, which includes pho-

tographs, local information on the wound, general

information on the patient’s health state, informa-

tion on the treatments and Nursing clinical inter-

ventions on the wound, informal carer’s data, etc.

On the other hand, this central panel is also used to

manage all the information regarding the creation,

query and edition of training/evaluation tests for

the students.

The ﬁelds in the forms for PrU evaluation are clas-

siﬁed in three different levels (Figure 1): beginner, in-

termediate and advanced. When a training/evaluation

test is presented to a student for the ﬁrst time, all the

diagnosis and treatment questions corresponding to

the beginner level are set up. The student can then

interact with the system by reading the on-line tuto-

rials and contextual information, and answering the

proposed questions on tissue identiﬁcation, diagnosis

and treatment. The student also can monitor their pro-

gresses, as well as consult and edit their answers to

the proposed questions. Once the number of correct

answers from an user with student proﬁle has risen

above an established threshold (which is previously

conﬁgured by the teacher when they designed the

training/evaluation test), the student’s level increases

and they get the intermediate level. This new level

would include more complex questions on PrU diag-

nosis and treatment, which were previously conﬁg-

ured by the teacher by using their own interface. Sim-

ilarly, the advanced level could be get by the students

once a new learning threshold is reached.

2.2 ePULab Student’s Interface

The student’s interface (Figure 2) is located at a URL

that is different from that used for the teacher’s in-

terface (section 2.1). Nevertheless, the login page to

access to the system by an authenticated connection

(with user/password login) is similar to that used by

the teachers. As in the case of the teacher’s interface,

the student’s interface is also provided with the SSL

encrypting protocol to get a secure access to all the

speciﬁc functionality that the students are supplied

with.

Once a user with student proﬁle has been granted

access to ePULab, a welcome page is displayed,

which consists of a list of training/evaluationtests that

a teacher would have left available for their students.

The student is then able to choose a particular train-

ing test to start with the evaluation questions of all

the PrU cases that it consists of. With this purpose,

the student can select a training test by clicking on it;

from that moment on, the student will get all the con-

textual information necessary to the effective under-

standing of each one of the PrU cases that the test is

grouping together as established by the teacher when

they designed the test. For each PrU, the student is

able to read its contextual information and navigate

through the sequential evaluation phases by answer-

ing the different diagnosis and treatment questions

that the system poses. During this training process,

the student can also get all the necessary feedback

about their progresses and check their responses to

the different questions on PrU evaluation.

When a user with student proﬁle gets access to the

system for the ﬁrst time, they start at a beginner level,

so that they only have to answer those question on

ePULab-AnAdaptivee-LearningToolforPressureUlcerEvaluation

157

Figure 1: A screenshot of the teacher’s interface, which shows the list of available PrUs and training tests for the students,

as well as the central frame for visualization, query and edition of data from PrU evaluations. (The text in the image is in

Spanish).

Figure 2: A screenshot of the student’s interface, which shows the section of tissue identiﬁcation on a particular case of PrU

evaluation. (The text in the image is in Spanish).

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158

PrU evaluation that are included in that initial level,

such us tissue identiﬁcation (Figure 2), PrU classiﬁca-

tion, Health education for the informal carer, state of

the surrounding skin and presence of infection signs.

As the student is making progresses for the questions

in the beginner level and ﬁnally reaches an established

threshold, they go forward to the intermediate level

and, subsequently, to the advanced level. In each one

of these levels, the student has to answer all the ques-

tion on PrU evaluation corresponding to that level and

the lower ones. Some questions included in the inter-

mediate levels are: wound depth, presence of cavi-

tation, PUSH index, or cleaning types necessary for

the hygiene of the wound. The advanced questions

include some treatment issues such as the necessity

of debridement, dressing type, handling of bacterial

load, number of position changes, etc. In all mo-

ment, the student is able to query the contextual in-

formation that the teacher has included for each PrU

in the training test. That information involves addi-

tional comments and observations on the wound, such

as the amount of exudate, the location of the wound,

the patient’s sex and age, the wound area, etc. Fur-

thermore, a complete set of on-line tutorials on PrU

diagnosis and treatment are available to be looked up

by the students.

One of the most important sections that each stu-

dent has to go through when evaluating each one of

the PrUs included in a training/evaluation case is the

identiﬁcation of all the signiﬁcant tissues present in

the PrU image. In Figure 2 one of the PrU tissues pro-

posed for classiﬁcation is shown, as it is displayed on

the student’s interface. The ePULab software supplies

the user with a PrU image-viewer which allows the

student to display the original PrU image and navigate

friendly through the different tissues previously seg-

mented in the image (Figure 2). The image segmenta-

tion maps, as well as the classiﬁcation of the tissues,

are provided by the teacher when they insert a new

PrU case in the teacher’s interface. Those segmen-

tation maps can be manually or automatically gener-

ated by using the image processing tools designed and

implemented by this same research group as a result

of previous projects (see (Veredas et al., 2010) for a

complete review of these techniques and results).

3 DESIGN OF A VALIDATION

STUDY FOR ePULab

In order to count with an initial validation of the ePU-

Lab tool as an effective adaptive e-learning software

on PrU diagnosis and treatment, we have designed an

analytical and experimental study of educational re-

search by conﬁguring a randomized trial with a non-

concurrent control group. The main objective of this

study is to compare the educational efﬁcacy of the

ePULab software with that obtained from the tradi-

tional on-campus face-to-face instruction of Nursing

undergraduate students.

The population of the study was composed of 73

Nursing undergraduate students enrolled in the Nurs-

ing degree in the Escuela Universitaria de Enfermer

ıa

of the Provincial Council of M

alaga, Spain. This pop-

ulation sample was divided into two different groups:

an experimental/intervention group, which used the

ePULab software for e-learning education on PrU;

and a control group, which receivedan on-campus ed-

ucation on PrU evaluation and treatment.

The variables measured in the a priori knowledge

questionnaire (pre-test), as well as in the acquired

knowledge questionnaire (post-test), are the same for

both groups of the population (experimental and con-

trol group), and are based on the observation of a PrU

image that is printed on a paper and projected on a

screen in the classroom at the same time. On the ba-

sis of that PrU image, which was always the same for

both groups of students, we evaluated the following

aspects: the student’s ability to classify the wound;

the student’s ability to evaluate the characteristics of

the peri-ulcer skin; the student’s faculty to detect in-

fection signs in the wound; and the degree of correct-

ness in the choice of the type of dressing necessary

for the wound healing. On the other hand, there has

been also designed a question in both the pre- and

post-tests to evaluate the student’s skill to determine

which Nursing care interventions are appropriate for

that wound in the image. Finally, the last issues in

the questionnaires were designed to measure the stu-

dent’s ability to identify the different signiﬁcant tis-

sues present in the wound image.

3.1 General Validation Results

The results from the global scores obtained by the stu-

dents in the experimental and control groups, for both

the pre- and post- tests (questionnaires), are shown in

Figure 3, wherein the boxplots show the different dis-

tribution of the total scores from the pre- and post-

questionnaires: while no differences were found be-

tween the experimental group and control group for

the pre-test (a priori knowledge), signiﬁcant differ-

ences between the two groups were observed for the

post-test (acquired knowledge) however. The total

score from the tests ranged from 0 to 22 points and

was obtained from the summation of all the scores

from the items included in the different categories of

the questionnaires. By observing the results shown

ePULab-AnAdaptivee-LearningToolforPressureUlcerEvaluation

159

in Figure 3, we can ﬁrst highlight the comparability

of the initial knowledge conditions of both groups,

with an averaged total score of 8.23 (standard devi-

ation 1.23) for the control group, and 8.27 for the ex-

perimental group (standard deviation 1.39). Never-

theless, although the results from the post-tests reveal

the effectiveness of both education strategies (as an

increase in the averaged total scores can be observed

for both groups of students), the averaged total score

from the experimental group (15.85) is signiﬁcantly

higher (p < 0.01, t-test) than that obtained from the

control group (11.6), giving a higher efﬁcacy of the

educational scheme based on the use of the ePULab

e-learning tool than that of the traditional on-campus

approach.

Control

Experim.

Initial evaluation

Group

Score

Control

Experim.

Final evaluation

Group

Score

Figure 3: Boxplots of the total score (range [0, 22]) from

the items in the pre- and post- questionnaires for the con-

trol group (with an educational approach based on a tra-

ditional on-campus teaching) and the experimental group

(with an educational strategy based on the use of the ePU-

Lab e-learning tool for PrU evaluation).

4 CONCLUSIONS

In the previous sections, we have presented a new

adaptive e-learning tool, namely ePULab, which was

speciﬁcally designed for education on PrU evaluation.

The main characteristics of the ePULab software have

been exposed in detail, and the design of an exper-

imental study to measure the efﬁcacy of ePULab as

an effective educational tool has been also presented.

The general results obtained from this study show

how knowledge acquisition on PrU evaluation is sig-

niﬁcantly higher for those students who used the ePU-

Lab tool, compared to the students who received a tra-

ditional on-campus instruction. These results reveal

the validity of the ePULab e-learning tool as a very ef-

fective instrument for the learning on PrU evaluation

and treatment, as well as for the efﬁcient acquisition

of skills for those processes of a high signiﬁcance in

Nursing daily practice.

ACKNOWLEDGEMENTS

This study has been supported by the Consejer´ıa

de Salud, Servicio Andaluz de Salud, of the Junta

de Andaluc´ıa, project id. PI-0502/2009. The au-

thors also acknowledge partial support through grants

TIN2010-16556from MICINN-SPAIN and P08-TIC-

04026 from Junta de Andaluc´ıa, all of which include

FEDER funds.

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