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Show me where: app improves care of non-verbal adults and children

A tool created by a school nurse that enables children with communication difficulties to express pain and discomfort has been developed into an app and is being used in special schools and hospitals.

A tool created by a school nurse that enables children with communication difficulties to express pain and discomfort has been developed into an app and is being used by special schools and hospitals in Wales

Originally developed for children, the app - Show me where - has been seized upon by pain management teams as an important aid to improve the care of adults who are non-verbal. The Welsh Ambulance Service is trialling the tool through its ambulance crews and first responders.

Irene Hammond created its prototype while working as a nurse in special school The Hollies in Cardiff. She says: Having worked in the fields of autism and disability for many years, Id been concerned that these vulnerable children are often unable to describe pain or discomfort. This can lead

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A tool created by a school nurse that enables children with communication difficulties to express pain and discomfort has been developed into an app and is being used by special schools and hospitals in Wales


Irene Hammond with an early version of Show me where. Picture: Martin Ellard

Originally developed for children, the app - Show me where -  has been seized upon by pain management teams as an important aid to improve the care of adults who are non-verbal. The Welsh Ambulance Service is trialling the tool through its ambulance crews and first responders. 

Irene Hammond created its prototype while working as a nurse in special school The Hollies in Cardiff. She says: ‘Having worked in the fields of autism and disability for many years, I’d been concerned that these vulnerable children are often unable to describe pain or discomfort. This can lead to untreated conditions and an increase in severe behavioural problems. Often these children cannot be physically examined, so I tried to develop a consistent method of communication for children with communication difficulties.’

Her idea was developed with the help of medical artist Jan Sharp. Laminated pictures of a body and smaller illustrations of different parts of the body were made and used in every classroom as part of the personal and social education curriculum.

Relieving anxiety 

It proved such a success that Ms Hammond secured Health Lottery funding to develop the prototype into magnetised books and wallcharts. Children were taught to retrieve the appropriate symbol if they were experiencing pain and comply with examinations when presented with a picture. ‘During the examination the child often holds on to the symbol like a talisman. It appears to relieve anxiety,’  she says.

The funding was used to produce 100 books and 300 wall charts. Some were distributed freely to the trust’s clinical paediatric areas, such as the children’s assessment unit and the emergency department. The remainder and new orders have been sold to respite care homes, other special schools and Ty Hafan Children’s Hospice. The Ethnic Minority Achievement Service in Cardiff opened a lending library of 65 books for families.

A business was formed within the trust, which owns the intellectual property, with profits divided between the trust, Ms Hammond and Ms Sharp. Revenue has so far been ploughed back into production, product development and advertising. Ms Hammond has presented the project to parent and NAS groups, student nurses, the all Wales Special School Heads Conference, Nursing and Midwifery Conference, Cardiff 2014 and the Autism Show.

An evaluation in January 2015 recorded positive feedback from people who had purchased and were currently using Show me where.

Giving back control

Consultant community paediatrician Sian Moynihan agrees it improves patient care. She says: ‘It is an essential tool in any clinical setting where assessment of health of a child with communication difficulties or autism may be necessary.’

The clinical director of community child health at Cardiff & Vale UHB uses the tool for children with a diagnosis of autism or children who are presenting with social communication difficulties and/or significant difficulties with their language and communication.

‘It changes a child who is anxious or non-engaging to a child who co-operates with most of the examination,’ she says. ‘The child is given back control of what is happening to them and often wants to continue the process at the end of the examination.’

The tool’s relevance for all patients with communication difficulties has become apparent to nurses in other specialties.

Alzheimer’s and stroke care

Ms Hammond says: ‘The evaluation showed people would welcome an adult version as the tool would be useful for Alzheimer’s patients and those in stroke care.’

In January, £12,000 in funding was awarded by Health Technology Challenge Wales to produce a new handheld adult and paediatric version – a lightweight and washable version.

The Cardiff and Vale Health Board Clinical Standards Group has endorsed the use of the handheld version of Show me where as part of a pain assessment tool for adult patients with communication difficulties. The paediatric version has also been endorsed. 

Sue Mogford, senior nurse pain management services at University Hospitals of Wales and Llandough, says: ‘The assessment and management of pain in patients with communication difficulties can be challenging and problematic.

Assessments enhanced

‘Show me where can help facilitate the pain assessment process, especially for those with dementia, expressive dysphasia post-stroke, confusion, learning difficulties, hearing impairment, cerebral palsy, autism, intubations, tracheostomies or those for whom English is not a first language.’

She adds that the assessment of patients who have sustained extensive injuries and require quick, effective, systematic assessment in the clinical area or at the roadside may be enhanced by the communication tool.

Despite having retired after more than four decades in children’s nursing, Ms Hammond shows no sign of slowing down. She is still the tool’s main marketer and has planned a website and a promotional video.

Until it becomes financially successful, all her work is undertaken on a voluntary basis. ‘It has been a huge journey and a huge commitment,’ says Ms Hammond. ‘There have been a lot of ups and downs along the way. My dream is to see more children use it from a young age, alleviating the anxiety they have when in pain or being medically examined.’

The multilingual app is available from the App Store or GooglePlay.

Irene Hammond’s advice on innovation
  • Be aware of new technology, which might prove a better vehicle for your idea. 'My communication tool started off as a book, but producing it as an app has been successful because it can be updated quickly, cheaply and easily.'
  • Be prepared to give hours of your own time. 'It takes a great deal of hard work and commitment and you still have your job to do.'
  • Build a network of support. 'The co-operation and support from the staff at the school was invaluable. Keep the people who helped you create the idea as partners throughout the journey.'
  • Be prepared to market your innovation yourself. 'I showcased it through presentations, conferences and the Autism Show.'
  • Believe in your product. 'Be determined to succeed despite obstacles, of which there could be many.'
Evaluation results
  • A cross-section of people who had purchased and used the tool were sent a survey using a semi-structured questionnaire. 
  • The majority of respondents were from schools, with clinicians such as paediatricians the second-largest group. Broadly, respondents dealt with two core categories of communication difficulty – autism and complex disability.
  • Respondents said the tool made a positive difference in their relationship with their client. One consultant community paediatrician wrote: ‘An excellent tool. It changes a consultation where a child is anxious, aloof and disengaged to one inwhich an examination is possible.’
  • The evaluation also showed the tool was being used for sexual health education and for other groups, such as for people with dementia. A deputy headteacher wrote: ‘Very good package. Also used for sex education, relationships, first aid and well-being.’  While a learning support assistant reported: ‘Show me where is the only way children can communicate if feeling unwell. Not exclusively for children but also for Alzheimer's sufferers.’

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