The use of a Lester Tool-based physical health app in mental health inpatient settings
evidence and practice    

Free The use of a Lester Tool-based physical health app in mental health inpatient settings

Jaspreet Phull Interim medical director and consultant forensic psychiatrist, Lincolnshire Partnership NHS Foundation Trust, Sleaford, England
Victoria Naoui CT3 in psychiatry (third-year of core training), Lincolnshire Partnership NHS Foundation Trust, Sleaford, England

Background People with mental health problems have a greater risk of developing physical health problems, yet in England only 76% of such patients have an annual check of their physical health.

Aim To explore the effects of implementing a physical health app in a mental health rehabilitation hospital.

Methods Following the creation and implementation of the app, which was based on the Lester Tool, a questionnaire was developed and sent to staff to assess their experience. Quality of physical health plans was also assessed.

Findings The physical health app was viewed by clinicians as being a helpful tool and there was a small but statistically significant improvement in the quality of care plans.

Conclusion The use of the physical health app in a psychiatric rehabilitation setting offers a cost-effective opportunity to improve clinical quality and engage clinicians.

Mental Health Practice. doi: 10.7748/mhp.2018.e1287


Phull J, Naoui V (2018) The use of a Lester Tool-based physical health app in mental health inpatient settings. Mental Health Practice. doi: 10.7748/mhp.2018.e1287

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software


Conflict of interest

None declared

Published online: 17 December 2018

A report by the Royal College of Psychiatrists (2013) recommends that people with mental health problems should receive the same quality of physical healthcare as those without mental health problems and receive appropriate intervention and support to address the factors affecting their much higher rates of health risk behaviour.

The report was prompted by the awareness that the life expectancy of many groups of people with mental illness is at least 20% lower than for the population as a whole in high income countries (Newman and Bland 1991).

People with a serious mental illness have a greater risk of having raised blood pressure and cholesterol, glucose intolerance and cardiovascular disease (McCreadie 2003). In England, 46% of people with a mental illness also have a chronic physical illness, compared with 30% of the general population (McCreadie 2003). Yet the average proportion of people with a severe mental health problem who have an annual physical health check is just 76% (Naylor et al 2012). These statistics suggest that improving the physical healthcare that patients receive as an inpatient should be prioritised.

In this article, the effects of implementing a physical health app designed to improve care for physical health conditions in an adult mental health inpatient setting are explored.


The authors designed a physical health app based on the Lester Tool (Proudfoot et al 2010). The Lester Tool is a summary poster to guide healthcare workers to assess the cardiometabolic health of people experiencing psychosis and schizophrenia, and to enable them to deliver safe and effective care to improve the physical health of people with mental health problems (Proudfoot et al 2010). The app was developed incorporating the National Institute for Health and Care Excellence (NICE) (2015, 2016a, 2016b, 2017, 2018) guidelines and is now in an electronic downloadable PDF app that allows the user to navigate around the six categories of the Lester Tool:

  • Smoking.

  • Blood pressure.

  • Blood glucose regulation.

  • Lifestyle and life skills.

  • Weight.

  • Blood lipids.

Each section uses condensed NICE guidance-based pathways to highlight the recommended interventions, monitoring and intended treatment targets.

The intention of the app was to improve physical health management in psychiatric wards and the confidence of clinical staff in dealing with the most common physical health issues. It was hoped that nursing and other staff could use the app to create and update physical healthcare plans for inpatients.

Use in mental health settings

A number of mental health apps have been developed and made available to smartphone and tablet users. These apps are aimed at improving mental health and well-being, from guiding mental illness recovery to encouraging beneficial habits that improve emotional health (NHS England 2014). The demand for such technology appears strong: a recent survey that found 76% of 525 respondents were keen to use their mobile phone for self-management and self-monitoring of mental health, if the service was free and accessible (Donker et al 2013).

Zhang et al (2015) provided an outline on the use of smartphone apps for mental healthcare and identified benefits including patient empowerment, psychoeducation and greater professional insight into a person’s condition.

The NHS Apps Library (NHS Choices 2012) provides healthcare apps that are reviewed by healthcare professionals, app developers and the general public.

The authors believe that health-based apps can improve:

  • Communication between staff and patients.

  • Access to and reference to clinically relevant information.

  • Education and teaching.

  • Effectiveness of existing interventions.


The aims of this research were to:

  • Improve knowledge of the Lester Tool among nursing staff.

  • Improve the physical health of patients with mental health problems.

  • Evaluate the experience of using the physical health app.

  • Improve the quality of physical healthcare plans.


The physical healthcare app was piloted in three rehabilitation wards at Discovery House, a psychiatric rehabilitation hospital at Lincolnshire Partnership NHS Foundation Trust. The evaluated outcomes were user experience and quality of physical healthcare plans. A pilot study in one rehabilitation ward had suggested improvement in care plan quality following implementation of the app.

Initially it was envisaged that nursing staff would feel more confident in screening and managing the six headings of the Lester Tool after implementation. It was hoped that any acquired knowledge would be applied to new care plans and the information appropriately shared with the patients.

A care plan quality tool was developed by the team following a literature review, discussion with nursing staff and consideration of care plan quality review tools used by the Care Coordination Association (2016). The care plan quality tool was used by the same assessors to ensure all care plans were scored consistently.


The patients in the sample were adults aged between 18 and 65, male and female, who experienced mental health problems. Patients who were discharged during the project period were excluded. Consent was obtained for each patient, although the project was considered a service evaluation.

Data collection

The project ran over four months, between December 2016 and April 2017, with the initial implementation occurring in January 2017.

Once the pre-implementation data were collected, a teaching session lasting approximately 45 minutes was provided so that nursing staff were introduced to the app. The session also included content provided by a ward-based junior doctor covering the six areas of the Lester Tool. All nursing staff had also been sent an electronic teaching package and been given access to the app. The app was also installed onto the wards’ iPads and desktop computers for accessible reference purposes.

The intention was for staff to use the app regularly to write and update care plans.

A post-implementation evaluation was conducted by obtaining feedback from the nursing staff on their experience.

Data analysis

The app project was evaluated by assessing the physical care plans of all the patients in the study using a care plan quality tool before and after the implementation of the app. Feedback about the app from nursing staff was also collected via an online survey after the implementation period. A one‑tailed paired t-test was chosen to assess the improvement in care plan quality based on an assumption of limited harm and a prediction of an improvement.


The findings of the research focused on the quality of the care plans and user experiences of the app.

Care plan quality

Only a few nursing staff could attend face‑to‑face teaching but all those involved were sent the presentation in an email with further instructions and an electronic presentation.

Out of the 45 patients in the unit, there were eight discharges in the study period, so the total number of physical care plans evaluated in the sample was 37.

The quality of the care plans was evaluated using a quality tool constructed by the project team and, while the observations demonstrated a modest improvement in quality (Table 1), this was statistically significant (P=0.0506).

Table 1.

Care plan quality before and after intervention

Measured outcome (care plan quality)January 2017 (before implementation)April 2017 (after implementation)
Total score145177
Mean score (out of 12)6.37.1
Lowest score34
Highest score1011

User experience questionnaire

The questions were rated on a five-point scale from ‘strongly agree’ to ‘strongly disagree’, with the respondents asked to respond once to each question (Table 2). A total of 21 out of 33 staff involved in the evaluation answered the questionnaire, giving a respondent rate of 64%. Two respondents did not complete the questionnaire. None of the respondents disagreed or strongly disagreed, with all other responses marked as ‘undecided’.

Table 2.

Post-intervention survey

I feel confident managing physical health issues on the ward16/21 agreed or strongly agreed (76%)
I am aware of the Lester Tool and what it involves17/21 agreed or strongly agreed (81%)
The physical healthcare app is easy to use12/19 agreed or strongly agreed (63%)
The content of the physical healthcare app is clinically useful13/19 agreed or strongly agreed (68%)
The physical healthcare app supports individualised care15/19 agreed or strongly agreed (79%)
The healthcare app helps improve patient care16/19 agreed or strongly agreed (84%)
The physical healthcare app closely matches guidance14/20 agreed or strongly agreed (70%)
Any additional comments?None

The app questionnaire was answered by nursing staff who had been involved in the training and had used the app. The overall results suggest a positive experience when using the app in relation to its ease of use, clinical utility and its ability to deliver individualised patient care.

Ease of use had the lowest score and might have been related to the accessibility to training.


The first aim of the project was to improve nursing staff’s knowledge of the Lester Tool and thereby improve the physical health of patients. Unfortunately, only a few nursing staff attended face-to-face training, which suggests that the teaching on the app and the medical teaching needed to be more flexible. This was also why all staff were emailed the material.

It was observed that the face-to-face sessions were a valuable opportunity to gain instant feedback on how staff felt about screening and managing physical health conditions in an inpatient setting. Immediate feedback was also available on the app following its demonstration.

Staff reported appreciating the interface and being able to access the guideline‑based information it included.

Staff said the app was a useful reference tool, but they emphasised the importance of ensuring that care plans are individualized.

In a staff focus group following implementation, it was discussed how the use of clinical terms, such as HbA1C, with appropriate patient education would help patients take more responsibility for their health once discharged into the community and benefit more from the better outcomes.

The user experience of the app was broadly positive, and it appeared that staff benefited from the use of the physical health app, in that they noted greater confidence in managing and recognising physical health conditions.

The final aim of the research was to improve the quality of physical healthcare planning. There was a statistically significant improvement in the quality of healthcare plans, in terms of mean and total scores.


The main limitations of this study included the sample size and responder bias via the use of an online questionnaire. The sampling period was another limitation and it would be helpful to explore if the recorded improvements would continue over time.


The authors believe that the physical health app can be helpful in day-to-day inpatient mental healthcare. The quality of the care plans improved, and staff evaluated the app positively. Further evaluation is required to clarify whether such changes are sustained, and whether using the app would produce ongoing meaningful improvements in patient-based outcomes.

Implications for practice

  • Using an electronic teaching aid can improve staff knowledge of physical healthcare

  • Electronic teaching materials can be used to inform staff who cannot attend teaching sessions, but they need to be delivered in an accessible way

  • Using such an app can improve the quality of care plans


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