Nurses May Under-Rate Nutritional Status in Pediatric Patients

Nurses were found to be significantly more likely to under-rate the nutritional status of their pediatric patients, suggesting the need for guidelines for nutritional assessment of children.

According to a study published in the Journal of Pediatric Oncology Nursing, nurses were significantly more likely to under-rate the nutritional status of their pediatric patients and select far fewer cues than the compared experts. 

Given these findings, the researchers suggested that evidence-based guidelines for nutritional assessment of children with cancer should be developed to ensure the highest quality of care is afforded to this patient population. 

“Consistently under-rating patients’ nutritional status may expose well-nourished patients to unnecessary nutritional interventions,” the authors wrote. “Failing to recognize a patient who is over-nourished is also highly problematic; overnourished pediatric oncology patients are at increased risk for morbidity and mortality.” 

Using an electronic survey consisting of 3 sections, including the study overview and consent procedures, demographic information, and the study instruments, researchers looked to assess the complex decisions nurses must make within the clinical environment. The survey also accounted for nurse specific factors, such as experience and education level. Additionally, 15 patient vignettes were utilized to explore the decision making regarding the nutritional assessment of children diagnosed with cancer. 

A total of 318 participants consented to the study, and only participants with complete data were included. There were complete data available for 136 participants for nutritional ratings and confidence scores (the first dataset) and complete data for cue selection for 94 participants (the second dataset).

Across the vignettes within the first dataset, when comparing the participants’ rating to the experts’ rating, the participants chose the same ratings 41% of the time. Moreover, there was a significant difference between the vignette conditions the experts’ rated as being under-nourished (M = 36.17; SD, = 7.36) and vignettes rated at-risk of over nourishment [(M = 71.33; SD = 1.53); t(3) = -7.93; ≤ 0.001]. However, when the vignette represented an under-nourished patient vs an over-nourished patient, the accuracy of the nurses significantly improved. 

Looking at the vignettes of the second dataset, the participants chose the same number of cues as the experts 55% of the time. The differences observed in cue selection between the participants and the experts were 1 to 16 (M = 8.44; SD = 2.46). Furthermore, an analysis of demographic factors and cue selection accuracy found that participants who worked in free-standing pediatric institutions had the best cue selection and those who worked in a pediatric facility embedded in a larger adult facility had the second-best cue selection, followed by those who worked in a mixed pediatric and adult facility. 

“All the education, training, and resources in free-standing pediatric facilities are focused solely on the pediatric population,” the authors wrote. “The improved accuracy in these settings could indicate a need for more dedicated pediatric focus in other institutions.”

The New General Self-Efficacy Scale (NGSE) was also included in the survey to measure the nurses’ perception of their own ability to complete tasks successfully. The scores ranged from 25 to 40, with a median of 32 for both the rating (M = 33.51; SD = 3.37) and cue selection data (M = 33.63; SD = 3.62). The participants’ confidence in their rating was also evaluated, and confidence ranged from 10% to 100% (M =70.06; SD = 18.13) with a median confidence score of 50%. These results indicated that, as a group, the nurses were not confident with their own nutritional ratings. 

Given that nutrition plays such an important role in children’s growth and development, as well as their health and healing, oncology nurses should be well-versed in the nutritional assessment of their patients. The researchers indicated that future studies should implement a standardized nutritional assessment tool specifically for pediatric oncology patients. They suggested that this could be done through tool development, or through the widespread testing, refinement, and utilization of some of the tools currently available. 

“Oncology nursing should focus on increased education, training, and standardization of nutritional assessment to ensure the best possible outcome for this patient population,” the authors wrote.


Lulloff AJ, Vessey JA, Bashore L, Gregas M. Nutrition-Related Clinical Decision Making of Pediatric Oncology Nurses. Journal of Pediatric Oncology Nursing. doi:10.1177/1043454219844233.