The researchers found that the participants’ ratings were below the experts’ ratings on average and the degree of difference increased as the patient depicted in the vignette became more nourished. “The findings of my study included a 41% accuracy in rating of the patient’s nutritional status and a 55% accuracy in cue selection of nutritional status by staff nurses,” said Dr Lulloff.

The rating accuracy was significantly improved (t (3)=–4.59, P =.002) when the patient in the vignette was undernourished vs well-nourished or overnourished. No correlation was observed between the accuracy of the staff nurse’s rating and their confidence in that rating (r=0.01; n=680; P =.893). “My conclusions were pediatric oncology staff nurses overall accuracy in nutritional assessments was limited and complicated by not being highly confident in their assessments,” Dr Lulloff reported.

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She said participants tended to underrate the patient’s nutritional status (assuming the patient is less nourished than they are), select fewer nutritional cues than the experts, and were less likely to rely on anthropomorphic data than the experts. The participants also were more likely to consider albumin, which is generally thought to be an unreliable marker of nutritional status in children who may have inflammation from a disease process or treatment.

“I did find something in the data I wasn’t anticipating. Nurses in free-standing pediatric facilities had the greatest accuracy, followed by nurses in a pediatric facility within an adult facility, with the least accurate cohort being nurses who worked in a facility that took care of both adults and children in the same area,” said Dr Lulloff. 

Patients are falling through the cracks, especially in the outpatient environment. Most pediatric inpatient electronic health records (EHRs) have a nutritional screen that is completed upon admission that will alert a registered dietitian (RD) to perform a more comprehensive assessment if there are concerns, explained Dr Lulloff. “They also have flags that will notify the RD if nutritional concerns develop during the hospitalization. But the nutritional screen often isn’t built on the ambulatory side, and often the data entered that would trigger a nutritional screen (such as weight change) doesn’t cross encounters in the ambulatory setting,” she said.

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This study is one of the first to explore nutritional assessment of staff nurses working with pediatric oncology patients, and it suggests that oncology nursing should focus on increased education, training, and standardization of nutritional assessment. Many nurses get very little formal education on nutrition, and most oncology nurses accept that periods of anorexia or excessive eating when on steroids will occur, explained Dr Lulloff.

“Nurses, who usually spend the most face-to-face time with patients and are in the best position to recognize concerning nutritional changes and eating patterns, may need to be stronger advocates for physical activity and attempting to find innovative ways to manage steroid cravings,” said Dr Lulloff. “Part of the problem is there is no gold standard for assessing nutritional status in pediatric oncology patients, multiple tools exist, but in the absence of a solid EBP [evidenced-based practice] or best practices, nutrition is likely to remain challenging in this population.”


1. Lulloff AJ, Vessey JA, Bashore L, Gregas M. Nutrition-related clinical decision making of pediatric oncology nurses. J Pediatr Oncol Nurs. 2019;36(5):352-360.