Abstract
Background
Childhood cancer often entails long-term treatment, with various side effects that affect the nutritional status of patients. Nurses play a pivotal role in assessing and promoting nutritional support. Therefore, we aimed to explore the experiences of clinical nurses assessing and promoting optimal nutrition supportive care during pediatric cancer treatment.
Method
Four focus groups involving 22 clinical nurses were conducted at the four tertiary hospitals in Norway treating children with cancer. Analysis was guided by Braun and Clarke's reflexive thematic approach. The study adhered to the consolidated criteria for reporting qualitative research.
Results
Four themes were created. Nurses employed a holistic approach to plan and integrate nutritional care in collaboration with families, dietitians, doctors, and other professionals. Barriers in nutritional oncology care identified were treatment side effects, time constraints, and inadequate use of guidelines. Nurses experienced difficulties discussing overweight conditions with patients.
Discussion
Our study offers insight into the importance of close collaboration with every single family, thus promoting family-centered care for assessing and promoting optimal nutritional status during treatment for pediatric oncology. Nurses must have a broad perspective on what constitutes optimal nutritional care. Using guidelines in a systematic manner is crucial to prevent malnutrition during childhood cancer treatment.
Introduction and Background
This study investigates the experiences of Norwegian pediatric oncology nurses in assessing and promoting optimal nutrition for children undergoing cancer treatment. Suboptimal nutrition during and after treatment of childhood cancer has a negative impact on prognosis, quality of life, and growth (Diakatou & Vassilakou, 2020). Treatment with chemotherapy can be ongoing for months and even years, requiring repeated hospital admissions (Heyman et al., 2020; Keller et al., 2024). The most prevalent side effects during cancer treatment are fatigue, nausea, pain, constipation, oral ulcers, fluctuations in appetite, fear, changes in body image, and anxiety (Linder & Wawrzynski, 2018). Cancer and the side effects of chemotherapy lead to impaired nutrition because of insufficient intake and impaired absorption (Teixeira et al., 2021). During treatment, many children become malnourished, understood as both undernutrition (having a lower intake of micro- and macronutrients than needed) and overnutrition (having a higher intake of micro- and macronutrients than needed; Cohen et al., 2021). Patients can be both undernourished and obese at the same time (Murphy et al., 2015).
Undernutrition increases the risk of prolonged hospitalization, a higher infection rate (Martinez & Mehta, 2021), and overall poorer prognosis (Teixeira et al., 2021). Steroid treatment, in addition to a less active lifestyle and mental distress, can lead to a higher intake of nutrients than needed, causing overnutrition (Arpe et al., 2015; Ladas et al., 2005). Overnutrition increases the risk of obesity, cardiovascular diseases, Type 2 diabetes, and mortality (Arpe et al., 2015; Bratteteig et al., 2022; Egnell et al., 2022). Optimal nutrition can be obtained through a broad approach, for example, nutritional support such as tube feeding (TF; Teixeira et al., 2021), mental well-being, and through education on physical activity and nutrition (Ladas et al., 2005).
Nurses experience uncertainty when assessing patients’ nutritional status, giving precedence to anthropometrics or dietary intake over other indicators (Lulloff et al., 2019). Anthropometrics are valuable for nutritional assessment; however, factors like diagnosis, social background, oral intake, laboratory nutrient tests, and psychological aspects are equally critical in determining malnutrition (Lulloff et al., 2019).
Nurses and nurse assistants are available around the clock and play a vital role in supporting both patients and their families within the framework of family-centered care (FCC).
They require extensive knowledge on organizing services in ways that include families in decision-making during the entire illness trajectory (Aarthun & Akerjordet, 2014). As nurses have a central role in providing the foundations for optimal nutritional care during pediatric cancer treatment, it is important to explore how nurses perceive their role. Therefore, the purpose of our study is to explore nurses’ experiences in assessing and promoting optimal nutrition supportive care during pediatric cancer treatment, and how the families are included in the care.
Aim of the Study
To explore nurses’ experiences in assessing and promoting optimal nutritional supportive care during pediatric cancer treatment.
Method
Design and Methodological Framework
An explorative qualitative study was conducted in accordance with Krueger and Casey's (2015) method description of focus groups (FGs; Krueger & Casey, 2015). FGs were chosen because we wanted a range of opinions and ideas from expert nurses. FGs are suitable for generating rich data and enhancing opportunities for discussion and interactions between participants that go beyond the planned questioning route (Krueger & Casey, 2015).
Study Setting and Recruitment
The population in Norway is approximately 5.5 million people, with a population of 1.2 million below 20 years of age (Statistics Norway [SSB], 2024). Nationally, approximately 200 children are diagnosed with cancer every year (NORDCAN, 2024). Diagnostics and treatment plans are conducted exclusively at the four university hospitals providing tertiary pediatric oncology care in Norway. In addition, smaller rural hospitals participate in the follow-up and supportive care guided by the university hospitals. Some families travel a considerable distance to their nearest tertiary facility. The Norwegian government covers all expenses for diagnostics, treatment, and follow-up for the child, as well as the parents’ travel costs (Helfo, 2019).
One FG was conducted at each of the four hospitals using a convenience sampling method (Polit & Beck, 2021). An invitation containing all the study details was sent via email to the nurse manager at each location. Nurse managers approved the study, invited nurses to participate, and allocated a nurse as the contact point. The nurse managers did not participate otherwise. The corresponding nurse contacted eligible participants and scheduled an FG at each hospital.
Inclusion Criteria
Inclusion criteria included a minimum of 2 years’ experience in a pediatric oncology hospital ward, with nurses eligible to participate regardless of their degree of specialization.
Data Collection
A questioning route with important topics was developed based on prior research, clinical experience, as well as discussions with the research group. The questions were further tested in a pilot FG, where discussions on topics such as using anthropometrics were considered an important marker for nutritional challenges. The opening question for all FGs was: What are the important factors that affect children's growth during cancer treatment? The subsequent questioning route was: How do you document and manage children's weight changes during cancer treatment? How do you, as a nurse, contribute to obtaining optimal growth during cancer treatment? Follow-up questions were designed to encourage further discussion. The first and third authors conducted all the FGs in October 2022. The first author moderated the FG, and the third author acted as an assistant moderator, as described by Krueger and Casey (2015). The moderator ensured that all questions were discussed within the allocated time. The assistant moderator provided field notes and summaries.
Data Analysis
All the FGs were digitally recorded and stored on a secure server and transcribed verbatim by the first author. We used reflexive thematic analysis following Braun and Clarke's approach (2022 ). The initial step in thematic analysis involves familiarizing oneself with the data (Braun & Clarke, 2022). To achieve this, recordings were listened to multiple times, and a diagram with interrelated topics was developed for each FG and compared with the corresponding field notes. This initial step was performed by the first and third authors.
The first author coded FGs using the NVivo 14 software (Lumivero, 2023), by grouping segments that shared similar meanings under a single code. These codes were subsequently compiled and organized to formulate the preliminary themes. After the initial coding, several meetings were held with all authors, where the codes and themes were discussed, constructed, deconstructed, and refined. Figure 1 illustrates how segments of meaning are coded and transposed into themes and subthemes.
Example Route From Quote to Code, Subtheme, and Theme.
Ethical Considerations
This study adhered to the Helsinki Declaration of Ethical Research (World Medical Association, 1964). Participants were informed about the study, their right to withdraw at any time, and were asked to sign a written consent form before starting the interviews. This study was approved by the Norwegian Governmental Data Protection Agency (Approval No. 875728). Statements from the FGs were identified and transcribed anonymously.
Rigor and Reflexivity
In accordance with Krueger and Casey (2015), we aimed to recruit a minimum of four to eight participants per FG to ensure a rich dataset. A pilot FG was conducted to refine the interview guidelines. The results of the pilot FG were not included in the analysis.
Immediately after each FG, the researchers reflected on them. We included participants from all tertiary hospitals, and nurses with different degrees of specialization, and gender. We concluded that no further FGs were necessary, as the data obtained were comprehensive and informative, encompassing representative samples. The transcripts were reviewed within the research team to ensure comprehensive understanding and that no pertinent comments or meanings were overlooked. Codes were developed, rigorously discussed within the research group, and refined through an iterative process of revisiting the transcripts and the themes, ensuring a coherent linkage from transcripts to codes and themes. All researchers were well versed in the FCC framework. FGs were conducted in Norwegian, and quotations were independently translated by the first and last authors, then cross-verified to ensure the fidelity of the quotes’ meanings during translation.
Results
Twenty-four nurses agreed to participate in this study. Of these, 22 nurses attended the four FGs, as detailed in Table 1, which provides demographic information. Two nurses were unable to attend on the day of the FG. All FGs were conducted in hospital wards, attended solely by moderators and participants. The FGs lasted between 85 and 110 min, with an average duration of 101 min.
Participants’ Demographics per Focus Group
Using reflexive thematic analysis, we identified four main themes and four subthemes (Table 2). The main themes included “Everything affects nutrition—seeing the whole picture is paramount,” “Sufficient nutrition is part of the treatment,” “Collaboration to achieve optimal nutritional care,” and “Barriers in nutritional oncology care.” Quotes from participants (Px) across the four FGs (FGx) exemplify these themes.
Themes and Subthemes
Everything Affects Nutrition—Seeing the Whole Picture Is Paramount
In all FGs, participants noted that the treatment was complex and frequently resulted in significant side effects. Some side effects are dangerous, and it was widely held that a robust physique could aid in the child's ability to endure treatment.
Participants concurred that providing appropriate nutritional support necessitates understanding the child, their developmental stage, and the family's background. Only with a comprehensive understanding of these elements could they offer informed advice on nutrition-related questions. Comprehensive nutritional care involved considering various components, including the patients’ and families’ pretreatment circumstances, the children's physical constitution, and the ongoing need for information throughout the treatment process: We must see the whole picture of cancer treatment with various kinds of chemotherapy: the length of the treatment, how you feel during treatment, physically and mentally, and the whole shebang will paint a picture of how it will be. And then you have different ages and everything. (P1, FG4) My experience is that if you talk about older children, you will accept that they do not eat for some time at the hospital as long as they eat at home. […] This is a difference from younger kids. If they have a very steep growth curve, you should pay more attention than to a 15-year-old who is in maintenance therapy. (P7, FG2) You need to be conscious of whom you weigh and why. We do not have to measure everybody simply because we are supposed to do so. If teenagers come to the outpatient clinic, they may not have to be weighed every week. We don't have to nag so much, especially if they have a large weight gain. (P7, FG2) Yeah, you cannot really tell what's the chicken and the egg. Do they have the energy to be physically active because they eat, or do they eat because they become hungry after being active? It is hard to tell, but I am sure there is a connection between the two. (P2, FG2)
However, the hospital environment did not encourage physical activity. The participants strived to arrange condition-adjusted activities, as they perceived physical activity as an important part of nutritional care: “If you can be physically active, you will feel better. And if you feel better, it is easier to eat. Everything is connected” (P5, FG2).
Although the participants encouraged physical activity and employed various strategies to prevent overeating, nurses encountered challenges in addressing issues of overeating and obesity with their patients. This was related to the stigma associated with weight gain, and challenges with excessive food intake. Distraction away from food thoughts was explained as a useful strategy for mitigating overeating caused by steroid treatment. Some argued that it was inappropriate to initiate dietary changes during illness, suggesting these issues be addressed postrecovery. Others discussed their concern with the parents instead of engaging directly with the child: I don't address the child and say: “you need to eat less!” That's not my job. I rather talk to the parents about their routines and try to make them think about what they can do differently. […] But I do find it difficult to talk about being overweight with the child. (P1, FG4) Of course, it is hard for the family. Anyway, you stay away from home for a long time. You miss your siblings, the other parent, grandparents, friends, and it is extremely hard. We do try to adapt and to make it possible to have visitors and everything, but it is difficult. (P3, FG4)
Participants reported that parents struggled to adjust to the hospital's unique habits, routines, and regulations. Concerns were also raised about the potential negative effects of hospitalization on family dynamics and the child's dietary habits: A lot of the families will develop poor habits around meals, food, and physical activity and that is not easy. And yes, you are sick now, but you are going to get better at some point. And then the habits and weight gain will continue. (P3, FG1)
Sufficient Nutrition Is Part of the Treatment
This main theme discusses how nutritional supportive treatment should be an integrative part of all oncology treatment. Two subthemes were developed: systematic follow-up on food intake and weight development, and nutritional support. Participants highlighted the need to maintain a robust body to be prepared for the treatment and side effects. A normal, healthy diet was described as necessary for everyone, and nutritional support was escalated as needed. Monitoring and assisting with nutritional intake were perceived as the nurses’ responsibility.
Subtheme 1: Systematic Follow-Up on Food Intake and Weight Development
Although nutrition was highlighted as a central component of cancer treatment, it was merely seen as a supportive treatment. Other aspects of the treatment, such as chemotherapy or medication, were prioritized over nutritional care: “There are so many things going on with the chemotherapy and this and that, and blood tests and so forth, that the little things like nutrition intake kind of disappear” (P3, FG1).
Nonetheless, participants mentioned that the treatment itself affected nutritional status, especially the use of glucocorticoids and their side effects. Participants agreed that weight should be measured regularly at every admission and before the onset of each chemotherapy session. Anthropometrics were crucial in the calculation of the chemotherapy dosage, but not necessarily to change nutritional support. Weight had to be followed over time to see if the patient's weight would stabilize: They need a normal diet, like any other child. But sometimes it is hard to know when they have had enough. You balance between having enough and having too little nutrition. And that's where the weight comes in; if it goes up—they eat enough. But sometimes you would accept a small weight loss before you initiate nutritional support. You wait a little and see if it stabilizes. Therefore, one weight measure is not enough, you need to see the trends. (P4, FG4) …we have a list where the parents write down everything the child eats, or we ask them at the end of the shift. And then we are supposed to write it down in the records. I think everybody does that. Like half a piece of bread, and so on. (P3, FG3)
Participants used their observational skills and experience to evaluate the nutritional status of their patients: I feel that when they are readmitted after a period at home you can see how they are doing. I often don't notice what the weight or height is, but I can see that they have more muscles, and their cheeks have a better color. You don't go in and check “oh, what was the number last time,” “have you had an increase or a decrease in weight?.” No, it's more like “I think you have lost weight because you look so pale and scrawny.” (P7, FG3)
Participants across the FGs expressed varying opinions on the frequency of anthropometric measurements: “We should have a strict routine for measuring Monday, Wednesday and Friday” (P4, FG1). “For nutrition there is really no point in measuring twice per day, twice per week is more than sufficient” (P5, FG2). “We do measure at least once per week, preferably more. And for some, once per day, or even twice per day too” (P4, FG3). It depends on the size and age. The infants at least a couple of times per week and more often than a 16-year-old. We use our clinical discretion. But we do say if it is twice per week, we should do it Monday and Thursday. (P4, FG4)
Subtheme 2: Nutritional Support
Nutritional support was discussed in all FGs. Participants mentioned various levels of nutritional support, ranging from increasing levels of fat and nutrients in the food to TF and parenteral nutrition (PN) if weight loss was detected: I do believe that we are more willing to start PN for a short period just to get them over the worst bit. Even if it's not our first choice because it carries risks of side effects for the liver and coagulopathy and all that. But it is a way to make sure they have a minimum intake of nutrients for a while. (P3, FG4) The feeding tube is a very good aid, and we make sure to tell the parents this. Nutritional support is part of the treatment package to best help the child. The tube is not a threat to make them eat but a helpful aid in the early stages. (P4, FG3)
Collaboration to Achieve Optimal Nutritional Care
In all FGs, participants claimed that collaboration was paramount for nutritional management in pediatric oncological care. Collaboration was defined as teamwork between the patient, the family, and other healthcare professionals.
Collaboration with the child was discussed in all FGs, and involving the child was considered pivotal. Nurses encouraged patients to express their feelings and concerns, although this could be challenging. Teenagers were described as negotiators and could sometimes oppose treatment. Nurses tried to collaborate by allowing them to make some decisions on their own. If patients were able to partake, it was easier for them to accept the treatment “We want them to join in. For example, they can rinse the tube before and after medication. They can take part in the treatment” (P4, FG1).
All participants agreed that building a good rapport with the family was crucial. Some parents were seen as highly interested in nutritional intake and ready to take on an active role in food-related decisions “There are many parents who say food is the one thing where they can contribute. They cannot be responsible for the treatment, but regarding food—that's where they have a job” (P4, FG1).
Including parents in care was challenging, but failing to do so could disrupt treatment. Measures adapted to each patient and inviting parents to take part in decision-making could be helpful: I had a family where the mother seemed not to care about helping at all. I discussed it with her, and her experience was that we nurses ignored her view and just ran the show. She felt her opinion didn't matter. After that talk, it was much easier to include her in the care. (P5, FG2)
Importantly, participants concurred that nurses and parents should collaborate as a team in nutritional care, considering the individual needs of each family. Moreover, some participants noted that the level of conflict within families often decreased with the installation of an NFT, as it obviated the need for arguments about the child's intake, ensuring sufficient nutrition was obtained.
Participants claimed that working as an interdisciplinary team on nutritional care was important. The team included, among others, doctors, dietitians, physiotherapists, teachers, kitchen staff, and hospital clowns. Clowns could be used as a distraction, to help the child become physically active, or as a friend to increase the children's well-being. Participants perceived themselves as coordinators and naturally initiated discussions on interventions being bedside: We see the patient every day, and the doctors don't necessarily. Then there's a different doctor from one day to the next, but the nurses are always available. It is so important that we inform and guide the patients on nutrition and physical activity, register the weight, and initiate interventions when needed, and document it so that the others [in the interdisciplinary team] can be aware. (P4, FG1) Previously, we contacted the dietitians when the parents reported that the food intake was low. But now we contact them almost immediately and map the family's habits even from before the illness, so that we know what the challenges have been earlier. If they were a fussy eater before the disease, we know we must pay attention to that during treatment. (P2, FG1) Our hospital schoolteacher has a tradition. Every Friday, she will make wheat buns with the children. The families will come from the outpatient clinic just to have a bun before the weekend. Having this normal, homely sensation and even a tradition is so helpful in making the kids eat. (P2, FG2) Sometimes we just need to put a foot down and say, “We have to do something!” We use our clinical discretion towards weight and weight loss. We discuss it together, us nurses, to see what the best route of action is, and then ask the doctors. (P3, FG4)
Barriers in Nutritional Oncology Care
In all FGs, challenges regarding nutritional care were discussed. This main theme further consists of two subthemes: Inadequate use of guidelines and insufficient documentation routines; the side effects of treatment as a hindrance to sufficient nutrition. Although cancer treatment was perceived as the most prominent issue, participants admitted that it could displace other nonemergencies, such as weight loss or gain.
Subtheme 1: Inadequate Use of Guidelines and Insufficient Documentation Routines
The participants reported insufficient documentation routines and inadequate documentation tools, such as suboptimal use of growth charts and deficient computer systems. Similarly, guidelines for documentation in the medical records were not always adhered to: “We are supposed to register everything in the electronic records at every admission, but we don't always do that. […] I think that you will find that only about 50% of our patients have a recorded weight” (P1, FG3).
Most participants reported the need to prioritize their time owing to limited resources. Therefore, treatment and medical emergencies took precedence over weight management and nutritional intake: “Even though physical activity and nutrition are basic needs and nursing responsibilities, we just don't have the time to do it properly. The administration of medicine consumes all our time. We must prioritize” (P3, FG1)
Subtheme 2: The Side Effects of Treatment as a Hindrance to Sufficient Nutrition
Among other issues, the side effects related to steroids were considered a major concern. The children experienced an intense feeling of hunger, and their mood was significantly impacted, affecting familial relationships. Steroids had adverse effects on the body. Participants explained that parents needed advice and support, especially regarding the types of food the children should eat: Some kids finish one meal and start planning the next. They have a fixation on food. And you see a lot more side effects when using steroids, like increases in blood glucose and blood pressure, and mood changes. […] I have had some parents asking: how much the child can actually eat? Several times during the night: eating pancakes and all sorts. (P4, FG1) We don't have any nice settings for meals, except for Friday mornings, when we prepare a great table where all the patients, parents, and the staff on shift can eat together. We've done that since the dawn of time, and it is so nice to eat together. (P1, FG3) We treated a boy aged 13–15 undergoing chemotherapy. Despite administering the usual treatments, including steroids, his nausea persisted. It was almost as if the more we tried, the more nauseated he became. Eventually, we decided not to focus on that at all. We just agreed to accept that nausea was present. No one was allowed to ask him; he had to report himself if he felt nauseated. We hid all the IV tubes and wrapped them up, so he didn't see the chemo itself; he had no visual stimuli. (P4, FG4) Sometimes our greatest challenge is ensuring the doctors prescribe sufficient antiemetics. Our procedures include this practice, but there is some reluctance. Starting with too low a dosage initially can lead to significant anticipatory nausea. And then you are in big trouble. It's crucial to start with a high dosage from the beginning. (P1, FG2)
Discussion
This study explored the experiences of Norwegian clinical nurses in trying to obtain optimal nutrition supportive care during childhood cancer treatment. One of the main findings was the necessity for nurses to see the whole picture in nutritional care. Nurses needed to understand the child's habits, developmental stage, and family dynamics to provide tailored nutritional care and monitor changes in the patient's nutritional status. This observation aligns with the findings of Chua et al. (2019), which demonstrated that familiarity with the patient enabled nurses to monitor effectively and safely, recognize subtle shifts in condition, and initiate timely interventions.
Awareness of family dynamics underscores the importance of adopting an FCC approach. FCC operates on the foundation of mutually beneficial partnerships between healthcare providers, patients, and families, emphasizing dignity and respect, information sharing, participation, and collaboration throughout all phases of treatment (Johnson et al., 2008).
In our study, nurses focused on integrating nutritional care into the patients’ and families’ everyday lives as a means of achieving optimal nutritional outcomes. Nutritional support extends beyond mere nutrient intake; families also require guidance on various elements of nutritional management. The nurses in our study explained that normality in this setting included remaining active, preserving usual dietary patterns, and spending time with friends and family whenever feasible. These practices can enhance appetite during periods of reduced intake (Christensen et al., 2021). Parents seek normality, also as being a parent, taking care of everyday chores. Meals are an integral part of family life in many cultures, and parents find it meaningful to engage in their children's nutritional care (Christensen et al., 2021). Often, parents perceive meal preparation as their only means of assistance, replicating their role at home and expressing love through cooking. Parents want to actively participate in nutritional care (Christensen et al., 2021).
Participants explained that nutrition was not always prioritized, with medical treatment taking precedence. Adequate nutrition is crucial for enduring treatment and to maintain normal growth (Arpe et al., 2015; Egnell et al., 2022; Freedman et al., 2023). Therefore, it should be prioritized as a long-term task on par with medical treatment. By undertaking some of the administrative aspects of nutritional support, the entire family can enhance their sense of control and involvement in care (Roug et al., 2023). An additional benefit of family inclusion and participation is that the nursing team can concentrate more on the administration of medication, and clinical changes in patient status. Family inclusion and participation are important aspects of FCC and must be coordinated. The parents must be trained in the specific procedures that they take part in.
Our findings indicate that nurses played a pivotal role in coordinating nutritional care, collaborating extensively with doctors, dietitians, play therapists, kitchen staff, and other members of the multidisciplinary team. As noted by Chua et al. (2019), nurses require advanced training in communication and delegation skills to effectively coordinate nutritional care. According to their study, nurses faced challenges in conveying the deterioration of the patient's status to doctors. Lulloff et al. (2019) highlight a lack of common language and understanding among clinical care workers regarding nutritional care. Therefore, it is crucial to define malnutrition clearly and develop specific guidelines that address the various dimensions of nutritional care implications.
Discussions across all FG highlighted challenges in monitoring weight changes and initiating necessary nutritional interventions. The participants emphasized time constraints, unsatisfactory use of guidelines, evaluation tools, and documentation practices. Although some guidelines were available, their inconsistent use was noted. Participants relied more on their clinical experience and observational skills than on the established guidelines. This aligns with the findings of Wang et al. (2023), who reported that clinical guidelines were sometimes disregarded because they did not align with the specific clinical context or were too vague. In some cases, healthcare professionals neglected the guidelines due to a lack of trust, or because roles within the healthcare system were undefined or unclear (Wang et al., 2023). As discussed in all FGs in our study, clinical guidelines were perceived as too imprecise, particularly regarding the recommended frequency of measurements.
Although anthropometrics are required at admission, later measurements and assessments are to be taken on a regular, repeated basis (Mehta et al., 2017; Muscaritoli et al., 2021; Thibault et al., 2021). Inclusion of family training on how to measure, and perhaps even record the measures, should be included in guidelines.
Sufficient training and flexibility within the guidelines are important for the successful implementation of guidelines (Wang et al., 2023). Guidelines should allow customization to meet individual patient needs but remain specific enough to monitor individual changes and prompt interventions (Wang et al., 2023). Precise definitions in clinical guidelines for initiating interventions would enable consensus among nurses, older children, and their families on necessary actions. Implementing evidence-based guidelines has improved length of stay, reduced mortality, boosted patient satisfaction, and other general positive outcomes (Connor et al., 2023).
Nurses recognized nutritional support as crucial for maintaining adequate nutrition during challenging periods. Although NFTs were favored for younger children, they were seen as obstructive for teenagers. Consequently, nurses honored teenagers’ preferences to avoid NFTs, exploring alternative methods to secure minimum nutritional intake. Within the holistic framework of FCC, nurses acknowledged teenagers’ decision-making capacity.
The perception of a larger body as more robust may lead nurses to underestimate the importance of overweight issues, despite the risks of stigmatization and the long-term effects on teenagers’ health-related quality of life. Notably, Mulrooney (2022) highlighted nurses’ reluctance to discuss overweight conditions with their patients, despite their professional duty, like the participants in our study. Pediatric cancer patients can be simultaneously overweight and undernourished (Murphy et al., 2015), emphasizing that a larger body size does not equate to better health; an essential insight for nurses. In the context of FCC, respecting the patient involves addressing difficult topics.
From the beginning of treatment, families should receive clear guidance on nutrition, healthy weight management, and physical activity. Parents often want to be involved in everyday care, which can enable healthcare professionals to focus on more pressing clinical tasks. The FCC model—which emphasizes information sharing, inclusion, shared decision-making, and active participation—is therefore beneficial in pediatric nutritional nursing care in oncology.
Strengths and Limitations
A key strength of this study is the involvement of clinical nurses from all four tertiary Norwegian hospitals treating childhood cancer. The discussions across the four FGs provided rich, diverse insights into this complex topic. While these findings are context-specific and should be cautiously generalized, they align with international research, suggesting that similar opportunities and barriers may exist for clinical nurses in nutritional care. The limitation of conducting only one FG per hospital and low participation in some FGs, despite recruitment efforts, should be noted. The literature presents differing views on whether the size of FGs may be considered a limitation or a strength (Krueger & Casey, 2015; Polit & Beck, 2021). Smaller FGs facilitate easier participation and more time for individuals to share their thoughts (Polit & Beck, 2021). One limitation of this study is that the FGs included only nurses. The perspectives of families and children—who hold valuable insights—were not explored. Including participants from other professional backgrounds could also have enriched the study's multiprofessional dimension.
Implications for Practice and Further Research
Childhood cancer and its treatment-related side effects pose significant risks for malnutrition. To address these challenges effectively, nursing teams should allocate time for structured discussions. Interdisciplinary team meetings can help identify and address key issues. Systematic monitoring of food intake and weight progression, guided by evidence-based protocols, is essential. Electronic medical record systems should include regular reminders for anthropometric measurements and nutritional screening to support prioritization by nursing staff. Nutritional nursing care must be emphasized throughout all phases of cancer treatment—from hospital ward organization to active family involvement. Including families in the planning and evaluation of nutritional status is crucial, and a detailed family history of dietary and nutritional challenges should be collected at each admission. By understanding the family context, nurses can better engage parents in information sharing and involve them in practical tasks, such as administering TF. Further research should explore the management of nutritional care in multiprofessional teams to better understand nurses’ roles. Collaboration on nutritional oncological care among nurses, families, and other healthcare workers in various settings, including outpatient wards and home care, should also be examined.
Conclusion
Our study offers insight into the importance of close collaboration with every single family, thus promoting FCC for assessing and promoting optimal nutritional status in clinical settings. Nurses, who observe each patient's and their family's comprehensive needs across all treatment stages, have a key role in optimizing personalized, systematic nutritional care. Nevertheless, they frequently encounter time constraints and inefficient documentation routines that impede further enhancement of nutritional care. Nurses must have a broad perspective on what constitutes optimal nutritional care. Using guidelines in a systematic manner is crucial to prevent malnutrition during childhood cancer treatment.
Footnotes
Acknowledgments
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data are not publicly available, as this would risk participant anonymity.
Data Protection Agency Approval
The study was approved by the Norwegian Governmental Data Protection Agency (SIKT; Approval No. 875728; June 27, 2022).