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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.46 no.4 São Paulo Aug. 2012 



The evaluation of an instrument for pediatric oncology patient classification*



Sandra de AndradeI; Sérgio Vicente SerranoII; Maria Salete de A. NascimentoIII; Stela Verzinhasse PeresIV; Allini Mafra da CostaV; Regina Aparecida Garcia de LimaVI

IMSc in Medical Biotechnology from the Universidade Estadual Paulista. Registered Nurse of the Barretos Cancer Hospital. Barretos, SP, Brazil.
IIPhD in Medical Sciences from the University of São Paulo. Physician of the Clinical Oncology Service of the Barretos Cancer Hospital. Barretos, SP, Brazil.
IIIPhD in Medical Sciences from the University of São Paulo. Physician of the Palliative Care Service of the Barretos Cancer Hospital. Barretos, SP, Brazil.
IVPhD student in Public Health of the University of São Paulo. Biostatistician of the Teaching and Research Institute of the Barretos Cancer Hospital. Barretos, SP, Brazil.
VUndergraduate Nursing Student. Database Manager of the Teaching and Research Institute of the Barretos Cancer Hospital. Barretos, SP, Brazil.
VIRegistered Nurse. Full Professor of the Maternal-Infant Nursing and Public Health Department of the University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil.





The objectives of this study were to assess the interrater reproducibility of the instrument to classify pediatric patients with cancer; verify the adequacy of the patient classification instrument for pediatric patients with cancer; and make a proposal for changing the instrument, thus allowing for the necessary adjustments for pediatric oncology patients. A total of 34 pediatric inpatients of a Cancer Hospital were evaluated by the teams of physicians, nurses and nursing technicians. The Kappa coefficient was used to rate the agreement between the scores, which revealed a moderate to high value in the objective classifications, and a low value in the subjective. In conclusion, the instrument is reliable and reproducible, however, it is suggested that to classify pediatric oncology patients, some items should be complemented in order to reach an outcome that is more compatible with the reality of this specific population.

Descriptors: Child; Neoplasms; Classification; Pediatric nursing




In Nursing the need is being increasingly felt for the use of a scientific method as a framework for the organization of the care. This would allow professionals to develop practical, efficient and rapid methods to obtain results, related to the improvement of the care and to the assignment of the staff(1). The adoption of a Patient Classification System (PCS), as a tool for the administrative practice of nursing, provides decision-making in areas related to the assignment of the staff, quality and monitoring the cost of the nursing care(2-3). Patients have been classified according to few parameters such as medical diagnosis, age and gender, among others. Although these criteria are objective, they offer no clear distinction regarding the need for nursing care for the patients(2,4). In 1920, Florence Nightingale suggested that patients who present a more severe clinical condition should stay in the beds closer to the nursing station(5). However, only from this decade have the hospitals in the U.S.A. begun to classify patients according to disease severity and type of care(6).

In the 1970s in Brazil, studies were initiated concerning Progressive Patient Classification (PPC) as an instrument for the assignment of nursing human resources for adult patients, in order to provide a more equitable distribution of the care, and to increase hospital productivity and efficiency(7). Some classification instruments for adult patients based on the individualized nursing care needs have also been validated by authors assuming that the severity of the patient of the unit has vital importance in the assignment of staff in the healthcare institutions(8-10).

The lack of an adequate reference leads the nursing staff to classify these patients in an equivocal manner, using parameters that do not reflect the real care needs of these clients and, consequently, cause distortions in the quantitative prediction of the nursing staff. To meet this need, an instrument used as a classification system for pediatric patients was validated, with the aim of evaluating the degree of dependency of the patient in relation to the nursing care(11). In this instrument eleven nursing demand indicators are presented, with each indicator being assigned four graduated care dependency situations with a numerical value of one to four points, with one point representing a lower nursing demand and four points a greater requirement for the nursing care. Because of the difficulty in the assignment of the nursing staff in the care of pediatric oncology patients, this study aimed to implement and apply, in the oncology inpatient unit of the Barretos Cancer Hospital, the pediatric patient classification instrument, in order to evaluate the degree of reproducibility between evaluators and to see if it integrally meets the characteristics of the pediatric oncology patient.



A descriptive, exploratory, cross-sectional study was performed. This study evaluated 34 pediatric patients with cancer, hospitalized in the Pediatric Inpatient Unit of the Barretos Cancer Hospital - Pio XII Foundation, between September and December 2008. The evaluations were undertaken by the staff of the pediatric department which consisted of three physicians, three nurses and six nursing technicians.

The pediatric department consists of 10 inpatient beds and daily there is a physician, a nurse and three technicians per shift, each physician is responsible for visiting the ward for seven consecutive days and the duty roster of the nurses and technicians is completed on a daily basis. Each patient was evaluated separately by a physician, a nurse and a nursing technician, as well as the researcher. The evaluations of the patient were carried out in the first 24 hours of hospitalization, during the same work shift, at times as close as possible. The duly completed forms were collected at the end of each evaluation by the principal researcher. This study was considered as a standard to compare the evaluation of the principal researcher (specialist oncology nurse). As this is an analysis of reproducibility, in which the interpretation of the subjects regarding the instrument is a fundamental part of the results, the explanations were brief and succinct. The evaluators were instructed not to consult the others during this process, and not to disclose their evaluations.

For the data collection, a previously validated pediatric patient classification instrument was used. This instrument consists of 11 nursing demand indicators: activity, interval of measurement of controls, breathing, pharmacological therapy, nutrition and hydration, elimination, bodily hygiene, skin and mucosa integrity, mobility and walking, support network, and support and participation of the partner. A degree of care dependence is assigned to the indicators, ranging from one to four points, in accordance with the increase in the nursing requirement. To determine the final level of complexity the scores of each of the 11 indicators are summed. The score ranges from a minimum of 11 points to a maximum of 44 points. This score is divided into five levels of nursing care complexity:

Level I - minimal nursing care (11 to 18 points)

Level II - intermediate nursing care (19 to 23 points)

Level III - high dependence nursing care (24 to 30 points)

Level IV -semi-intensive nursing care (31 to 36 points)

Level V - intensive nursing care (37 to 44 points)

For data collection, the principal investigator and the other teams of evaluators applied the collection instrument and recorded the information on a form consisting of three parts: The first part consists of the 11 nursing demand indicators. In this the evaluators attributed a score (grade) of 0 to 4 for each indicator. The sum of these scores (grades) was used later to obtain the classification of the level of complexity of nursing care as described above, i.e. level I to V. This classification was called the Objective Classification and was obtained by the investigator without the knowledge of the evaluators and does not reflect the opinion of the evaluators. The second part asks for the opinion of the evaluator regarding the level, I to V, in which the patient should be classified according to level of nursing care complexity. This classification was called the Subjective Classification. The third part asks the evaluator to give their opinion on the need to include other indicators in the instrument and for any suggestions.

In order to measure the reproducibility of the pediatric patient classification instrument, the Kappa Coefficient was used. This coefficient can be defined as a measure of association used to describe and test the degree of concordance (reliability and accuracy) in the classification. The degree of concordance was based on the classification of Landis and Koch as follows: when the Kappa coefficient obtains a value <0.40 it is interpreted as low concordance, when the coefficient obtains a value from 0.40 to 0.75 it is interpreted as intermediate concordance, and when this value was > 0.75 it is interpreted as high concordance(12).

The data were tabulated and analyzed using the program SPSS for Windows, version 15.0 and intercooled STATA version 9.0. The sample characterization was performed by means of absolute and relative frequencies and measures of central tendency and dispersion (mean, median, standard deviation, minimum and maximum). A level of 5% (p <0.05) was assumed for statistical significance. This study was approved by the Research Ethics Committee of the Barretos Cancer Hospital on July 11, 2008 (158/2008). In order to verify that this instrument was adequate for the classification of pediatric cancer patients, the levels of care complexity attributed by the evaluators in the subjective classification were compared with the levels of complexity obtained by summing the scores of the 11 indicators of the instrument, in the objective classification.



In the 34 patients of this sample the mean age was 10.94 (sd=5.5) years, with a median of 12 years, ranging between 01 and 20 years. Table 1 shows the characteristics of the patients according to gender, type of neoplasm and the reason for hospitalization.



Table 2 presents the comparison between the objective classification made by the physician, nurse and nursing technician evaluators and the classification made by the researcher.

Within the sample studied, there was no indication and/or classification of patients needing intensive or semi-intensive care by any of the professionals in the objective classification, possibly due to the care profile of the service. Note that between the researcher and the physicians an intermediate value of the Kappa coefficient (K=0.69), p <0.001 was obtained, between the researcher and the nurses the results showed a high Kappa coefficient (K=0.84); p <0.001, and between the researcher and the nursing technicians the Kappa coefficient was intermediate (K=0.71), p <0.001. The resulting classification of the scores was called the objective classification and did not necessarily reflect the opinion of each evaluator. The comparison of the objective classifications of the evaluators with the subjective classifications, regarding the levels of nursing care complexity, was performed together with the consideration of the comments and suggestions of the evaluators, to verify that the proposed pediatric patient instrument is adequate for infant-juvenile cancer patients.

Table 3 presents the comparison between the levels of nursing care complexity obtained for the objective classifications and the levels obtained for the subjective classifications of the evaluators.

These data show a low Kappa coefficient (K=0.12) p=0.095 for the opinions of the physicians and a low Kappa coefficient (K= 0.31), p<0.001 for the opinions of the nursing technicians. This demonstrates a low concordance between the subjective classification and the objective classification obtained from the opinion of the physicians and nursing technicians. Concerning the objective and subjective classifications attributed by the nurses surprisingly a higher Kappa coefficient (K=0.91) p <0.001 was observed.



Analyzing the suggestions and comments made by the evaluators a correlation was observed between some aspects of the clinical condition of the patients and the subjective classification of the levels of nursing care complexity attributed by physicians, nurses and nursing technicians. It was verified that the teams of physicians and technicians subjectively classified the patients with a greater degree of dependence, mainly due the particularity and complexity of the pediatric oncology patient. As previously mentioned there was high concordance between the objective classifications and the subjective classifications made by the nursing team, which did not occur in the physician and nursing technician evaluators. As verified by the teams of evaluators, with pediatric oncology patients the classification instrument does not take into consideration the presence of an important clinical characteristic, i.e. febrile neutropenia. The complexity of the disease imposes a greater demand on the healthcare teams for care to these patients. Therefore, in the majority of cases the pediatric patient classification instrument used classified the neutropenic patient as level I (minimal care), whereas this patient should be classified as level II (intermediate care). Febrile neutropenia is defined as the absolute neutrophil count below 1000 per mm3. When the neutrophil level falls below 500 per mm3 the possibility of infections occurring increases significantly. The clinical signs or symptoms are probably manifested due to the reduction in the inflammatory response, because of the lack of neutrophils. The patient should be watched carefully, avoiding major complications, and therefore requires greater care from the nursing team(13).

This study showed that when the evaluators classified the patients objectively, i.e. through the instrument, the Kappa coefficient was shown to be intermediate to high (K=069 to K=0.84), which shows that the instrument is useful, reproducible and practical. However when the comparison of the subjective classification of patient complexity was performed through the sum of the scores versus the subjective opinion of the evaluators, there was a discrepancy in the concordance, especially that of the physicians and of the nursing technicians, with low Kappa coefficient values (K=0.12 and K=0.31 respectively). However, the Kappa coefficient of the nursing team was high (K = 0.91). Thus, the study verified the reproducibility of the instrument among the evaluators, since in the Brazilian literature there is only one instrument for the classification of pediatric patients and this is an instrument for the classification of pediatric non-oncology patients.

The lack of specific instruments for the classification of pediatric oncology patients was the motivating factor for this study, since the patient classification instrument is essential for the assignment of the nursing team to ensure quality care. In addition to minimizing costs to the hospital and providing better utilization of both the physical area and the nursing team, it is the job of the nurse to classify the patients according to the care required in order to establish an adequate framework of personnel(14). In the literature, some studies of the classification of adult patients that included pediatric patients in their sample classified the pediatric patient as high nursing care dependency regardless of the level of complexity presented(9). Studies conducted with nurses in the use of the patient classification system show that nurses do not use the patient classification system appropriately in their daily clinical practice(15).

The limitations of the study were the small number of evaluators in the pediatric department, the rotation of the nursing duty rosters, and the reduced number of inpatients during the study period. In the literature authors(16) have studied the properties of the Kappa coefficient and, among other topics, have approached statistical significance, presenting the test power for different sample sizes and null hypotheses. It was have found that the sample size of 30, considering a two-tailed test hypothesis with null value = 0, has a test power 0.9 (90%) to identify a Kappa Coefficient index 0.6 (60%) being statistically different from zero. Therefore, considering that the significant Kappa Coefficients in this study were all greater than or equal to 0.6 (60%) with a sample size of 34 patients, it can be considered that the results can be expanded to the population taking into consideration the conclusions reached in the interpretation of the estimates. The lack of classification instruments for pediatric patients makes it impossible to compare the data from this study.



The present study demonstrated the importance of the classification of pediatric oncology patients. The pediatric patient classification instrument used is an easy to apply tool with high inter-evaluator reproducibility. A limitation of this instrument is that it does not contemplate a clinical feature frequently observed in pediatric oncology patients and that has great importance for the classification of the level of nursing care complexity. Therefore it is proposed to adapt the pediatric patient classification instrument used in this study, with an additional indicator for febrile neutropenia. The instrument can be used as a basis for further studies aiming to improve the nursing care process, and in future investigations, to test the instrument and apply it as a management tool in the clinical practice.



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Sandra de Andrade
Fundação Pio XII - Hospital de Câncer
Av. Antenor Duarte Vilela, 1331 - Bairro Dr. Paulo Prata
CEP 14784-400 - Barretos, SP, Brazil

Received: 11/26/2010
Approved: 01/12/2012



* From the dissertation "Adaptação de um instrumento para classificação de pacientes baseado nas necessidades individualizadas no cuidado de enfer-magem do paciente pediátrico oncológico", Post-graduate Program in Research and Development, Medical Biotechnology, Universidade Estadual Paulista, 2009.

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