Nurse Education Today 35 (2015) 444–449
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Nurses' knowledge and educational needs regarding genetics Memnun Seven a,⁎, Aygül Akyüz b, Burcu Elbüken c, Heather Skirton d, Hatice Öztürk c a
Koç University, School of Nursing, Koç Universitesi Hemşirelik Yüksek Okulu, Güzelbahçe sokak no. 20, Nişantaşı, Şişli, İstanbul, Turkey Koç University, School of Nursing, Istanbul, Turkey c Haydarpasa Gulhane Military Medical Academy Training and Research Hospital, Istanbul, Turkey d Plymouth University Faculty of Health and Human Sciences, Plymouth, United Kingdom b
a r t i c l e
i n f o
Article history: Accepted 12 November 2014 Keywords: Genetic Registered nurse Knowledge Survey Confidence
s u m m a r y Background: Nurses now require a basic knowledge of genetics to provide patient care in a range of settings. Objectives: To determine Turkish registered nurses' current knowledge and educational needs in relation to genetics. Design: A descriptive, cross-sectional study. Settings: Turkish registered nurses working in a university hospital in Turkey were recruited. Participants: All registered nurses were invited to participate and 175 completed the study. Methods: The survey instrument, basic knowledge of health genetics, confidence in knowledge and the nurses' need for genetics education were used to collect data. Results: The majority (81.1%, n = 142) of participants indicated that genetics was not taught during their degree program, although 53.1% to 96% of respondents felt confident in defining different genetic concepts. The average genetics knowledge score was 6.89 ± 1.99 of a possible 11 (range 0–11). The majority (70.3%) expressed a strong wish to attend a continuing nursing education program in genetics. Conclusions: The study shows that although Turkish nurses are not sufficiently knowledgeable to apply genetics in practice, they are willing to have more education to support their care of patients. Nurses need to have more education related to genetics in accordance with advances in human genetics to optimize health care. © 2014 Elsevier Ltd. All rights reserved.
Introduction The Human Genome Project built on decades of genetics research and enhanced our understanding of human genetics (Thompson and Brooks, 2011; Godino et al., 2013a; Bancroft, 2013). Since completion of the project, there has been increasing development and availability of new treatments and expanded genetic testing options (Williamson and LeBlanc, 2008; Umberger et al., 2013). Although genetic health services have been provided by specialist genetics centers for several decades, genetic and genomic information is now being utilized in almost all healthcare settings (Daack-Hirsch et al., 2011; Bancroft, 2013). Therefore, all health care professionals should be able to provide genetic information, education and support to individuals with a current or potential genetic condition (Daack-Hirsch et al., 2011; Godino et al., 2013a). To achieve this, health professionals require a basic knowledge of genetic principles and the ability to integrate genomics into their daily clinical practice (Thompson and Brooks, 2011; Umberger et al., 2013; Boyes, 2013).
As part of the largest health care profession, nurses in all settings have an important role in improving health to prevent and reduce the burden of disease, and to educate patients and their families (Lea et al., 2011; Bancroft, 2013; Umberger et al., 2013). Developments in genetics, particularly in fields such as oncology, gastroenterology, pediatric, and prenatal care, have led to an increase in demand for genetic and genomic healthcare, requiring nurses to develop competences in both skills and knowledge regarding genetics to support their clinical practice (Burke and Kirk, 2006; Umberger et al., 2013). In addition, numerous authors (Jenkins and Calzone, 2007; Godino et al., 2013a; Thompson and Brooks, 2011) suggest that all nurses, regardless of country or practice setting, need to be appropriately trained in genetics and genomics in order to provide best practice for prevention, detection and/or treatment of disease. Unlike many other fields of nursing, genetics is relevant to every life stage, and therefore, it should be addressed across all patient groups from neonatal to geriatric care (Skirton et al., 2012a,b; Umberger et al., 2013). Background
⁎ Corresponding author. Tel.: +90 2123112659. E-mail addresses: [email protected] (M. Seven), [email protected] (A. Akyüz), [email protected] (B. Elbüken), [email protected] (H. Skirton), [email protected] (H. Öztürk).
http://dx.doi.org/10.1016/j.nedt.2014.11.008 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Although there have been recommendations to integrate genetics into the nursing curriculum for many years, there is some evidence that it has not been included in nursing education in any consistent
M. Seven et al. / Nurse Education Today 35 (2015) 444–449
manner (Tomatir et al., 2006; Jenkins and Calzone, 2007; Umberger et al., 2013). Umberger et al. (2013) stated that there are several factors contributing to the lack of progress in integrating genetics/genomics into nursing education, such as a shortage of nursing faculty prepared to teach genetics and failure to recognize the value of genetics/genomics in nursing practice. The deficit in nursing education of genetics results in nurses having an insufficient knowledge of genetics as shown in studies conducted in different countries (Kim, 2003; Terzioğlu and Dinç, 2004; Tomatir et al., 2006; Vural et al., 2009; Gharaibeh et al., 2010; Godino et al., 2013a). Moreover, in some reviews, it is reported that nurses do not have adequate knowledge in specific areas (such as inheritance patterns, drawing a pedigree, utility of genetic tests, and ethical and legal issues) that would enable them to educate and consult patients and their family members appropriately (Burke and Kirk, 2006; Dodson and Lewallen, 2011; Gibbs, 2011). Genetics/Genomics knowledge should not be merely included in educational programs without addressing the cultural context. It is important to conduct research in different countries in order to have a better understanding of the effect of genetics and genomics information from many perspectives (Skirton et al., 2012a,b). As a first step, it is thought that current knowledge and awareness of nurses towards genetics needs to be assessed to identify the changes needed in nursing education and to offer appropriate nursing education. Little research on genetics related issues in Turkish nurses or nursing students has been found and the few existing studies were conducted some years ago (Terzioğlu and Dinç, 2004; Tomatir et al., 2006; Vural et al., 2009). In the five years since that last study (Vural et al., 2009) was published, much has changed in the area of genetic healthcare and it was timely to conduct a further study. The aim of this study was to investigate the current knowledge level of registered nurses in relation to genetics, to assess the self reported self-confidence of qualified nurses in defining basic concepts in genetics and to determine the educational needs of nurses for genetics knowledge in Turkey. Methods
445
Table 1 Demographic background of female participants. n = 175
n
Age (year) Highest qualification in nursing Vocational high school Associate degree nursing programs, Baccalaureate nursing program Master program PhD program An average time of working as a nurse (year) (1–27) Area in which nurses' work Medicine (such as respiratory, neurology, gastroenterology) Gynecology/Obstetrics Neonatology/Pediatrics Emergency and out-patient clinics Intensive care Cardiology/coronary care Oncology/hematology Surgery (such as orthopedic, plastic, ear–nose–throat surgery)
30.3 ± 5.91
%
3 1.7 3 1.7 110 62.9 55 31.4 4 2.3 10.46 ± 6.64 48 4 8 18 16 14 15 52
27.7 2.3 4.6 10.2 9.1 8.0 8.7 29.6
the concepts. An open-ended question asking nurses to list diseases related to genetics was included. The knowledge level of nurses related to genetics was assessed in the third section. Nurses were asked to respond ‘true’, ‘false’ or ‘do not know’ to 11 statements regarding topics that included consanguineous marriage, preimplantation genetic diagnosis, prenatal screening tests, breast and ovarian cancer gene mutations, family history of breast, ovarian and colorectal cancers, and the relationship between genetics and multifactorial disorders. One point was given for each statement answered correctly; the total possible score was 11. In the final section, we collected data by asking participants whether they felt the need for genetics education to help them in their daily nursing practice. A list of specific topics was provided. Options for answering these questions were given as ‘I would like’, ‘I would not like’ and ‘it does not matter’. The instrument was pilot tested with five nurses who were not planning to participate in the study to determine face validity and clarity of questions. Minor changes were made after this process.
Study Design This was a descriptive, cross-sectional study. Participants The study was carried out in a university hospital in İstanbul, Turkey in April 2014. All registered nurses working in the institution were eligible to participate. At the time of the study, there were a total of 345 nurses working in the hospital, however 55 nurses were unavailable due to absence for reasons such as maternity leave, paid or unpaid leave and were excluded from the study (due to long term absence from duty). A total of 175 (of a possible 290) nurses took part, a response rate of 60.3%. Instrument The study instrument comprised four sections, addressing demographic characteristics, genetics knowledge level, confidence in knowledge level, and the educational needs of nurses related to genetics (see Tables 1, 2, 3 and 4). The instrument was developed by the researchers based upon literature (Terzioğlu and Dinç, 2004; Tomatir et al., 2006; Daack-Hirsch et al., 2011; Skirton et al., 2012a,b; Godino et al., 2013a). In the first section of the form, nurses were asked for demographic information, including information about their work settings. In the second section, nurses were asked to self-assess their basic knowledge of genetic concepts. A total of 12 concepts were included and nurses were asked whether they felt confident about their understanding of
Data Collection The study was conducted after receiving approval from the institutional ethics committee. The researchers informed the nurses in all settings about the aim and method of the study. Nurses who were willing to participate in the study were given the questionnaire forms and information about completing the form. Return of the completed questionnaires to the researchers was deemed to indicate consent.
Table 2 Educational background and opinion of participants on genetics in nursing education. n = 175 Having genetics course (or at some point within the curriculum) during nursing education No Few hours in some other courses (such as obstetrics, medicine etc.) Opinions on genetics science knowledge in nursing educationa It was enough in the nursing education It should be covered in more detail in the nursing education It should be offered as a part of continuing nursing education It should be covered in masters degree program in nursing Wish to have a continuing nursing education regarding genetics Yes No a
Participants could choose more than one answer.
n
%
143 81.7 32 18.3 18 108 87 38
20.3 61.7 49.7 21.7
123 70.3 52 29.7
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Table 3 Participants' confidence about defining concepts related to genetics. n = 175
Yes
Concepts, n (%) 1. Mutations 2. Mitosis 3. Meiosis 4. Heterozygous 5. Homozygous 6. Gene 7. Genotype 8. Phenotype 9. Allele 10. X-linked inheritance patterns 11. Autosomal dominant inheritance patterns 12. Autosomal recessive inheritance patterns The average number of concepts defined by nurse (0–12)
168 (96) 159 (90.9) 158 (90.3) 154 (88) 152 (86.9) 149 (85.1) 129 (73.7) 118 (67.4) 106 (60.6) 96 (54.9) 93 (53.1) 93 (53.1) 8.91 ± 3.43
Statistical Analyses The SPSS for Windows (SPSS Inc., Chicago, IL, USA) software, version 20.0, was used for the statistical analysis. The distribution of the data was performed using frequency distribution both counts and percentages. The Student ‘t-test’ was used for statistical comparison between groups. A p-value of less than .05 was accepted as statistically significant.
Results The demographic backgrounds of the 175 study participants are shown in Table 1. Study participants ranged in age from 22–46 years, with a mean age of nurses of 30.3 ± 5.91 and average number of years of experience as a nurse of 10.46 ± 6.64 years (range from 1 to 27). The majority (81.1%, n = 142) of participants indicated that genetics was not taught during their degree program (Table 2). However, 20.3% of them thought that they had been given sufficient information related to genetics in that program. Of nurses 70.3% expressed a strong wish to attend a continuing nursing education program in genetics. Nurses in this study were most interested in receiving more education on issues that were directly related to prenatal and newborn screening, or familial cancer. However, fewer nurses regarded some topics in genetic healthcare, including ‘genetic centers in Istanbul’ and ‘taking family history and drawing a pedigree’ as important. The majority of nurses felt confident in defining the concepts ‘mutations’, ‘mitosis’ and ‘meiosis’, however felt less confident about terms such as ‘autosomal dominant and recessive inheritance patterns’, and ‘X-linked inheritance patterns’ (Table 3). Table 4 shows the diseases which nurses' thought might be relevant to genetics. Down syndrome, thalassaemia and diabetes were the diseases most cited as a genetic condition (Table 4). Table 4 Conditions related to genetics that were mentioned by nurses. n (%) Down syndrome Thalassaemia Diabetes Cancers Familial mediterranian fever Haemophilia Heart diseases Hypertension Trisomies Cystic fibrosis Phenylketonuria Turner syndrome
104 (59.4) 54 (30.9) 54 (30.9) 37 (21.1) 36 (20.6) 32 (18.3) 31 (17.7) 18 (10.3) 13 (7.4) 12 (6.9) 11 (6.3) 9 (5.1)
The average genetics knowledge score was 6.47 ± 2.02 of a possible 11 (range 0–11) (Table 5). The majority of nurses (96%, n = 168) were aware of the importance of the links between consanguinity and recessive genetic disease. Most nurses also knew of the relationship between genetic risk and diseases such as breast cancer (92%, n = 161), ovarian cancer (90.9%, n = 159), heart conditions and diabetes (89.7%, n = 153). The lesser known issues were frequency of hereditary breast cancer syndromes (12.6%, n = 22), inheritance pattern of Down syndrome (13.1%, n = 23), and relationship between BRCA 1–2 gene mutations and both breast and ovarian cancer (20%, n = 35). There was no statistically significant relationship between education level and the knowledge level of nurses. In this study, the factors such as nurses' level of knowledge on genetics and having a genetics course during nursing education were evaluated to determine their effects on nurses' desire to have more education on genetics. There were statistically significant relationships between the average number of genetic concepts correctly defined by nurses and two other variables; nurses' desire to have a continuing nursing education regarding genetics, and whether or not they undertook a genetics course during nursing education (Table 6). Regarding knowledge of genetic services, only 20% (n = 35) of participants stated that they knew where the genetic centers in Istanbul were located, while 51.4% (n = 90) did not know about the health services offered by genetic centers. Services provided by genetics centers cited by nurses answering the free-text question were: diagnosis, early detection, treatment of genetic conditions, research on genes and genetic conditions, prenatal genetic testing, infertility treatment and other health services for infertile couples, chromosomal abnormality analysis and research, newborn screening for genetic conditions and genetic counseling.
Discussion Nurses' Knowledge Level on Genetics With advances in human genetics affecting so many aspects of healthcare, it is essential that nurses should be genetically literate and able to incorporate genetic and genomic knowledge into providing professional nursing care (Giarelli and Reiff, 2012). Recent studies have focused on the minimum requirements in terms of core competences in genetics for graduate nurses. These include being able to recognize individuals who may have an genetic condition, knowing how to make a referral to genetic centers, being able to take a family history, draw a pedigree, understanding the benefits and limitations of genetic testing, and being able to obtain and convey genetic information to patients (Skirton et al., 2012b). The core competences are developed for use in different countries, however while some are close to achieving the incorporation of these competencies into health professional education and practice, in others considerable progress is still required (Kirk et al., 2011). There are 57 registered genetic centers in Turkey (personal communication with the Ministry of Health of Turkey) and to our knowledge there are no nurses working in genetic centers or working with the title of genetic nurse in other health care settings. Although some graduate nursing programs include genetics courses, there is no undergraduate nursing program in Turkey in which genetics is specifically included. However, this situation may change, as counseling for families at risk of genetic conditions is now a responsibility of women's health nurses, according to amendments to the Turkish nursing regulations that came into force on 19th April 2010 (Republic of Turkey Ministry of Health's Web site). Genetic counseling is also one of the nursing interventions that can be undertaken according to either the nurse's own clinical decision or on the order of a physician. This regulation indicates that Turkish nurses do not have any legal restriction to undertake genetic healthcare and to educate to their clients in every setting (Republic of Turkey Ministry of Health's Web site). However, such
M. Seven et al. / Nurse Education Today 35 (2015) 444–449
447
Table 5 Nurses' knowledge on genetics. n = 175
Correct answer
1. Couples who have consanguinous marriage are at high risk for autosomal recessive conditions such as phenylketonuria, cystic fibrosis and thalassemia 2. Genetic risk (e.g., as indicated by family health history) has clinical relevance for breast cancer 3. Genetic risk (e.g., as indicated by family health history) has clinical relevance for ovarian cancer 4. Genetic risk (e.g., as indicated by family health history) has clinical relevance for either diabetes or heart disease 5. Every pregnant woman should be tested by double or triple test for early detection of genetic conditions such as aneuploidies (e.g. Trisomy 21), and neural tube defects 6. Genetic risk (e.g., as indicated by family health history) has clinical relevance for colon cancer 7. It is possible for couples who are carriers or have a history of a child with a genetic condition to have a healthy baby, by preimplantation genetic diagnosis (PGD) 8. Today, genetic testing for genetic conditions such as β-thalassemia, cystic fibrosis, haemophilia, and fragile X have been available 9. BRCA1-2 gene mutations can be responsible for both ovarian and breast cancer 10. The majority of Down syndrome (Trisomy 21) is not inherited due to the fact that translocation is very rare in Down syndrome cases 11. Hereditary breast cancer syndromes are accountable for about 5 to 10 percent of all breast cancer cases The average knowledge score (0–11)
responsibilities must be supported by appropriate education and clinical mentorship. In this study, the literacy level of nurses in genetic concepts was assessed. Overall, around 50%–95% of all the nurses stated that they felt confident in defining basic genetic concepts. Kim (2003) reported that Mendelian and single gene inheritance patterns were better known concepts to nurses. However, in Terzioğlu and Dinç’ study (2004), 75% to 90% of nurses stated that their knowledge of basic genetic concepts was insufficient (Terzioğlu and Dinç 2004). Similarly, in another Turkish study (Tomatir et al., 2006), a high percentage of nurses also admitted they had insufficient knowledge about the genetic basis of disease and inheritance patterns (98.9%). When the data on level of knowledge from this study are compared to the other Turkish studies, some concepts such as mitosis, meiosis and mutation appear to be more familiar to nurses since 2004. In this study, only half of the nurses stated that they could explain X-linked, autosomal dominant and autosomal recessive inheritance patterns correctly. Interestingly, this contrasts with the earlier findings of Terzioğlu and Dinç (2004), who found that autosomal and recessive inheritance patterns were very well known concepts. While in another Turkish study, the inheritance pattern of genetic disease was only known by less than 5% of nurses (Tomatir et al., 2006). However, the level of genetic literacy may differ according to the study population. The deficit in genetic literacy may cause limitations in nursing care for individuals with current or possible genetic conditions. In a systematic review on this topic, Skirton et al. (2012b) stated that there were no studies indicating that nurses had an appropriate level of knowledge and skills to be able to fulfil the genetic core competences. In the current study, knowledge level was assessed by giving true or false statements to nurses. According to these statements, the relationship Table 6 Comparison of nurses' status of having a genetics course and interest in further education on genetics. Having genetics course during nursing education No The average knowledge score The average number of concepts defined by nurses
Yes/Few hours
t
6.59 ± 1.54 6.43 ± 1.97 8.58 ± 3.58 10.40 ± 2.12
p 0.431 0.177 2.773 0.004
Wish to have a continuing nursing education regarding genetics No The average knowledge score The average number of concepts defined by nurses
Yes
6.50 ± 1.55 6.44 ± 2.029 −0.168 0.353 7.90 ± 4.54 9.34 ± 3.00 2.574 0.000
n
%
168 161 159 157 153
96 92.0 90.9 89.7 87.4
135 99
77.1 56.6
86 49.1 35 20 23 13.1 22 12.6 6.89 ± 1.99
between consanguinity and genetic conditions is well known by nurses. This may not be surprising, as Turkey has a high rate of consanguineous marriages, around 20%–25% (Tomatir et al., 2006). In addition, the community in general has been informed of the negative effects of consanguineous marriage, including increased risk of genetic diseases, through programs such as pre-marriage education and family education for all people offered by The Ministry of Family and Social Policies (MFSP) (Web site of MFSP). In the study, the majority of nurses were aware of the importance of genetic risk for breast and ovarian cancer. In Turkey, the incidence of breast cancer reached 40.6 per 100,000 in 2009 and ovarian cancer is the seventh most common cancer in women with an incidence 6.9 per 100,000 (Web site of Department of Cancer Turkish Ministry of Health). However, only one in five nurses knew that having a family history of either breast or ovarian cancer can also be related to the each other type of cancer due to BRCA1-2 gene mutations. Moreover, only one in ten nurses knew that hereditary breast cancer syndrome accounts for only 5%–10% of all breast cancer. These findings show that, despite the fact that the relationship between cancer and familial tendency is well known by Turkish nurses, they did not appear to know that ovarian and breast cancer may be due to the same gene mutation and needs to be considered together while taking a family history. Bottorff et al. (2005) reported that half of nurses in their study correctly responded regarding questions on testing for breast cancer gene mutations, while the number of correct responses was greater for items related to cancer inheritance patterns. Although, genetic knowledge is an important aspect in the optimal nursing care of patients in every setting, nurses need to have particular expertise and deep genetic knowledge in some health fields such as oncology (Umberger et al., 2013). This should be above that required by nurses working in more general settings. Down syndrome has a reported incidence of 1.2 per 1000 live births in Turkey (Tunçbilek, 2001). It may be therefore unsurprising that it was cited as a genetic condition by the majority of nurses (59.4%, n = 104). However, the sporadic nature of the majority of cases was known by only 13.1% (n = 23). Moreover, only 6.3% (n = 11) of nurses cited phenylketonuria as a genetic condition, despite the fact that Turkey has the highest incidence of phenylketonuria in the world, with approximately one case in 2600 births (MoH report 2004). The results show that, in spite of the high incidence of some conditions, many nurses do not know that these are genetic diseases. It is also worth noting that almost half of the nurses were not aware that genetic testing for genetic conditions such as β-thalassemia, cystic fibrosis, haemophilia, and fragile X is currently available. As genetic tests have been becoming widespread, nurses will be required to know the risk factors and inheritance pattern of genetic conditions, and available genetics tests to refer patients or their families for help and advice (Boyes, 2013).
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Educational Background and Further Educational Needs of Nurses on Genetics In this study, only 19.9% nurses indicated that basic principles of genetics were taught at some point within their nursing curriculum. Terzioğlu and Dinç, 2004 reported that only 23.3% of Turkish nurses claimed that they had been informed about genetics during their education, and almost all of them (98.4%) found this information insufficient. Similarly, in some studies conducted in different countries such as Italy and Taiwan, majority of nurses had not studied a specific course or module on genetics during their nursing training, but had studied basic principles of genetics at some point within the curriculum (Godino et al., 2013b; Hsiao et al., 2013). In addition, this inadequate level of education during undergraduate programs may also be reflected in the findings of a study conducted in the USA, where 30% nurses reported taking a genetic course since licensure (Coleman et al., 2014). When it is considered that there were significant genetic discoveries over the last decade, this indicates that scientific advances have not been translated into clinical education, although this is not confined to Turkey (Lea et al., 2011; Hsiao et al., 2013; Coleman et al., 2014). Three in four of the nurses expressed a strong wish to attend a continuing nursing education program in genetics. Previous studies conducted in Turkey report that the majority of nurses would like to attend a training on genetics (Terzioğlu and Dinç, 2004; Tomatir et al., 2006). Moreover in another Turkish study (Vural et al., 2009), 3rd and 4th year nursing undegraduate students would like to receive more education related to genetic diseases and counselling (Vural et al., 2009). Hsiao et al. (2013) reported that more than half of Taiwanese nurses in a RN-to-BSN program (58.4%) required more education about genetic disease and genetic counselling. Similarly, studies in a range of countries show that nurses have a low level of knowledge, despite a high interest in learning more about genomics (Kim, 2003; Calzone et al., 2012, 2013; Coleman et al., 2014). These results indicate that current nursing education programs require more comprehensive genetics knowledge and skills. There is obviously a need to include genetics within the nursing curriculum. On the other hand, in this study, some topics particularly regarding prenatal genetic screening, genetic screening in newborns and genetic in cancers are reported by most of the nurses as their priority for further education. Therefore, it is thought that these priority topics should be considered for curriculum development as well as core topics. Although in this current study, nurses were less willing to learn about genetic centers location and health services offered by them, the competency of knowing how to make a referral to genetic centers should not be ignored. Nurses should be taught genetic centers and health service related genetics as well as the referral requirements of individuals to these centers in Turkey. In this study, nurses wished to have continuing nursing education regarding genetics, regardless of their knowledge levels, but those who had genetics courses during nursing education were more confident and motivated to have further education in genetics as well. Kim (2003) also reported that the nurses' level of knowledge has a positive effect on their interest in genetics. Conclusion This study has shown that although nurses are not ready to put their knowledge regarding genetics into practice, they are ready to have more education and learn more about genetics to support their care of patients. The implications of this study are that genetics should be integrated into nursing education as a priority. Genetic education at the undergraduate level should be improved to prepare nurses for current and future health service needs. For qualified nurses, a continuing educational program regarding genetics might be an option to close the knowledge gap. Nurse educators need to urgently develop effective educational strategies to integrate genetics appropriately into practice.
This study has some limitations. The first limitation is that the participants were recruited from one hospital. A high proportion of nurse participants were educated at bachelor degree level. Almost all nurses are trained in the same school of nursing, which trains nurses for certain hospitals; the hospital in which the study was conducted is the second biggest hospital among them. Therefore nurses with different educational backgrounds may have been poorly represented. When it is considered that many nurses in Turkey have trained via from different educational pathways, such as vocational school and associate degree school, it is feasible that the nurses in this study may be more knowledgeable and aware of genetics than other nurses in Turkey. The second limitation is that there were no male participants. Thus, it is not generalizable to all Turkish nurses. Therefore, further assessment is needed in other nursing populations. 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Nurse Education Today journal homepage: www.elsevier.com/nedt
Nurses' knowledge and educational needs regarding genetics Memnun Seven a,⁎, Aygül Akyüz b, Burcu Elbüken c, Heather Skirton d, Hatice Öztürk c a
Koç University, School of Nursing, Koç Universitesi Hemşirelik Yüksek Okulu, Güzelbahçe sokak no. 20, Nişantaşı, Şişli, İstanbul, Turkey Koç University, School of Nursing, Istanbul, Turkey c Haydarpasa Gulhane Military Medical Academy Training and Research Hospital, Istanbul, Turkey d Plymouth University Faculty of Health and Human Sciences, Plymouth, United Kingdom b
a r t i c l e
i n f o
Article history: Accepted 12 November 2014 Keywords: Genetic Registered nurse Knowledge Survey Confidence
s u m m a r y Background: Nurses now require a basic knowledge of genetics to provide patient care in a range of settings. Objectives: To determine Turkish registered nurses' current knowledge and educational needs in relation to genetics. Design: A descriptive, cross-sectional study. Settings: Turkish registered nurses working in a university hospital in Turkey were recruited. Participants: All registered nurses were invited to participate and 175 completed the study. Methods: The survey instrument, basic knowledge of health genetics, confidence in knowledge and the nurses' need for genetics education were used to collect data. Results: The majority (81.1%, n = 142) of participants indicated that genetics was not taught during their degree program, although 53.1% to 96% of respondents felt confident in defining different genetic concepts. The average genetics knowledge score was 6.89 ± 1.99 of a possible 11 (range 0–11). The majority (70.3%) expressed a strong wish to attend a continuing nursing education program in genetics. Conclusions: The study shows that although Turkish nurses are not sufficiently knowledgeable to apply genetics in practice, they are willing to have more education to support their care of patients. Nurses need to have more education related to genetics in accordance with advances in human genetics to optimize health care. © 2014 Elsevier Ltd. All rights reserved.
Introduction The Human Genome Project built on decades of genetics research and enhanced our understanding of human genetics (Thompson and Brooks, 2011; Godino et al., 2013a; Bancroft, 2013). Since completion of the project, there has been increasing development and availability of new treatments and expanded genetic testing options (Williamson and LeBlanc, 2008; Umberger et al., 2013). Although genetic health services have been provided by specialist genetics centers for several decades, genetic and genomic information is now being utilized in almost all healthcare settings (Daack-Hirsch et al., 2011; Bancroft, 2013). Therefore, all health care professionals should be able to provide genetic information, education and support to individuals with a current or potential genetic condition (Daack-Hirsch et al., 2011; Godino et al., 2013a). To achieve this, health professionals require a basic knowledge of genetic principles and the ability to integrate genomics into their daily clinical practice (Thompson and Brooks, 2011; Umberger et al., 2013; Boyes, 2013).
As part of the largest health care profession, nurses in all settings have an important role in improving health to prevent and reduce the burden of disease, and to educate patients and their families (Lea et al., 2011; Bancroft, 2013; Umberger et al., 2013). Developments in genetics, particularly in fields such as oncology, gastroenterology, pediatric, and prenatal care, have led to an increase in demand for genetic and genomic healthcare, requiring nurses to develop competences in both skills and knowledge regarding genetics to support their clinical practice (Burke and Kirk, 2006; Umberger et al., 2013). In addition, numerous authors (Jenkins and Calzone, 2007; Godino et al., 2013a; Thompson and Brooks, 2011) suggest that all nurses, regardless of country or practice setting, need to be appropriately trained in genetics and genomics in order to provide best practice for prevention, detection and/or treatment of disease. Unlike many other fields of nursing, genetics is relevant to every life stage, and therefore, it should be addressed across all patient groups from neonatal to geriatric care (Skirton et al., 2012a,b; Umberger et al., 2013). Background
⁎ Corresponding author. Tel.: +90 2123112659. E-mail addresses: [email protected] (M. Seven), [email protected] (A. Akyüz), [email protected] (B. Elbüken), [email protected] (H. Skirton), [email protected] (H. Öztürk).
http://dx.doi.org/10.1016/j.nedt.2014.11.008 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Although there have been recommendations to integrate genetics into the nursing curriculum for many years, there is some evidence that it has not been included in nursing education in any consistent
M. Seven et al. / Nurse Education Today 35 (2015) 444–449
manner (Tomatir et al., 2006; Jenkins and Calzone, 2007; Umberger et al., 2013). Umberger et al. (2013) stated that there are several factors contributing to the lack of progress in integrating genetics/genomics into nursing education, such as a shortage of nursing faculty prepared to teach genetics and failure to recognize the value of genetics/genomics in nursing practice. The deficit in nursing education of genetics results in nurses having an insufficient knowledge of genetics as shown in studies conducted in different countries (Kim, 2003; Terzioğlu and Dinç, 2004; Tomatir et al., 2006; Vural et al., 2009; Gharaibeh et al., 2010; Godino et al., 2013a). Moreover, in some reviews, it is reported that nurses do not have adequate knowledge in specific areas (such as inheritance patterns, drawing a pedigree, utility of genetic tests, and ethical and legal issues) that would enable them to educate and consult patients and their family members appropriately (Burke and Kirk, 2006; Dodson and Lewallen, 2011; Gibbs, 2011). Genetics/Genomics knowledge should not be merely included in educational programs without addressing the cultural context. It is important to conduct research in different countries in order to have a better understanding of the effect of genetics and genomics information from many perspectives (Skirton et al., 2012a,b). As a first step, it is thought that current knowledge and awareness of nurses towards genetics needs to be assessed to identify the changes needed in nursing education and to offer appropriate nursing education. Little research on genetics related issues in Turkish nurses or nursing students has been found and the few existing studies were conducted some years ago (Terzioğlu and Dinç, 2004; Tomatir et al., 2006; Vural et al., 2009). In the five years since that last study (Vural et al., 2009) was published, much has changed in the area of genetic healthcare and it was timely to conduct a further study. The aim of this study was to investigate the current knowledge level of registered nurses in relation to genetics, to assess the self reported self-confidence of qualified nurses in defining basic concepts in genetics and to determine the educational needs of nurses for genetics knowledge in Turkey. Methods
445
Table 1 Demographic background of female participants. n = 175
n
Age (year) Highest qualification in nursing Vocational high school Associate degree nursing programs, Baccalaureate nursing program Master program PhD program An average time of working as a nurse (year) (1–27) Area in which nurses' work Medicine (such as respiratory, neurology, gastroenterology) Gynecology/Obstetrics Neonatology/Pediatrics Emergency and out-patient clinics Intensive care Cardiology/coronary care Oncology/hematology Surgery (such as orthopedic, plastic, ear–nose–throat surgery)
30.3 ± 5.91
%
3 1.7 3 1.7 110 62.9 55 31.4 4 2.3 10.46 ± 6.64 48 4 8 18 16 14 15 52
27.7 2.3 4.6 10.2 9.1 8.0 8.7 29.6
the concepts. An open-ended question asking nurses to list diseases related to genetics was included. The knowledge level of nurses related to genetics was assessed in the third section. Nurses were asked to respond ‘true’, ‘false’ or ‘do not know’ to 11 statements regarding topics that included consanguineous marriage, preimplantation genetic diagnosis, prenatal screening tests, breast and ovarian cancer gene mutations, family history of breast, ovarian and colorectal cancers, and the relationship between genetics and multifactorial disorders. One point was given for each statement answered correctly; the total possible score was 11. In the final section, we collected data by asking participants whether they felt the need for genetics education to help them in their daily nursing practice. A list of specific topics was provided. Options for answering these questions were given as ‘I would like’, ‘I would not like’ and ‘it does not matter’. The instrument was pilot tested with five nurses who were not planning to participate in the study to determine face validity and clarity of questions. Minor changes were made after this process.
Study Design This was a descriptive, cross-sectional study. Participants The study was carried out in a university hospital in İstanbul, Turkey in April 2014. All registered nurses working in the institution were eligible to participate. At the time of the study, there were a total of 345 nurses working in the hospital, however 55 nurses were unavailable due to absence for reasons such as maternity leave, paid or unpaid leave and were excluded from the study (due to long term absence from duty). A total of 175 (of a possible 290) nurses took part, a response rate of 60.3%. Instrument The study instrument comprised four sections, addressing demographic characteristics, genetics knowledge level, confidence in knowledge level, and the educational needs of nurses related to genetics (see Tables 1, 2, 3 and 4). The instrument was developed by the researchers based upon literature (Terzioğlu and Dinç, 2004; Tomatir et al., 2006; Daack-Hirsch et al., 2011; Skirton et al., 2012a,b; Godino et al., 2013a). In the first section of the form, nurses were asked for demographic information, including information about their work settings. In the second section, nurses were asked to self-assess their basic knowledge of genetic concepts. A total of 12 concepts were included and nurses were asked whether they felt confident about their understanding of
Data Collection The study was conducted after receiving approval from the institutional ethics committee. The researchers informed the nurses in all settings about the aim and method of the study. Nurses who were willing to participate in the study were given the questionnaire forms and information about completing the form. Return of the completed questionnaires to the researchers was deemed to indicate consent.
Table 2 Educational background and opinion of participants on genetics in nursing education. n = 175 Having genetics course (or at some point within the curriculum) during nursing education No Few hours in some other courses (such as obstetrics, medicine etc.) Opinions on genetics science knowledge in nursing educationa It was enough in the nursing education It should be covered in more detail in the nursing education It should be offered as a part of continuing nursing education It should be covered in masters degree program in nursing Wish to have a continuing nursing education regarding genetics Yes No a
Participants could choose more than one answer.
n
%
143 81.7 32 18.3 18 108 87 38
20.3 61.7 49.7 21.7
123 70.3 52 29.7
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Table 3 Participants' confidence about defining concepts related to genetics. n = 175
Yes
Concepts, n (%) 1. Mutations 2. Mitosis 3. Meiosis 4. Heterozygous 5. Homozygous 6. Gene 7. Genotype 8. Phenotype 9. Allele 10. X-linked inheritance patterns 11. Autosomal dominant inheritance patterns 12. Autosomal recessive inheritance patterns The average number of concepts defined by nurse (0–12)
168 (96) 159 (90.9) 158 (90.3) 154 (88) 152 (86.9) 149 (85.1) 129 (73.7) 118 (67.4) 106 (60.6) 96 (54.9) 93 (53.1) 93 (53.1) 8.91 ± 3.43
Statistical Analyses The SPSS for Windows (SPSS Inc., Chicago, IL, USA) software, version 20.0, was used for the statistical analysis. The distribution of the data was performed using frequency distribution both counts and percentages. The Student ‘t-test’ was used for statistical comparison between groups. A p-value of less than .05 was accepted as statistically significant.
Results The demographic backgrounds of the 175 study participants are shown in Table 1. Study participants ranged in age from 22–46 years, with a mean age of nurses of 30.3 ± 5.91 and average number of years of experience as a nurse of 10.46 ± 6.64 years (range from 1 to 27). The majority (81.1%, n = 142) of participants indicated that genetics was not taught during their degree program (Table 2). However, 20.3% of them thought that they had been given sufficient information related to genetics in that program. Of nurses 70.3% expressed a strong wish to attend a continuing nursing education program in genetics. Nurses in this study were most interested in receiving more education on issues that were directly related to prenatal and newborn screening, or familial cancer. However, fewer nurses regarded some topics in genetic healthcare, including ‘genetic centers in Istanbul’ and ‘taking family history and drawing a pedigree’ as important. The majority of nurses felt confident in defining the concepts ‘mutations’, ‘mitosis’ and ‘meiosis’, however felt less confident about terms such as ‘autosomal dominant and recessive inheritance patterns’, and ‘X-linked inheritance patterns’ (Table 3). Table 4 shows the diseases which nurses' thought might be relevant to genetics. Down syndrome, thalassaemia and diabetes were the diseases most cited as a genetic condition (Table 4). Table 4 Conditions related to genetics that were mentioned by nurses. n (%) Down syndrome Thalassaemia Diabetes Cancers Familial mediterranian fever Haemophilia Heart diseases Hypertension Trisomies Cystic fibrosis Phenylketonuria Turner syndrome
104 (59.4) 54 (30.9) 54 (30.9) 37 (21.1) 36 (20.6) 32 (18.3) 31 (17.7) 18 (10.3) 13 (7.4) 12 (6.9) 11 (6.3) 9 (5.1)
The average genetics knowledge score was 6.47 ± 2.02 of a possible 11 (range 0–11) (Table 5). The majority of nurses (96%, n = 168) were aware of the importance of the links between consanguinity and recessive genetic disease. Most nurses also knew of the relationship between genetic risk and diseases such as breast cancer (92%, n = 161), ovarian cancer (90.9%, n = 159), heart conditions and diabetes (89.7%, n = 153). The lesser known issues were frequency of hereditary breast cancer syndromes (12.6%, n = 22), inheritance pattern of Down syndrome (13.1%, n = 23), and relationship between BRCA 1–2 gene mutations and both breast and ovarian cancer (20%, n = 35). There was no statistically significant relationship between education level and the knowledge level of nurses. In this study, the factors such as nurses' level of knowledge on genetics and having a genetics course during nursing education were evaluated to determine their effects on nurses' desire to have more education on genetics. There were statistically significant relationships between the average number of genetic concepts correctly defined by nurses and two other variables; nurses' desire to have a continuing nursing education regarding genetics, and whether or not they undertook a genetics course during nursing education (Table 6). Regarding knowledge of genetic services, only 20% (n = 35) of participants stated that they knew where the genetic centers in Istanbul were located, while 51.4% (n = 90) did not know about the health services offered by genetic centers. Services provided by genetics centers cited by nurses answering the free-text question were: diagnosis, early detection, treatment of genetic conditions, research on genes and genetic conditions, prenatal genetic testing, infertility treatment and other health services for infertile couples, chromosomal abnormality analysis and research, newborn screening for genetic conditions and genetic counseling.
Discussion Nurses' Knowledge Level on Genetics With advances in human genetics affecting so many aspects of healthcare, it is essential that nurses should be genetically literate and able to incorporate genetic and genomic knowledge into providing professional nursing care (Giarelli and Reiff, 2012). Recent studies have focused on the minimum requirements in terms of core competences in genetics for graduate nurses. These include being able to recognize individuals who may have an genetic condition, knowing how to make a referral to genetic centers, being able to take a family history, draw a pedigree, understanding the benefits and limitations of genetic testing, and being able to obtain and convey genetic information to patients (Skirton et al., 2012b). The core competences are developed for use in different countries, however while some are close to achieving the incorporation of these competencies into health professional education and practice, in others considerable progress is still required (Kirk et al., 2011). There are 57 registered genetic centers in Turkey (personal communication with the Ministry of Health of Turkey) and to our knowledge there are no nurses working in genetic centers or working with the title of genetic nurse in other health care settings. Although some graduate nursing programs include genetics courses, there is no undergraduate nursing program in Turkey in which genetics is specifically included. However, this situation may change, as counseling for families at risk of genetic conditions is now a responsibility of women's health nurses, according to amendments to the Turkish nursing regulations that came into force on 19th April 2010 (Republic of Turkey Ministry of Health's Web site). Genetic counseling is also one of the nursing interventions that can be undertaken according to either the nurse's own clinical decision or on the order of a physician. This regulation indicates that Turkish nurses do not have any legal restriction to undertake genetic healthcare and to educate to their clients in every setting (Republic of Turkey Ministry of Health's Web site). However, such
M. Seven et al. / Nurse Education Today 35 (2015) 444–449
447
Table 5 Nurses' knowledge on genetics. n = 175
Correct answer
1. Couples who have consanguinous marriage are at high risk for autosomal recessive conditions such as phenylketonuria, cystic fibrosis and thalassemia 2. Genetic risk (e.g., as indicated by family health history) has clinical relevance for breast cancer 3. Genetic risk (e.g., as indicated by family health history) has clinical relevance for ovarian cancer 4. Genetic risk (e.g., as indicated by family health history) has clinical relevance for either diabetes or heart disease 5. Every pregnant woman should be tested by double or triple test for early detection of genetic conditions such as aneuploidies (e.g. Trisomy 21), and neural tube defects 6. Genetic risk (e.g., as indicated by family health history) has clinical relevance for colon cancer 7. It is possible for couples who are carriers or have a history of a child with a genetic condition to have a healthy baby, by preimplantation genetic diagnosis (PGD) 8. Today, genetic testing for genetic conditions such as β-thalassemia, cystic fibrosis, haemophilia, and fragile X have been available 9. BRCA1-2 gene mutations can be responsible for both ovarian and breast cancer 10. The majority of Down syndrome (Trisomy 21) is not inherited due to the fact that translocation is very rare in Down syndrome cases 11. Hereditary breast cancer syndromes are accountable for about 5 to 10 percent of all breast cancer cases The average knowledge score (0–11)
responsibilities must be supported by appropriate education and clinical mentorship. In this study, the literacy level of nurses in genetic concepts was assessed. Overall, around 50%–95% of all the nurses stated that they felt confident in defining basic genetic concepts. Kim (2003) reported that Mendelian and single gene inheritance patterns were better known concepts to nurses. However, in Terzioğlu and Dinç’ study (2004), 75% to 90% of nurses stated that their knowledge of basic genetic concepts was insufficient (Terzioğlu and Dinç 2004). Similarly, in another Turkish study (Tomatir et al., 2006), a high percentage of nurses also admitted they had insufficient knowledge about the genetic basis of disease and inheritance patterns (98.9%). When the data on level of knowledge from this study are compared to the other Turkish studies, some concepts such as mitosis, meiosis and mutation appear to be more familiar to nurses since 2004. In this study, only half of the nurses stated that they could explain X-linked, autosomal dominant and autosomal recessive inheritance patterns correctly. Interestingly, this contrasts with the earlier findings of Terzioğlu and Dinç (2004), who found that autosomal and recessive inheritance patterns were very well known concepts. While in another Turkish study, the inheritance pattern of genetic disease was only known by less than 5% of nurses (Tomatir et al., 2006). However, the level of genetic literacy may differ according to the study population. The deficit in genetic literacy may cause limitations in nursing care for individuals with current or possible genetic conditions. In a systematic review on this topic, Skirton et al. (2012b) stated that there were no studies indicating that nurses had an appropriate level of knowledge and skills to be able to fulfil the genetic core competences. In the current study, knowledge level was assessed by giving true or false statements to nurses. According to these statements, the relationship Table 6 Comparison of nurses' status of having a genetics course and interest in further education on genetics. Having genetics course during nursing education No The average knowledge score The average number of concepts defined by nurses
Yes/Few hours
t
6.59 ± 1.54 6.43 ± 1.97 8.58 ± 3.58 10.40 ± 2.12
p 0.431 0.177 2.773 0.004
Wish to have a continuing nursing education regarding genetics No The average knowledge score The average number of concepts defined by nurses
Yes
6.50 ± 1.55 6.44 ± 2.029 −0.168 0.353 7.90 ± 4.54 9.34 ± 3.00 2.574 0.000
n
%
168 161 159 157 153
96 92.0 90.9 89.7 87.4
135 99
77.1 56.6
86 49.1 35 20 23 13.1 22 12.6 6.89 ± 1.99
between consanguinity and genetic conditions is well known by nurses. This may not be surprising, as Turkey has a high rate of consanguineous marriages, around 20%–25% (Tomatir et al., 2006). In addition, the community in general has been informed of the negative effects of consanguineous marriage, including increased risk of genetic diseases, through programs such as pre-marriage education and family education for all people offered by The Ministry of Family and Social Policies (MFSP) (Web site of MFSP). In the study, the majority of nurses were aware of the importance of genetic risk for breast and ovarian cancer. In Turkey, the incidence of breast cancer reached 40.6 per 100,000 in 2009 and ovarian cancer is the seventh most common cancer in women with an incidence 6.9 per 100,000 (Web site of Department of Cancer Turkish Ministry of Health). However, only one in five nurses knew that having a family history of either breast or ovarian cancer can also be related to the each other type of cancer due to BRCA1-2 gene mutations. Moreover, only one in ten nurses knew that hereditary breast cancer syndrome accounts for only 5%–10% of all breast cancer. These findings show that, despite the fact that the relationship between cancer and familial tendency is well known by Turkish nurses, they did not appear to know that ovarian and breast cancer may be due to the same gene mutation and needs to be considered together while taking a family history. Bottorff et al. (2005) reported that half of nurses in their study correctly responded regarding questions on testing for breast cancer gene mutations, while the number of correct responses was greater for items related to cancer inheritance patterns. Although, genetic knowledge is an important aspect in the optimal nursing care of patients in every setting, nurses need to have particular expertise and deep genetic knowledge in some health fields such as oncology (Umberger et al., 2013). This should be above that required by nurses working in more general settings. Down syndrome has a reported incidence of 1.2 per 1000 live births in Turkey (Tunçbilek, 2001). It may be therefore unsurprising that it was cited as a genetic condition by the majority of nurses (59.4%, n = 104). However, the sporadic nature of the majority of cases was known by only 13.1% (n = 23). Moreover, only 6.3% (n = 11) of nurses cited phenylketonuria as a genetic condition, despite the fact that Turkey has the highest incidence of phenylketonuria in the world, with approximately one case in 2600 births (MoH report 2004). The results show that, in spite of the high incidence of some conditions, many nurses do not know that these are genetic diseases. It is also worth noting that almost half of the nurses were not aware that genetic testing for genetic conditions such as β-thalassemia, cystic fibrosis, haemophilia, and fragile X is currently available. As genetic tests have been becoming widespread, nurses will be required to know the risk factors and inheritance pattern of genetic conditions, and available genetics tests to refer patients or their families for help and advice (Boyes, 2013).
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Educational Background and Further Educational Needs of Nurses on Genetics In this study, only 19.9% nurses indicated that basic principles of genetics were taught at some point within their nursing curriculum. Terzioğlu and Dinç, 2004 reported that only 23.3% of Turkish nurses claimed that they had been informed about genetics during their education, and almost all of them (98.4%) found this information insufficient. Similarly, in some studies conducted in different countries such as Italy and Taiwan, majority of nurses had not studied a specific course or module on genetics during their nursing training, but had studied basic principles of genetics at some point within the curriculum (Godino et al., 2013b; Hsiao et al., 2013). In addition, this inadequate level of education during undergraduate programs may also be reflected in the findings of a study conducted in the USA, where 30% nurses reported taking a genetic course since licensure (Coleman et al., 2014). When it is considered that there were significant genetic discoveries over the last decade, this indicates that scientific advances have not been translated into clinical education, although this is not confined to Turkey (Lea et al., 2011; Hsiao et al., 2013; Coleman et al., 2014). Three in four of the nurses expressed a strong wish to attend a continuing nursing education program in genetics. Previous studies conducted in Turkey report that the majority of nurses would like to attend a training on genetics (Terzioğlu and Dinç, 2004; Tomatir et al., 2006). Moreover in another Turkish study (Vural et al., 2009), 3rd and 4th year nursing undegraduate students would like to receive more education related to genetic diseases and counselling (Vural et al., 2009). Hsiao et al. (2013) reported that more than half of Taiwanese nurses in a RN-to-BSN program (58.4%) required more education about genetic disease and genetic counselling. Similarly, studies in a range of countries show that nurses have a low level of knowledge, despite a high interest in learning more about genomics (Kim, 2003; Calzone et al., 2012, 2013; Coleman et al., 2014). These results indicate that current nursing education programs require more comprehensive genetics knowledge and skills. There is obviously a need to include genetics within the nursing curriculum. On the other hand, in this study, some topics particularly regarding prenatal genetic screening, genetic screening in newborns and genetic in cancers are reported by most of the nurses as their priority for further education. Therefore, it is thought that these priority topics should be considered for curriculum development as well as core topics. Although in this current study, nurses were less willing to learn about genetic centers location and health services offered by them, the competency of knowing how to make a referral to genetic centers should not be ignored. Nurses should be taught genetic centers and health service related genetics as well as the referral requirements of individuals to these centers in Turkey. In this study, nurses wished to have continuing nursing education regarding genetics, regardless of their knowledge levels, but those who had genetics courses during nursing education were more confident and motivated to have further education in genetics as well. Kim (2003) also reported that the nurses' level of knowledge has a positive effect on their interest in genetics. Conclusion This study has shown that although nurses are not ready to put their knowledge regarding genetics into practice, they are ready to have more education and learn more about genetics to support their care of patients. The implications of this study are that genetics should be integrated into nursing education as a priority. Genetic education at the undergraduate level should be improved to prepare nurses for current and future health service needs. For qualified nurses, a continuing educational program regarding genetics might be an option to close the knowledge gap. Nurse educators need to urgently develop effective educational strategies to integrate genetics appropriately into practice.
This study has some limitations. The first limitation is that the participants were recruited from one hospital. A high proportion of nurse participants were educated at bachelor degree level. Almost all nurses are trained in the same school of nursing, which trains nurses for certain hospitals; the hospital in which the study was conducted is the second biggest hospital among them. Therefore nurses with different educational backgrounds may have been poorly represented. When it is considered that many nurses in Turkey have trained via from different educational pathways, such as vocational school and associate degree school, it is feasible that the nurses in this study may be more knowledgeable and aware of genetics than other nurses in Turkey. The second limitation is that there were no male participants. Thus, it is not generalizable to all Turkish nurses. Therefore, further assessment is needed in other nursing populations. 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