Developments and innovations in genetics and genomics have increased knowledge and understanding of genetic and genomic factors underlying the etiology of all cancers (Beamer, Linder, Wu, & Eggert, 2013; Floria-Santos et al., 2013); consequently, health care providers have acquired new roles (Giarelli & Reiff, 2012). The understanding of these factors and how to contribute to the development and treatment of sporadic and hereditary cancers is important in risk assessment, prevention, diagnosis, treatment, and long-term management of cancer (Boucher, Habin, & Underhill, 2014; Floria-Santos et al., 2013; Percival et al., 2016). Nurses should be aware of these genetic developments to play an effective role in the prevention, early detection, and treatment of cancer. In addition, nurses should be well-equipped with genetic knowledge to integrate genetics into practice, especially in oncology (Boucher et al., 2014; Giarelli & Reiff, 2012).
Oncology nurses play a major role in every step of cancer control. From the beginning, nurses take roles in cancer prevention, education, and consultation. They also support individuals with risk-reduction strategies, including cancer screening and early detection. With a cancer diagnosis, the role is changed from preventing to caring during treatment, managing symptoms, and providing palliative care to patients and their families (Calzone, Jenkins, Bakos, et al., 2013; Floria-Santos et al., 2013). To successfully perform these practices, nurses should have adequate knowledge and skills in oncology genetics. Therefore, this study sought to determine the knowledge level and educational needs of Turkish oncology nurses regarding the genetics of hereditary breast and ovarian cancer.
In both medical and surgical disciplines, genetic knowledge is fundamental in nursing practice, including the assessment and diagnostics of clinical practice (Giarelli & Reiff, 2012). Although genetics and genomics are important aspects in all nursing fields, nurses should have in-depth genetic knowledge and skills in oncology settings (Umberger, Holston, Hutson, & Pierce, 2013). Regarding genetics in oncology care, some important nursing interventions include identifying high-risk individuals for cancer, discussing risk with families, providing support for informed consent, providing information about new genetic test options including its limitations, and helping patients develop surgical and nonsurgical risk reduction strategies (Appel & Cleiment, 2015; Beamer et al., 2013; Calzone, Jenkins, Culp, Bonham, & Badzek, 2013; Percival et al., 2016; Prolla, da Silva, Netto, Goldim, & Ashton-Prolla, 2015).
Determining the educational needs of nurses to help them apply genetic science to their daily practice is crucial to plan tailored educational activities (Andrews, Tonkin, Lancastle, & Kirk, 2014). Nurse educators are the key point to start integrating genetics into nursing education (Beamer et al., 2013; Percival et al., 2016). Identifying graduate nurses' educational needs also is important to increase their genetic knowledge that will affect their daily nursing practice. Strategies to enhance nursing education regarding specific areas of genetics services have been explored in some developed countries (Andrews et al., 2014; Beamer et al., 2013; Calzone, Jenkins, Culp, et al., 2013; Jenkins, 2011).
Although it has been recommended to integrate genetics into nursing education, this has not been as successful as desired (Jenkins, 2011; Seven, Akyuz, Elbuken, Skirton, & Ozturk, 2015; Umberger et al., 2013). The inadequate genetics education has led to a lack of genetics knowledge in nurses, which has been shown in studies conducted in different settings (Boucher et al., 2014; Calzone et al., 2012; Calzone, Jenkins, Culp, et al., 2013; Godino, Turchetti, & Skirton, 2013; Kiray Vural, Tomatir, Kuzu Kurban, & Taspinar, 2009; Percival et al., 2016; Tomatir, Sorkun, Demirhan, & Akdag, 2006).
Some studies in the literature have reported that nurses lack knowledge in certain topics, such as inheritance patterns, drawing a pedigree, use of genetic tests, and ethical and legal issues. An educational gap may be preventing nurses from providing the required education and consultation to patients and families (Beamer et al., 2013; Calzone, Jenkins, Culp, et al., 2013; Floria-Santos et al., 2013). A few studies have investigated genetics knowledge levels of general practicing nurses in Turkey (Kiray Vural et al., 2009; Seven et al., 2015; Tomatir et al., 2006), but none have focused specifically on oncology nurses.
Design and Sample
This descriptive study was conducted with a convenience sample of oncology and nurse academicians with interest areas in oncology in Turkey. The aim was to reach nurses who are members of the Turkish Oncology Nursing Society, a national society with approximately 400 members.
Prior to initiating the study, ethical approval was obtained from the university's committee on human research. An online survey was used to collect data. The link for the 25-item questionnaire was launched on the Web site of the Turkish Oncology Nursing Society and its social media pages. In addition, the researchers shared the online survey link on other social media pages to reach a greater number of nurses. Due to local restrictions, the link could not be sent by e-mail to the Society's members. A total of 104 nurses were included in the study sample. The aim of the study was explained in detail in the link, and it was implied that completion of the questionnaire gave consent for inclusion in the study.
The study survey was developed by the authors and consisted of three parts. In the first part, nurses were asked to provide sociodemographic information, such as age, place of residence, and information about their oncology experiences.
The second part of the survey queried the nurses' basic knowledge of genetics, particularly regarding hereditary breast and ovarian cancer. This section of the survey was developed by the authors who are experts in genetics and oncology nursing by reviewing the related literature (American Cancer Society, 2015; Cragun, Besharat, Lewis, Vadaparampil, & Pal, 2013; George, Kovak, & Cox, 2015). Thirteen statements with three possible answers (true, false, or do not know) were included for nurses to answer. Because genetics is a new area of interest for nurses in Turkey, the statements were focused on inheritance patterns of hereditary breast and ovarian cancer, risk factors, susceptibility, and current cancer screening practices. One point was given for each correctly answered statement, and the total possible score was between 0 and 13.
Nurses also were asked about their use of genetics knowledge in practice, genetic health care referral status in the nurses' current institutions, and criteria for referring patients to genetic counseling. The given referral criteria for cancer predisposition assessment were guided by the American College of Medical Genetics and Genomics and the National Society of Genetic Counselors (Hampel, Bennett, Buchanan, Pearlman, & Wiesner, 2015). The aim was to determine educational needs by asking Turkish oncology nurses whether they needed further genetics education to improve their knowledge and skills for use in their daily nursing practice.
SPSS® version 26.0 software was used for all statistical analyses. Descriptive statistics were presented as numbers, percentages, and mean ± SD. Kolmogorov-Smirnov was used to evaluate whether the data were normally distributed. Mann Whitney U and one-way analysis of variance tests were used in the comparison of variables.
Age of the participants ranged between 20 and 54 years (mean age = 33.8 ± 7.09 years). Most of the participants were from the central Anatolian region of Turkey (62.5%), and slightly more than half of the participants were single (53.8%). Twenty-nine percent of the nurses worked in nursing or health science colleges.
Regarding educational level, 39.4% of participants possessed a master of nursing degree, 18.3% had a doctor of philosophy degree, 25% had a baccalaureate nursing degree, 11.5% had an associate degree in nursing, and 3.8% had a vocational high school degree. Most of the nurses had worked in oncology areas for 5 to 10 years (42.3%) and in oncology clinics/polyclinics (70.2%).
In February 2014, oncology nursing was determined to be a field of training for certification by the Turkish Ministry of Health. Since that time, oncology nurses have been attending the certification training recognized by the Ministry of Health in Turkey. Prior to this regulation, oncology nurses could have taken other courses such as psychosocial oncology nursing or chemotherapy nursing educational program as continuing education training.
Table 1 shows participants' knowledge level of genetics in oncology. The mean knowledge level was 6.74 ± 3.85 (range = 3 to 13). The majority of nurses (71.4%, n = 70) were aware that “family history of ovarian or breast cancer is an important risk factor for the development of ovarian or breast cancer.” The statement that scored the lowest was “in women, BRCA1 mutations can be transferred by the father” (25.5%, n = 25).
Nurses' Knowledge of Genetics Related to Oncology
Table 2 shows the clinical use of genetics by nurses in their daily work and their knowledge on the criteria for referring patients for genetic counseling. More than half of the nurses thought that “patients with breast cancer diagnosed at age ⩽ 50” (57.7%, n = 60) should be referred for genetic counseling. The lesser known statements about referral for genetic counseling were for patients with “Ashkenazi Jewish ancestry and breast cancer at any age” (25%, n = 26) and “lobular breast cancer and diffuse gastric cancer in the same person” (21.2%, n = 22).
Clinical Use of Genetics and Genetics Health Services by Nurses in Daily Work
Table 3 shows the areas that nurses indicated they would like to learn more about in genetic education as well as specific topics related to oncology genetics. More than half of the nurses (59.6%, n = 62) indicated an interest in attending a continuing education program in genetics related to oncology.
Willingness to Take Continuing Nursing Education Related to Genetics (N = 104)
Table 4 depicts the nurses' level of knowledge regarding genetic oncology. The relationship between the level of knowledge and status, such as the area in which nurses work (p = .014) and nurses' interest in taking continuing education in genetics (p ⩽ .000), was statistically significant (p ⩽ .005).
Comparison of Knowledge Level and Sociodemographic Features of Nurses
The purpose of this study was to evaluate the knowledge levels of Turkish oncology nurses regarding the genetics of hereditary breast and ovarian cancer, and affecting factors. In this study, the knowledge level of oncology nurses was found to be moderate (6.74 of 13). Although there is no Turkish study specifically evaluating nurses' knowledge in oncology genetics, some studies have reported the majority of nurses acknowledged that their knowledge about fundamental genetics, inheritance, and genetic patterns of the disease was insufficient (Seven et al., 2015; Tomatir et al., 2006). Moreover, studies on health care providers have shown that the majority of nurses lack knowledge regarding genetics risk assessment and testing and do not feel confident in their ability to consistently identify and determine risk level based on personal and family history of cancer (Boucher et al., 2014; Prolla et al., 2015; Trivers et al., 2011).
These results reflect wide gaps in nursing education related to genetics in Turkey. Having the required level of knowledge is crucial and is the first step to ensure integration of genetic science into practice. Therefore, continuing education may be an option to close this gap in nurses' knowledge regarding genetics. There are guidelines on genetic and genomic nursing competencies, and these guidelines can be used to integrate genetics in nursing education at different levels (e.g., http://www.isong.org, http://www.agnc.org.uk, and http://www.ons.org).
In this study, the majority of oncology nurses (71.4%) were aware that “family history of ovarian or breast cancer is an important risk factor for the development of ovarian or breast cancer.” Most of the nurses also knew that “breast-ovarian cancer syndrome is linked with BRCA1 and BRCA2 gene mutations” (67.3%). However, only 25.5% of nurses were aware that “in women, BRCA1 mutations can be inherited by the father.” Similarly, Prolla et al. (2015) reported one fourth (26.2%) of oncology nurses knew that having a male relative with breast cancer increased the risk for developing hereditary breast cancer. These results show that although the link between ovarian and breast cancer and family history as a risk factor is well understood by the nurses, breast cancer is still perceived as a female cancer.
In the current study, more than half of the nurses reported there was no designated center or unit to provide genetic health care including counseling, 29.9% stated they had referred at least one patient, and 39.1% reported patients with breast cancer should be referred to genetic centers. Another study reported oncology nurses never thought to refer a patient or family members to genetic risk assessment, and they encountered difficulties in guiding patients and family members through genetic counseling (Prolla et al., 2015).
In this study, the rates of correctly answered referral criteria statements by oncology nurses ranged from 21.2% to 57.7%. Sussner, Jandorf, and Valdimarsdottir (2011) stated that although more than half of the health care clinicians including nurse practitioners had referred patients to genetic counseling, only 14.3% felt confident in making appropriate referrals.
The first step when identifying individuals who may benefit from genetic health services is to refer them to a unit to have any necessary genetic-related services and to develop risk-reduction strategies. Such services may lead to treatment-focused genetic testing for patients, which helps both patients and clinicians decide on an appropriate management plan for the presenting cancer, as well as future cancer prevention (Boucher et al., 2014). Therefore, referral to genetics centers and offering genetic tests if necessary around the time of a breast cancer diagnosis is beneficial (Boucher et al., 2014; Edwards, Maradiegue, Siebert, Saunders-Goldson, & Humphreys, 2009).
As the first point of contact, oncology nurses should know the red flags in family history and the referral criteria of cancer patients to genetic centers. If there is no designated center for genetic counseling where nurses practice, they should be aware of available genetic centers that could be used for the required referral.
In the current study, more than half of the nurses indicated they knew that patients “with breast cancer diagnosed at age ⩽50” and “⩾3 cases of breast, ovarian, pancreatic, and/or aggressive prostate cancer in close relatives, including the patient” should be referred for genetic counseling. The lesser known cases about referral for genetic counseling were patients with “Ashkenazi Jewish ancestry and breast cancer at any age” in their family history (25%) and “lobular breast and diffuse gastric cancer in the same person” (21.2%). In other studies, it also was reported that health care providers with insufficient knowledge in genetics had difficulty identifying individuals who could benefit from genetic counseling and testing, and they lacked knowledge in providing cascade genetic screening to both patients and their families (Brierley et al., 2012; George et al., 2015).
Moreover, some other factors such as treatment priority, patients lost to follow up, being hesitant in talking about sensitive topics, or genetic data not being shared among multidisciplinary professionals also would be barriers for health professions to cope with risk assessment and referral of the individuals to genetic health services as needed (Komatsu & Yagasaki, 2014). Therefore, nurses, as members of the multidisciplinary oncology team, also should improve communication and use of genetic information among patients and family members.
This study showed that the majority of nurses (59.6%) are willing to participate in continuing education programs in genetic oncology. In addition, nurses who are academicians, nurses who work in settings such as schools or workplaces other than hospitals or clinics, and nurses who are interested in taking more education in genetics showed higher levels of knowledge in genetics. Similarly, some studies have shown that nurses whose level of knowledge is low had a higher interest in genetics and genomics (Calzone, Jenkins, Culp, et al., 2013; Calzone et al., 2012). In contrast, Seven et al. (2015) found that nurses were interested in continuing their genetic education regardless of their knowledge levels.
The current study showed that nurses are interested primarily in continuing education on topics such as genetic inheritance characteristics of cancer, and genetic screening and diagnostic tests for cancers that have genetic characteristics. This is important to note because Sussner et al. (2011) reported health care professions noted they would integrate genetic risk assessment for cancer into their practice if they had the knowledge and the skills. However, in the current study, only a small number of nurses showed interest in topics such as “genetic centers in residential areas,” “the prognosis of genetic diseases,” and “drawing a pedigree and taking a family history.”
Taking family history is a cornerstone to screening and management of diseases, particularly in cancer; therefore, every nurse should know how to take a family history to identify individuals at high risk for developing cancer (Boucher et al., 2014; Sussner et al., 2011). From an individual's family history, nurses should be able to identify the red flags of cancer risk and know the referral criteria to provide the individual with the benefits of genetic counseling (Boucher et al., 2014).
The participants in this study were a convenience sample of Turkish oncology nurses, and the findings of the study cannot be generalized to all oncology nurses. In addition, data were missing due to the use of an online survey. However, this is the first study conducted in Turkey that evaluates genetic knowledge of oncology nurses, and there is potential for future studies and educational activities to enhance the use of genetics in oncology nursing practice. This study also shows the urgent need of genetics education, especially for nurses working in oncology clinics, as well as for nurse educators with an interest in oncology.
The results of this study provide baseline information on Turkish oncology nurses' knowledge regarding the genetics of hereditary breast and ovarian cancer. Oncology nurses have shown a moderate level of knowledge. Although the majority of the nurses in this study understood some topics on genetics, some important topics that every nurse should know were not known. In particular, the referral criteria of patients to genetic health care centers were not known by almost half of the nurses. The fact that more than half of the nurses in this study were willing to take further education in oncology genetics is promising. Nevertheless, some crucial educational topics did not draw the required interest. It is suggested that genetics should be an important part of continuing nursing education programs, with special interest in oncology as a priority.
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Nurses' Knowledge of Genetics Related to Oncology
|Family history of ovarian or breast cancer is an important risk factor for the development of ovarian or breast cancer||70||71.4|
|Breast and ovarian cancer syndrome is linked with BRCA1 and BRCA2 gene mutations||66||67.3|
|In community-based breast cancer screening, the target groups for mammography are women between the ages of 40 and 69 years||62||63.3|
|The mutations that occur in tumor suppressor genes may interfere with normal cell processes, such as programmed cell death||58||59.2|
|Familial or personal history of breast cancer in men is a genetic risk factor for breast cancer||53||54.1|
|Mutations occur in proto-oncogenes and activate the oncogenes that permit the continuation of cell proliferation||51||52|
|All cancers are caused by heredity, oncogene activation, tumor suppressor gene inactivation, and the telomerase production by the accumulated results of the acquired genetic mutation||50||51|
|Approximately 10% to 15% of breast cancers are hereditary||44||44.9|
|Cascade screening, followed by cascade processes, is aimed to test the first symptomatic person in the family to reduce testing costs and number of family members tested||41||41.8|
|Hereditary cancers are rare; approximately 5% to 10% of all cancers are inherited||36||36.7|
|Germline mutations show heredity as a result of the mutations in the chromosomes during meiosis of both parents' DNA or the DNA changes of the egg/sperm||27||27.6|
|Epigenetics, apart from the changes in the DNA sequence, the changes affect gene function||26||26.5|
|In women, BRCA1 mutations can be inherited by the father||25||25.5|
|Total score (minimum/maximum, 0–13)||6.74±3.85|
Clinical Use of Genetics and Genetics Health Services by Nurses in Daily Work
|General questions (n = 87)a|
| Is there any department offering genetic counseling in your institution?||34||39.1|
| Have you ever referred a patient with breast cancer to genetic counseling?||26||29.9|
| Do you think patients with breast cancer are referred to genetic counseling by other health care professionals?||34||39.1|
|Situations in which patients should be referred to genetic counseling (n = 104)a|
| Breast cancer diagnosed at age ⩽50 years||60||57.7|
| ⩾3 cases of breast, ovarian, pancreatic, or aggressive prostate cancer in close relatives, including the patient||56||53.8|
| ⩾2 primary breast cancers in the same person||45||43.3|
| Lobular breast cancer in one relative and diffuse gastric cancer in another, one diagnosed at age <50 years||44||42.3|
| Single-case male breast cancer||36||34.6|
| Triple-negative breast cancer diagnosed at age ⩽60 years||29||27.9|
| Ashkenazi Jewish ancestry and breast cancer at any age||26||25|
| Lobular breast and diffuse gastric cancer in the same person||22||21.2|
Willingness to Take Continuing Nursing Education Related to Genetics (N = 104)
|Willingness to take education in genetics|
| Missing variable||23||22.1|
|Topics for which nurses indicated yesa|
| Genetic inheritance characteristics of cancer||55||52.9|
| Genetic screening tests for cancers with genetic characteristics||52||50|
| Diagnostic tests for cancers with genetic characteristics||51||49|
| Developing treatment options based on the genetic characteristics of the cancer||44||42.3|
| Communication methods for individuals with genetic diseases||44||42.3|
| Ethical and legal regulations related to genetics||43||41.3|
| Services offered in genetic centers||42||40.4|
| Genetic centers in residential areas||40||38.5|
| Prognosis of genetic diseases||38||36.5|
| Drawing a pedigree and taking a family history||31||29.8|
Comparison of Knowledge Level and Sociodemographic Features of Nurses
|X̄ ± SD||f||p|
| 20 to 30||6.88±3.34|
| 3 to 40||6.51±3.72||.951||.390|
| 41 or higher||8.30±4.83|
|Place of residencea||2.043||.114|
| Marmara region||7.75±2.80|
| Aegean-Mediterranean region||4.83±3.86|
| Central Anatolia||7.07±3.93|
| Eastern-Southeast Anatolia-Black Sea region||4.00±3.74|
|Highest qualification in nursinga||1.797||.137|
| Vocational high school||6.66±5.85|
| Associate degree||8.77±4.17|
| Baccalaureate degree||5.56±3.69|
| Master's degree||6.70±3.40|
|Number of years working in oncology areaa||1.422||.242|
| 0 to 1 year||5.30±4.58|
| 1 to 5 years||6.17±3.18|
| 5 to 10 years||7.54±3.38|
| 10 years or more||7.07±4.49|
|X̄ ± SD||z||p|
|Area in which nurse worksa||−2.45||.014|
| Oncology clinics/polyclinic||6.40±3.54|
| Other (e.g., academy, nursing colleagues)||8.12±4.08|
|Wish to have continuing education in geneticsb||−4.92||.000|