Introduction

Background/rationale

Genetic/genomic data are increasingly used in health promotion, prevention, and treatment of diseases to provide precision health. As the largest group of healthcare professionals and primary patient contacts, nurses and midwives are uniquely positioned to integrate genetic/genomic advances into precision health by improving their genetic/genomic competencies in collecting detailed family medical histories, identifying patients at risk, providing genomic education, and coordinating specialist consultations, all with the sole aim of improving patient outcomes [1]. The integration of genetic/genomic education into nursing and midwifery curricula is essential for equipping healthcare professionals to effectively manage the genetic aspects of patient care.

The critical need to educate nurses in genetics and genomics has been recognized since the 1960s. There is a global movement, led by organizations like the Global Genomics Nursing Alliance (G2NA) and Consensus Panel, to incorporate genetic/genomic skills into nursing practice. Similarly, this is essential for midwives, ensuring they will be competent in genetic/genomic competencies. However, among 18 member countries of G2NA, only the United Kingdom, United States, and Japan have developed competency frameworks or curriculum guidelines for all nurses, while the European region has made strides in this area as well [2].

The absence of well-defined criteria for education and training in these disciplines remains a challenge in both developed and developing countries, including Albania [3]. To facilitate effective integration of relevant genetic/genomic content into academic curricula, it is essential to assess and validate students’ literacy in these fields. Several global investigations have been conducted to evaluate genetic/genomic literacy among nurses and undergraduate nursing students. Most results from studies suggest low, or at most moderate, levels of expertise in genetics/genomics for nurses [4,5] and nursing students [6,7]. Meanwhile, there are limited studies assessing the genetic/genomic literacy of midwives and midwifery students. The 2021 World Congress of the International Society of Nurses in Genetics highlighted the importance of diversity, inclusivity, and health equity in genomic nursing and midwifery, ensuring inclusive access to advancements in genetic/genomic knowledge regardless of a nation’s level of economic development [8].

To date, no studies have assessed the genomic literacy of Albanian nursing and midwifery students.

Objectives

This study aimed to adapt and validate the Albanian version of the Genomic Nursing Concept Inventory (GNCI-ALB) and assess the level of genomic literacy among nursing and midwifery students of the Faculty of Medical Technical Sciences, University of Elbasan in Albania.

Methods

Ethics statement

Considering the non-interventional design of the study, approval was granted by the Faculty of Technical Medical Sciences (letter no., 39 Prot.; March 15, 2023), in accordance with Albanian law. The study adhered to the ethical standards outlined in the Declaration of Helsinki. Informed consent was obtained from all participants prior to the online survey. Data were collected anonymously, without any personally identifiable information.

Study design

An observational, monocentric cross-sectional study was conducted among undergraduate nursing and midwifery students. A cross-sectional design was selected because it allows efficient data collection from a defined population at a single point in time and was deemed appropriate given the primary objective of assessing the current level of genetic and genomic literacy [9].

Setting

Data collection was conducted from June 1 to July 30, 2023. These undergraduate study programs are full-time, 3-year programs (180 European Credit Transfer and Accumulation System), including theoretical instruction and clinical practice experience primarily in hospitals [10]. Every year, approximately 300 nursing and midwifery students matriculate in the aforementioned programs. Their curriculum includes “Basics of Genetics” as an elective course, which is not highly preferred by students in either study program.

Participants

Convenience sampling was used to recruit participants due to its practicality in assessing the target population and ensuring high participation rates while minimizing logistical constraints. All students in their first, second, or third year of undergraduate nursing and midwifery courses were considered eligible. A total of 1,200 students, representing the entire population enrolled in these programs, were invited to participate. This approach was considered appropriate given the exploratory nature of the study and the academic setting.

Variables

The 31-item Genomic Nursing Concept Inventory Version Beta is a multiple-choice questionnaire designed to measure understanding of genomic concepts [11]. The GNCI assesses 18 genomic concepts across 4 domains: human genome basics (12 items), mutations (3 items), inheritance patterns (8 items), and genomic healthcare (8 items). Additionally, the following demographic data were collected: age, sex, year level, and whether participants had completed any genetics/genomics subjects or training/seminars, as reported in similar studies [6,7,11].

Data sources/measurement

The English-language GNCI is a validated scale with reported Cronbach’s α values between 0.73 and 0.83 [11]. Prior to its use in Albania, permission was obtained from the original author. The GNCI is a copyrighted instrument, and written permission for its use and cross-cultural adaptation in this study was granted by the original author, Dr. Linda Ward. The instrument was then adapted through a standardized cross-cultural process following the Guidelines by Beaton et al. [12], ensuring semantic, idiomatic, experiential, and conceptual equivalence with the original version. Content validity of the Albanian version (GNCI-ALB) was assessed by an independent panel of experts, including a genetics specialist, a registered nurse, a registered midwife, and an English professor. Each correct answer was awarded 1 point, for a total possible score ranging from 0 to 31, with higher scores indicating greater knowledge of genomic concepts.

Data were collected via Google Forms (Google LLC) by sharing the link through the students’ institutional email. Before distributing the questionnaire, face-to-face meetings were held with all the students during various seminars to explain the purpose of the study and the GNCI instrument. Students completed the questionnaire in dedicated classrooms according to the academic calendar, and participation was voluntary. All items were mandatory, ensuring complete responses. The questionnaire took approximately 30 minutes to complete. Raw data of responses is available at Dataset 1.

Bias

The questionnaire was administered anonymously to mitigate social desirability bias and ensure that participants’ responses could not be traced back to their identities. To reduce potential information bias, the GNCI-ALB was used. This version of the tool demonstrated acceptable psychometric properties in terms of validity and reliability. In addition, participants received clear ethical instructions emphasizing the importance of completing the questionnaire independently, without consulting external sources such as online materials or peers. They were also informed that participation was entirely voluntary and that choosing not to participate or to withdraw at any time would have no academic consequences. This reassurance likely reduced any incentive to search for answers online. Furthermore, the questionnaire was completed in a controlled environment to minimize distractions and promote honest responses.

Study size

An a priori sample size calculation was conducted to ensure the validity of the preliminary analysis using the GNCI instrument. Based on recommendations by Memon et al. [13], a minimum of 10 to 15 participants per item is advised for validation studies. Given the 31 items in the GNCI, a sample of approximately 310 students was considered appropriate. Additionally, Cochran’s sample size formula was applied to determine the minimum number of participants required for this cross-sectional study, considering the finite population size [14]. Using a 95% confidence level, a 5% margin of error, and a total population of 1,200 nursing and midwifery students enrolled during the data collection period, the calculated sample size was 292 students. To account for potential non-response and data loss due to the online survey format, a 20% increase was applied, resulting in a final target sample size of approximately 365 students. Ultimately, data were collected from 715 students, and all responses were included in the final analysis.

Statistical methods

All statistical analyses were performed using IBM SPSS ver. 26.0 (IBM Corp.). The internal consistency of the instrument was assessed using Cronbach’s α. Data were summarized using frequencies (n), percentages (%), means or medians for central tendency, and standard deviations for dispersion. The distribution of continuous variables was examined visually using histograms, boxplots, and Q–Q plots, and formally tested with the Kolmogorov-Smirnov test. Group comparisons of demographic variables and total GNCI scores were conducted using the Kruskal-Wallis test, Mann-Whitney U test, and chi-square test (χ²), as appropriate. Although the data were not normally distributed, means and standard deviations were reported to facilitate comparison with previous studies. Statistical significance was set at P≤0.05. A total GNCI score (range, 0–31) was calculated for each participant by summing the number of correct responses across 31 items, with higher scores indicating greater knowledge. The psychometric properties of the GNCI-ALB were preliminarily examined. Construct validity was evaluated through exploratory factor analysis and confirmatory factor analysis to assess the underlying factor structure.

Results

Participants

A total of 715 students out of 1,200 submitted complete responses to the GNCI-ALB, resulting in a response rate of 59.58%. The majority of respondents were female (88.5%), and the average age was 19.85±2.83 years (mean, 19 years; range, 17–42 years). Most respondents were nursing students (61.1%). Sixty-five percent reported having not taken a previous genetics subject, and 83.5% had not attended previous genetics training, seminars, or courses (Table 1).

Characteristics of the GNCI-ALB

To confirm the construct validity of the GNCI-ALB, both exploratory and confirmatory factor analyses were performed. While the original version of the GNCI was developed as a unidimensional tool, exploratory factor analysis in the Albanian context suggested a 4-factor solution. This structure was then confirmed through confirmatory factor analysis, which showed acceptable model fit (comparative fit index=0.85; Tucker–Lewis index=0.81; root mean square error of approximation=0.03; standardized root mean square residual=0.083), supporting the factorial validity of the adapted version in this population. The internal consistency of the scale was acceptable (Cronbach’s α=0.60), consistent with expectations for preliminary validations involving dichotomous items.

Main results

The Genomic Nursing Concept Inventory Score of Albanian Nursing and Midwifery students

The mean GNCI-ALB score was 7.49±2.65 (range, 2–31), with a scale difficulty of 24.38%, reflecting the percentage of correct answers. A detailed description of correct answers stratified by category, domains, and items is provided in Table 2. The GNCI-ALB scores across categories varied, with genome basics achieving an overall score of 22.08%, and individual domains such as genome composition ranging from 5.3% to 31.7%. Mutations had a total score of 21.6%, with item scores between 12.6% and 33.1%. Inheritance scored 28.2%, with the highest score (41.4%) in autosomal recessive inheritance. Genomic healthcare had an overall score of 24.2%, with genetic testing leading at 35.5%. Item 4, which pertains to the genome composition domain of the genome basics category, yielded the lowest score of 5.3%. In contrast, Item 16, related to the autosomal recessive domain of the inheritance category, achieved the highest score with a correct response percentage of 41.4%.

Correlations between demographic characteristics and GNCI score

Our study revealed a strong, positive, and statistically significant correlation between age and mean total GNCI-ALB score (r=0.74, P=0.047). Additionally, as shown in Table 3, a statistically significant difference was found between male and female students, with female students achieving significantly higher scores (7.62 vs. 7.47, P=0.017). A significant difference was also observed between midwifery and nursing students, with midwifery students reporting significantly higher mean scores (7.56 vs. 7.44, P=0.034).

Discussion

Key results

This study aimed to adapt and validate the GNCI and assess the understanding of genetics and genomics concepts among nursing and midwifery students. The construct validity of the GNCI-ALB was partially supported. While the original scale was developed as a unidimensional tool, the adapted version showed acceptable model fit for a 4-factor solution, suggesting that genomic literacy in this population may be better represented as a multidimensional construct. Overall, students’ performance on the inventory indicated limited genomic knowledge, with notable variation across content domains. Knowledge gaps were especially evident in areas related to genome composition and mutations. Additionally, higher scores were associated with older age, and midwifery students outperformed nursing students, suggesting potential differences in curriculum exposure or educational emphasis.

Interpretation

Approximately 41% of the students did not complete the questionnaire, likely due to the perceived difficulty of the content. Additionally, the elective course “Basics of Genetics,” in the general nursing curriculum, appears to generate limited interest among students, suggesting that it may not significantly impact their understanding or engagement with genomic concepts.

The majority of the participants were in their first year of study, and none had attended a dedicated genomic course, apart from some basic concepts covered in high school biology. This lack of prior exposure may explain the absence of significant correlations between the GNCI score and other variables. Assessing genetic literacy among nursing students provides valuable insight for educators in designing targeted curricula and instructional strategies to address existing knowledge gaps.

Comparison with previous study

Findings from this study showed that nursing and midwifery students in Albania have low genomic literacy, similar to other international studies demonstrating limited genomic literacy among nurses [5,7]. The overall mean score observed in our sample aligns with previous research [4,7], but is much lower than the total mean score reported by Zhao et al. [15] (69.1%), likely because 59.1% of participants in their study reported that their curriculum included genetic and genomic content. This highlights the pivotal role of education in equipping future health professionals with the genomic knowledge and skills needed to provide personalized, evidence-based healthcare. We found that female students achieved a higher GNCI-ALB mean total score compared to male students (7.62 vs. 7.47), aligning with results from other authors [7,15]. However, contrasting results have also been reported, such as those by Dewell et al. [6], where male students outperformed females. Regarding topical areas, students performed best in the “Inheritance” category, while the weakest scores were observed in “Mutations” (21.6%), a pattern also reported by Majstorović et al. [3]. This may reflect the emphasis on inheritance in high school genetics education. By assessing the baseline genetic literacy of students, educators can identify strengths and weaknesses in the curriculum and tailor educational interventions accordingly. This understanding allows them to better familiarize students with genomic concepts.

Limitations

While yielding reliable results, several limitations were identified. The monocentric design limits the generalizability of the findings, and the cross-sectional nature of the research does not allow for assessing changes in understanding of genetics and genomics over time—an issue that future longitudinal studies could address. The scarcity of similar studies also hampers comprehensive international comparisons, highlighting the need for future collaborations. Additionally, involving a broader range of Albanian health science students in further research would enhance the validity of the findings.

Implications

The results of this study have important implications for nursing and midwifery education in Albania. The low understanding of genetics and genomics concepts among students highlights the urgent need to enhance the curriculum in these areas. Improving the curriculum will boost students’ confidence and competence in using genomic information in clinical settings, enabling future healthcare professionals to provide precision, genomics-informed care. By addressing these knowledge gaps, educators can develop targeted teaching strategies that promote genomic literacy. Integrating genomics into education and practice will enhance patient outcomes, advance research in the field, and support the evolving area of precision health.

Conclusion

This study revealed that future Albanian nurses and midwives have a low level of knowledge regarding foundational genetic and genomics concepts. It is crucial to update nursing and midwifery curricula with relevant learning strategies to prepare a competent workforce for precision health. Addressing this need requires coordinated efforts among government entities, educators, and policymakers. These findings will aid in developing competence-based curricula that integrate genetic and genomic approaches into clinical practice, ultimately enhancing patient care.

Supplementary materials

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References

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