The authors first collected curriculums of all compulsory, additional and elective courses in undergraduate and graduate programs, reviewed them, and determined how many of those curriculums included a genomic component. Undergraduate programs were explored through the National Information System for Application to Higher Education Institutions (National Information System for Application to Higher Education Institutions, 2021 ; Working group, 2013), and graduate programs through the university websites (Supplementary Material S1). The types of courses in the undergraduate study of nursing are divided into compulsory courses which are prescribed by the core curriculum (47 courses, 158 ECTS) and additional courses (22 ECTS) which are designed by the university. Additional courses can be organized as compulsory and elective courses.

Table 2 shows the core curriculum for undergraduate studies (academic year 2020/2021) in Croatia. Ten universities in Croatia provide either full–time or part–time undergraduate study program, which enrolled 899 students in academic year 2020/2021. The nominal distribution among compulsory, additional and elective courses was similar between universities (Table 2). Genomics is included as a part of subject at each university, mainly throughout the Pediatrics course, with no defined learning outcomes and a number of hours related to genetic content. Only two undergraduate nursing programs (Undergraduate programs 5 and 10) provide independent genomic courses for Bachelor of nursing students.

Table 3 shows the curriculum for graduate studies (academic year 2020/2021) in Croatia. Nine universities in Croatia provide either full–time or part–time program, which enrolled 504 students in academic year 2020/2021. The nominal distribution among compulsory and elective courses vary a lot between universities (Table 3). Genomics modules are taught as part of other subject-matter courses (Table 3). Graduate programs 6 and 9 do not integrate any genomics content in their nursing curriculum. Curricula contents were not available for all courses at the Graduate programs 4 and 7. Only two graduate nursing programs (Graduate programs 5 and 8) provide independent genomic courses for Master of nursing students.

Initially, 189 students were invited to participate in the study, whereas 108 students clicked on the survey link. Sixty-eight inventories had missing responses to one or more test items. Those were excluded from analysis, which resulted in a final sample of 53 students. Ages ranged from 19 to 40 years (median 23.5 years). Most respondents identified as female (88.7%), were currently unemployed (81.1%), reported to be in the first year of their studies (73.6%) and acquired knowledge in genomics primarily by reading the literature (Table 1).

For each participant, a total number of correct answers (range 0–31) was calculated. Scores across all respondents ranged from 3 to 22, with a mean scale score of 9.8 (SD 5.3) (31.6% correct). Topical category scores were highest on “Inheritance” (33.2%), and lowest on “Mutations” (19.5%). A description of each item, along with the number of correct answers and the mean score of topical category is provided in Table 4. In relation to questions, student scores were highest in response to DNA sequence (Question 2, 69.8% answered correctly). In contrast, lowest scores were in distinguishing germline and somatic mutations (Question 18, 3.8% answered correctly).

This study represents the first evaluation of the current genomics content in the curriculum of undergraduate and graduate program of Studies in nursing in Croatia (academic year 2020/2021). Data were derived from the curriculum of ten undergraduate and nine graduate nursing programs. Our findings show that the genomics is marginalized in the education of nurses, both at the undergraduate and graduate levels.

Our findings corroborate that genomics curriculum is less developed at the undergraduate than the graduate level likely because graduate programs are mandated by the Ministry of Education (Ministry of Science and Education Republic of Croatia, 2014) to include genomics content to comply with European Directive 2005/36/EC) (EUR-Lex, 2020). The Directive prescribes in detail the minimum requirements for a 3-year education of nurses, 4,600 h of theoretical and clinical training, and compulsory courses in the field of nursing care, basic and social sciences. Representatives of all higher education institutions conducting undergraduate nursing study programs in Croatia organized in 2013 a working group for the harmonization of nursing study programs with the provisions of Directive 2005/36/EC. Besides, the working group has developed a core curriculum that defines each compulsory course at the undergraduate level (Working group, Ministry of Science and Education Republic of Croatia, 2014). During the development of the core curriculum, the working group did not follow the results of numerous studies showing a low level of genomic knowledge (Bankhead et al., 2001; Bottorf et al., 2005; Maradiegue et al., 2005; Tomatir et al., 2006). Neither recommendations of The European Society of Human Genetics (ESHG) to facilitate the development of genomic health care in the European community were adopted into the core curriculum (The European Society of Human Genetics, 2008). A review of the directive shows that genomics is only mentioned in the education study program for veterinary surgeons as part of the specific subjects related to basic science (EUR-Lex, 2020). As the significance of genomics in the education of nurses was not recognized, the opportunity to incorporate basic competencies in genomics (The European Society of Human Genetics, 2008) into the core curriculum was missed. However, curricula of the Undergraduate programs 5 and 10, include genomics both, as a part of other subject and as an independent subject. In all other universities’ curricula, genomics is present only as a part of compulsory courses. No expected learning outcomes are specified nor are guidance about the number of hours genomics should occupy in the total course schedule. At the graduate level, the situation is similar. Among nine universities, only Graduate programs 5 and 8 offer genomics both as part of the subject and independent subject.

Although the Undergraduate programs 5 and 10, as well as graduate programs 5 and 8, represent Croatian Universities that recognize the importance of genomic education among nurses, when compared to examples of good practice at the international level (e.g., The University of Texas Permian Basin, 2020), their programs are still insufficient. Namely, outcomes at the international level include higher levels of knowledge, which enables skills acquisition and the development of attitudes, content is focused on incorporating genomics knowledge and technologies in nursing practice, obligatory and recommended materials are from the field of nursing practice, and the curriculum is entirely based on established competencies.

Our results indicate that the genomic literacy of Croatian undergraduate nursing students (Undergraduate program 10) is low. Interestingly, the majority of participants that initially clicked the survey link gave up during the survey, because, as stated in their reasons, “it was too difficult.” This could signal a genomic knowledge deficit among the students we recruited to survey. The reason for this can perhaps be found in the fact that most of the participants were first-year students, and did not attend any genomic course that may improve their understanding of genomics (e.g., compulsory Pediatrics course or an elective course Human Genetic Disease).

With a mean total score of 9.8 (SD 5.3; score range 3–22; 31.6% correct answers), our results are marginally lower in comparison to the results of other studies that utilized the GNCI^© instrument. Namely, Wright et al. reported a mean score of 13.3 (SD 4.60; score range 3–29) (Wright et al., 2019), McCabe et al. 13.7 (SD 4.9; score range 5–26; 44% correct answers) (McCabe et al., 2016), while Ward et al., reported a mean score of 12.85 (SD 4.64; score range 3–28; 41.5% correct responses) (Ward et al., 2016b), and finally, Read and Ward published 14.9 (SD 5.3; score range 4–31; 48% correct answers) (Read and Ward, 2016). To reflect on the results of the other studies that used different methods for genomic literacy assessment, the integrative reviews by Wright et al., and Godino et al., were analyzed (Godino et al., 2013; Wright et al., 2018). The reported conclusions of these studies are similar, declaring inadequate genomic competency among nurses, which closely correlates with a level of their genomic literacy. The authors underline the importance of assessing actual content knowledge using a validated inventory instrument e.g., GNCI rather than self-reports to best capture genomic literacy in future studies. However, considering motivation as a very important factor in the learning process (Ferreira et al., 2011), the estimation of self-reported motivation and/or perceived knowledge should also be included.