Alcohol Associated liver disease Competencies

Final draft: March 2023

Review Date: March 2026

Alcohol-Associated Liver Disease (ALD) Competencies

The Canadian Association of Hepatology Nurses (CAHN) approved the Hepatology Nursing Standards in February 2007. The Standards provide a comprehensive framework for the evaluation of professional hepatology nursing practice. Subsequently, a CAHN working group began to develop competency documents that describe core competencies specific to particular liver diseases/conditions. The alcohol-associated liver disease (ALD) competencies pertain to adults and do not include specifics for pediatrics. These competencies should be interpreted within the context of your regional practice recommendations.

Purpose
The Canadian Association of Hepatology Nurses Alcohol-associated Liver Disease Competencies document provides a mechanism for nurses to examine their practice, determine their learning needs and ultimately improve their knowledge, skill and judgment related to ALD care.

Introduction
Alcohol is used by about three-quarters of people living in Canada (CCSA, 2022). Although a legal regulated substance, alcohol is a leading cause of liver mortality and morbidity that are preventable. In 2017, alcohol was responsible for 18,000 deaths and associated with $5.4 billion health care costs in Canada (CCSA, 2022). The rate of hospital admissions caused by alcohol was 277 per 100,000, and half of these hospitalizations were adults between the ages of 45 to 64 years (CIHI, 2022). In Canada, the incidence rate of cirrhosis related to ALD was estimated to be on the rise at 11.6 % per year. Young adults born after 1980 are projected to be the population with the highest incidence of cirrhosis by 2040 (Flemming, 2021).
Alcohol misuse is more than a personal choice, it is associated with mental health, violence, stigma, and addiction. Management of clients with ALD requires a multidisciplinary approach. Hepatology nurses have an important role to not only provide the expected care to clients along the spectrum of ALD but also to bring changes to Canada’s drinking culture and address harmful alcohol use in society.
The CAHN ALD Competencies document describes a range of ALD nursing competencies but does not identify educational preparation or specific experience needed for any of the competencies. These competencies are meant to assist nurses with the identification of learning needs appropriate for their specific practice context. The document articulates expectations that the regulatory bodies have for nurses involved in specialty areas of practice. This document can be used by nurses working in liver disease for ongoing self-assessment and by nurses transitioning to a practice that includes ALD.
Embedded in the competencies are the assumptions that nurses advocate not only for the individual but also at the policy and/or systems level, and that nurses engage in collaborative practice.

As this document reflects current knowledge, CAHN will review and revise it at least every three years. The next review will take place by January 2026.

ALD Competency Statements

The competencies are presented within four sections:

1) fundamental knowledge
2) nursing assessment
3) interventions
4) evaluation.

Each section contains competency statements with accompanying knowledge expectations. The nursing assessment section is framed within the determinants of health.

1. Fundamental Knowledge Competencies

1.1. Understand the epidemiology (prevalence and incidence) of NAFLD

Prevalence and incidence
Influencing demographic factors e.g., culture, ethnicity, gender, family history, geography
Risk factors for developing ALD e.g. trauma, genetics, co-morbid liver conditions, mental health, cigarette smoking

1.2. Identify the at-risk population

Recognize groups at higher risk e.g. alcohol consumption pattern, mental health, trauma, family history Understand role of stigma in alcohol use
Understand role of stigma in alcohol use
Use of screening tools e.g. CAGE

1.3. Describe the spectrum of ALD

Spectrum of ALD (Fig. 1 AASLD)
Disease recurrence

1.4. Recognize the role of neurobiology in substance use

2. Nursing Assessment Competencies

2.1. Describe the impact of income and social status in the development of ALD

The role of income security e.g., employed, retired, receiving social assistance, lower socioeconomic status

2.2. Describe the barriers to access to care

Regional/geographical differences in accessing care and treatment
Access to and affordable transportation

2.3. Describe the importance and impact of the client’s social support network

Access and retention in care
Presence of or lack of support from family and friends

2.4. Explain how the client’s level of education and literacy can impact health

Assess client’s understanding of information e.g., reading, writing, expression, and comprehension
Use of adult learning principles e.g., language that is appropriate to the client’s education, literacy level, and ethnocultural context
Facilitate client access to information e.g., peer support groups, internet
Impact of language barrier

2.5. Explain the impact of employment/working conditions

Individual’s rights to confidentiality
Planned or unplanned work interruption
Financial impact from missed work

2.6. Understand the influence of social environments

Importance and impact of social networks
Access to community resources
Access to peer support groups
Impact of stigma associated with ALD on health behaviors
Impact of social media and marketing influence

2.7. Understand the importance of physical environments

Community safety i.e., crime, violence
Safe domestic environment and shelter

2.8. Understand the importance of personal health practices and coping skills

Optimize liver health e.g., balanced nutrition, physical activity, harm reduction practices
Factors influencing patients’ choices e.g., psychosocial, financial, cultural and health literacy
Use of complementary and alternative (CAM) medicine e.g., milk thistle, liver detox

2.9. Explain the importance of healthy child development

Adverse childhood experiences (ACEs) and their impact on lifestyle choices and behaviours in adulthood e.g., childhood obesity, physical abuse and family alcohol use

2.10. Describe the role of biology and genetic endowment

Role of genetics
Importance of family history
Identification of at-risk individuals or groups

2.11. Describe the impact of health services on ALD

Client advocacy: self-advocacy, family and nurse’s role
Understand different treatment modalities and access to options
Local referral to treatment e.g., Rapid Access Addiction Medicine (RAAM) clinic
Effect of stigma and discrimination on service access and utilization
Role of remote community health services
Palliative care services
Impact of provider’s values on relationships and client decision-making

2.12. Understand the role of gender

Recognize biological gender differences in risk, progression of disease

2.13. Understand the impact of ethnoculture and religion

Culturally sensitive care

3. A: Intervention Competencies (Client Focused)

3.1. Describe health promotion activities associated with liver health

Harm reduction philosophy, strategies, and their effectiveness
Balanced nutrition and exercise
Medication reconciliation
Immunizations to prevent co-morbid diseases
Importance of a mutually agreed-upon plan of care

3.2. Aware of commonly used complementary and alternative therapies

Use and effects of complementary and alternative medicines (CAM)
Liver toxicity resource

3.3. Explain what the nurse needs to know about assessment of ALD patients

Importance of population screening
Knowledge of patients’ understanding of effect of alcohol
Assessment of functional and clinical status across the spectrum of ALD
Screening tools for at-risk use e.g., CAGE, AUDIT-C
Nutritional assessment
Potential triggers for recurrent use
Recognition of alcohol withdrawal symptoms and tools for monitoring (CIWA protocol)

3.4. Describe therapeutics and interventions for ALD

Treatment modalities including counselling, psychosocial and behavioral approaches and /or medical management
Impact of functional and clinical status (e.g., Child-Pugh score) in therapeutics selection
How and when to access additional services e.g., transplant or palliative care

B: Intervention Competencies (System Focused)

3.5. Recognize methods to influence policy change

Advocacy role of non-profit/community organizations e.g. Canadian Centre for Substance Use and Addiction (CCSA)
Governments’ role in health policy and resource allocation
Nursing activities that advocate/influence policy or health system change

3.6. Describe opportunities for collaboration

Identify opportunities to collaborate with other providers and support systems e.g., Addiction Service, Social Medicine, Peer Support Group
Recognize the importance of the Multidisciplinary Team (MDT) approach
Identify and participate in local, provincial, national, and international health and social service initiatives

4. Evaluation Competencies

4.1. Evaluate client responses, clinical outcome, cost-effectiveness, and ethical considerations of interventions

Share and discuss outcomes with the care team

4.2. Engage in self-reflective practice

Evaluate continuing competency
Identify knowledge gaps in your practice
Explore education and research opportunities
Alignment with requirements of regional professional regulatory body

Appendix

Figure 1: Natural history of alcohol-associated liver disease
(Adapted from Hepatology, VOL. 71, NO. 1, 2020 p. 308)

References

Canadian Centre on Substance Use and Addiction (CCSA). (2022). Update of Canada’s Low-Risk Alcohol Drinking Guidelines: Summary of findings from public consultation. Ottawa, Ont.: Author.
https://www.ccsa.ca/sites/default/files/2022-08/CCSA-LRDG-Update-of-Canada%27s-LRDG-Final-report-for-public-consultation-en.pdf

Canadian Institute for Health Information (CIHI). (2022). Hospitalizations entirely caused by alcohol. https://yourhealthsystem.cihi.ca/hsp/inbrief?lang=en#!/indicators/061/hospitalizationsentirely-caused-by-alcohol/;mapC1;mapLevel2;/

Flemming JA, Djerboua M, Groome PA, Booth CM, Terrault NA. NAFLD and Alcohol-Associated Liver Disease Will Be Responsible for Almost All New Diagnoses of Cirrhosis in Canada by 2040. Hepatology. 2021 Dec;74(6):3330-3344. doi: 10.1002/hep.32032. Epub 2021 Aug 15. PMID: 34174003.

Committee Members 2021-2022

Chair: Colina Yim NP, MN
Nurse Practitioner – Hepatology
University Health Network
Toronto, ON

Committee Members:
Lisa Douglas RN, MN, NP
Nurse Practitioner
Alberta Health Services
Calgary, AB

Jeanette Feizi RN
Clinical Hepatology Nurse
GI Research Institute
Vancouver, BC

Elizabeth Lee NP, MN, CGN(C)
Nurse Practitioner – Hepatology
University Health Network
Toronto, ON

Lindsay Myles MN NP-PHC
Nurse Practitioner
Simcoe Liver Centre
Barrie, ON

Wendy Schaufert RN CGN(C)
Nurse Clinician – High Risk NAFLD clinic
Alberta Health Services
South Health Campus
Calgary, AB