Alcohol Associated liver disease Competencies

Final draft: March 2023

Review Date: March 2026

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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.

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.

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


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


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.

Canadian Institute for Health Information (CIHI). (2022). Hospitalizations entirely caused by alcohol.!/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