Non-Alcoholic Fatty Liver Disease (NAFLD) Competencies

Approval Date: 05 Nov 2016
Review Date: 07 Nov 2021

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Non-Alcoholic Fatty Liver Disease

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, ethical nursing practice in hepatology. Subsequently, a CAHN working group began to develop
competency documents that describe core competencies specific to particular liver diseases/conditions. This NAFLD Competencies document pertains to adults. These competency statements do not include specifics for pediatrics or transplantation.

Purpose
The Canadian Association of Hepatology Nurses NAFLD 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 NAFLD care.

Introduction
Nonalcoholic fatty liver disease is the fastest rising chronic liver condition in Canada and has become the number one reason for liver transplant. The prevalence of obesity in Canada has increased significantly over the past 3 decades. According to the 2015 Canadian Health Measures Survey, one in three adults in Canada has obesity and may require medical services to manage their disease. Of these individuals, 75% will develop a fatty liver and of those 23% will progress to have fatty liver disease with inflammation or liver fibrosis (NASH). The risk factors for NAFLD include but not limited to metabolic syndrome, obesity, diabetes, hypertension and hyperlipidemia.

The diagnosis of NAFLD ranges from simple steatosis, fatty liver with inflammation, fatty liver disease with fibrosis, and liver cirrhosis. To date there is no pharmaceutical therapy available to prevent and treat this disease process. The only treatment at present is lifestyle modifications and management of
patients’ underlying risk factors that may lead to improvements in their biochemical and fibrosis markers. Nurses play a vital role in the education and management of NAFLD in collaboration with other health professionals. With increasing volume of referrals to hepatology, care for all patients diagnosed
with NAFLD is not tenable, hence the focus of NAFLD care is now on determining those individuals at higher risk for disease progression (fibrosis/cirrhosis) so that specialist care can focus on this population leaving “lower risk NAFLD “patient care in the primary care settings. One of the ways how this can be
achieved is with the development of provincial clinical care pathways to provide support and guidance for family physicians.

The CAHN NAFLD Competencies document describes a full range of NAFLD nursing competencies without identifying educational preparation or specific experience needed for any of the competencies. The document articulates expectations that the regulatory bodies have for Registered Nurses involved in
specialty areas of practice. This document can be used by nurses for ongoing self-assessments and by nurses preparing to transition NAFLD into their practice, education, administration and/or research.

These competencies are meant to assist nurses with identification of learning needs appropriate for their particular practice context.

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 in 2024.

NAFLD Competency Statements

The competency statements are presented within four sections: fundamental knowledge, nursing assessment, interventions and evaluation. Each section contains several competency statements with accompanying knowledge expectations. The nursing assessment sections are framed within the twelve determinants of health.

1. Fundamental Knowledge Competencies

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

  • Host and demographic characteristics
  • Associated lifestyle factors
  • Associated medical conditions

1.2. Define the at-risk population for NAFLD

  • Awareness of risk factors associated with the development of NAFLD e.g., type 2 diabetes, dyslipidemia, polycystic ovarian syndrome, sleep apnea, metabolic syndrome, cardiovascular disease and obesity

1.3. Describe pathophysiology and natural history of NAFLD

  • Understand risk factors for NAFLD progression
  • Understand the histopathology of steatosis versus Non-alcoholic steatohepatitis
  • Understand evolution of fibrosis (progression from steatosis to NASH)
  • Understand the relationship of the quantity of alcohol consumption as it relates to NAFLD
  • Awareness that the most common cause of death is cardiovascular disease

2. Nursing Assessment Competencies

2.1. Describe the importance of income and social status in NAFLD prevention, care and treatment.

  • The role of income as it relates to food security
  • The impact of barriers such as inadequate housing facilities, lack of nutrition and lack of affordable transportation on client health
  • Strategies that clients can use to access services such as weight management programs, diabetes management programs, access to recreational facilities, and nutrition counselling (e.g. free dietitian reviews at grocery stores)

2.2. Describe the importance and impact of the client’s current social network

  • Motivation assistance for lifestyle modification
  • Quality of life
  • Access and retention in care
  • Emotional and practical (e.g., transportation to appointments) support from family and friends

2.3. Explain how the client’s level of literacy can impact health

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

2.4. Explain the impact of employment/working conditions

  • Impact of sedentary jobs
  • Impact of shift work
  • Availability of healthy food choices e.g., packing a lunch versus fast food

2.5. Understand the influence of social environments

  • Importance and impact of social networks e.g., community groups
  • Access to community resources regarding healthy lifestyles e.g., YMCA
  • Impact of stigma associated with underlying disease on health behavior and human rights e.g., cirrhosis, obesity
  • Impact of peer pressure on lifestyle choices
  • Impact of media influence on lifestyle choices
  • Impact of pandemic (SARS, COVID-19) e.g. social isolation

2.6. Understand the importance of physical environments

  • Community and individual safety
  • Awareness of the client’s physical environment and its impact on lifestyle choices

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

  • Optimize liver health e.g., balanced nutrition, physical activity, alcohol abstinence
  • Choices can be affected by socio-economic environments e.g., self-care, advocacy and coping mechanisms
  • Self-esteem, self-worth and resilience can affect health practices
  • Awareness of use of complementary and alternative medicine (CAM), mindfulness meditation, traditional indigenous practices, self-hypnosis, support groups, homeopathic products, liver detoxification, and pseudo-scientific therapies (weight loss pills, fad diets)

2.8. Explain the importance of healthy child development

  • Experiences in early life that can affect lifestyle choices and behaviors in adulthood e.g., breastfeeding, childhood obesity, alcohol consumption, food choices, family activities, history of abuse
  • Role of technology in decreasing physical and social interaction
  • Modelling of healthy behaviors e.g., physical activity

2.9. Describe the role of biology and genetic endowment

  • Role of genetics
  • Importance of family history
  • Identification of at-risk individuals e.g., metabolic syndrome

2.10. Describe how health services impact NAFLD

  • Access to appropriate monitoring and management of co-morbidities
  • Nurse’s role in collaborative client care
  • Effect of stigma and discrimination on service access and utilization
  • Feasibility and appropriateness of NAFLD patients seeing a specialist
  • Different provincial lab testing and DI tests available and wait times
  • Role of specialty nurses educating primary care physicians on NAFLD care pathways (see Alberta Health Services NAFLD Primary Care Pathway weblink in References)

2.11. Understand the role of gender

  • Recognize that gender differences in likelihood of diagnosis, natural history of disease and disease progression.

2.12. Understand the impact of culture

  • Implications related to NAFLD e.g., alcohol as part of lifestyle, ethnicity, and diet
  • Importance of culturally sensitive care e.g., avoid actions that diminish, demean or disempower the cultural identity and well-being of an individual
  • Self-reflection of provider’s values and beliefs

3. A: Intervention Competencies (Client Focused)

3.1. Describe health promotion activities associated with NAFLD

  • Education of at-risk populations
  • Balance nutrition and exercise to maintain an ideal body weight
  • Avoid alcohol, tobacco, illicit substances, solvents and chemical irritants
  • Medication reconciliation and education
  • Impact of prescribed and non-prescribed medications on weight gain/ hepatotoxicity
  • Utilization of agents such as GLP1 that promote weight loss (obesity guidelines link)
  • Management of co-morbid conditions e.g., cardiac risk factors, diabetes control, dyslipidemia
  • Immunizations to prevent co-morbid diseases e.g., hepatitis A/B, pneumovax, influenza, COVID-19

3.2. Understand and access to available clinical pathway

  • Knowledge of emerging provincial care NAFLD pathways to assist primary care providers to help identify NAFLD, and guide them when to treat in primary care settings and when to refer e.g. Alberta Health Services NAFLD Primary Care Pathway (see weblink in References)

3.3. Identify what the nurse needs to know about NAFLD assessment

  • Importance of education for at risk individuals due to asymptomatic nature of presentation
  • Knowledge of lab investigations required to rule out other liver diseases to diagnose NAFLD e.g. viral hepatitis, autoimmune workup
  • The impact of co-morbid disease management
  • Use of invasive and non-invasive tests used to diagnose NAFLD e.g., liver biopsy, Fibroscan, MRE, shearwave elastography, Fibrotest, serum serological markers (APRI and FIB4)

3.4. Describe the management of disease progression of NAFLD

  • Signs and symptoms of progression e.g., jaundice, progression from F3-F4, muscle wasting, ascites
  • Screening and surveillance for those with fibrosis e.g., ultrasound for HCC , upper endoscopy for varices
  • Knowledge of resources to access additional services e.g., transplant, palliative care

3.5. Describe therapeutics and interventions for NAFLD

  • Awareness of cardiac risk factors and the role of statins and safety of their use in the liver
  • Education related to lifestyle modification e.g., weight loss, avoidance of alcohol
  • Awareness that there are no medications available to treat NAFLD but many ongoing clinical trials
  • Awareness of emerging therapies for optimal management i.e. obesity management, bariatric surgery, GLP-1 usage, opiate antagonist

3B: Intervention Competencies (System Focused)

3.6. Recognize methods to effect policy change

  • Advocate for partnerships with non-profit and community organizations
  • Government’s role in health policy changes e.g., resource allocation and access
  • Nurses’ role in advocating for improvement and access to care and treatment

3.7. Advocate for ongoing health care provider education and learning opportunities

  • Awareness of NAFLD education and learning opportunities
  • Participate in professional development activities related to NAFLD e.g., conferences from CAHN, CASL, CanNASH

3.8. Describe the importance of collaboration

  • Identify and collaborate with other specialists (e.g. cardiac, endocrinology, mental health specialists) and support systems including dietitians, allied health and social workers.
  • Identify and participate in local, provincial, national and international health and social service initiatives
  • Recognize the importance of multidisciplinary care including liver transplantation and palliative care when appropriate

4. Evaluation Competencies

4.1. Evaluate client responses and clinical outcome

  • Evaluate the effect of interventions and progress towards targeted outcomes
  • Share and discuss outcomes with appropriate health care professionals e.g., primary health care provider
  • Evaluate the cost effectiveness of interventions e.g. bariatric surgery

4.2. Participate in the dissemination of new knowledge in NAFLD

  • Share new evidence-based practices
  • Participate in research and/or disseminate findings e.g., journal club

4.3. Practice self-assessment

  • Evaluate continuing competency in NAFLD practice and knowledge
  • Reflect own practice competencies according to provincial regulatory bodies

Committee Members 2020

Chair: Jeanette Feizi-Farivar, RN (2019 – 2021)
Clinical Hepatology Nurse
GI Research Institute
Vancouver, BC

Chair: Colina Yim RN, MN, NP (2021- 2023)
Nurse Practitioner – Hepatology
Toronto Centre for Liver Disease
Toronto, ON

Revision Committee / Contributing Members:

Leeya Brind’Amour RN
Registered Nurse
Nelson Liver Clinic
Nelson, BC

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

Committee Members 2016

Chair: Cheryl Dale, RNEC, MScN
Nurse Practitioner
London Health Sciences Centre
London ON

Committee Members:
Carol Dupasquier, RN, BN
NAFLD Page 3 Version-3 Nov 2021
Community Hepatology Clinic
Mount Carmel Clinic
Winnipeg, MB

Jo-Ann Ford, RN, MSN
Associate Director – Clinical Research
BC Hepatitis Program
Gordon and Leslie Diamond Health
Care Centre, Vancouver, BC 

Geri Hirsch RN- NP, MN
Nurse Practitioner, Hepatology Services
Division of Gastroenterology
Capital District Health Authority
Halifax, NS

Kathy Poldre, RN, BN
Hepatitis Support Nurse/ Research Coordinator
Toronto Centre for Liver Disease
Toronto, ON

Colina Yim RN(EC), MN
Nurse Practitioner – Hepatology
Toronto Centre for Liver Disease
Toronto, ON

Lesley Gallagher RN
Positive Living Program
Saskatoon, Saskatchewan