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Liver disease 2: a framework to develop nurses’ liver care skills

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This article reports on a competency framework to improve nurses’ skills in caring for people with liver disease. It can be usefully complemented by our learning unit on liver disease


Following the overview of liver disease in part 1, the second part of this series looks at how a new competency framework was developed for nurses caring for people with or at risk of liver disease to address the increasing burden of the disease across public health, primary care and secondary care. Understanding of liver disease and its risk factors remains poor among many health professionals; a competency framework enables nurses and teams to identify and develop the skills, knowledge and understanding they need to provide high-quality, person-centred care.

Citation: Clayton M, Greenslade L (2014) Liver disease 2: a framework to develop nurses’ liver care skills. Nursing Times; 110: 30, 20-23.

Authors: Michelle Clayton is lecturer in liver care, University of Leeds, and liver transplant recipient coordinator at St James’s University Hospital; Lynda Greenslade is clinical nurse specialist in hepatology, at the Royal Free London Foundation Trust


Liver disease is the fifth most common cause of death in the UK (British Association for the Study of the Liver and British Society of Gastroenterology, 2009. The condition has three major causes of liver disease – alcohol, viral hepatitis and obesity leading to non-alcoholic fatty liver disease (NAFLD) (Department of Health, 2012a) – all of which are essentially preventable and have been attributed to changes in lifestyle, particularly over the last two decades. Public attention surrounding liver disease is not always positive due to its links to health inequalities and stigmatisation of the disease as being “self-inflicted”.

Age is no barrier to liver disease, and raising awareness of risk factors in the form of health education and promotion across the age spectrum is imperative. Established liver disease is generally life-limiting and the treatment options available, such as liver transplantation, are limited. Promoting a healthy liver as part of a healthy life to the next generation is therefore vital to help reverse this growing problem.

Nurses have been identified as key professionals in leading the fight against liver disease (NHS Future Forum, 2012). Those working in all areas of clinical practice can contribute by identifying individuals at risk because of alcohol consumption, hepatitis B and C, and obesity, and offering brief advice to help them to make informed choices. In primary, secondary and tertiary care, identifying risk factors, giving verbal and written information and signposting to support services can be invaluable in helping to reduce patients’ risk of liver disease. Nurses who care for people with diabetes and cardiometabolic risk factors can also help to promote a healthy liver.

Developing a competency framework

The significant burden of liver disease means it is essential that we have a nursing workforce with the skills and confidence to deliver high-quality services to patients with a diagnosis of liver disease or a risk of developing it. On behalf of the Department of Health in England and the Royal College of Nursing, a group of liver nurses developed Caring for People With Liver Disease: a Competency Framework for Nursing (RCN, 2013). Developing a competency framework, rather than competencies per se, reflects the need to encompass knowledge, skills and attitudes rather than just the performance of a skill (ten Cate and Scheele, 2007).

We identified and worked closely with a group of stakeholders to ensure the framework embodied what it is like to live with liver disease, as well as considering the wider public health impact of a generation that has increased risk factors for it. The completed framework encapsulates the professional standards expected of practitioners caring for adults and young people with or at risk of liver disease across the UK, against which skills, knowledge and understanding can be assessed. We also aimed to make it a flexible tool that individual nurses or teams can access easily.

It is important to recognise that competency levels are not equivalent to Agenda for Change banding and nurses’ competency levels may vary in different competencies (Table 1). The framework provides detail about each competency level to enable teams to build individual competencies for their workforce, and so individual nurses can recognise the level they are working towards or have achieved. For example, public health nurses or practice nurses can identify competencies relevant to their area of practice, such as working with people to achieve lifestyle goals, signposting and supporting, developing and evaluating self-management plans. Those working in a liver nursing environment such as liver intensive care, a liver unit or a gastrointestinal ward may identify with many or all of the competencies.

Competency frameworks are focused on outcomes and are an indispensable tool for those commissioning, managing and developing the workforce to improve the quality and efficiency of services. The goal of the liver disease framework is to improve liver care across the spectrum, from prevention and early identification through to end-of-life care. It is hoped that people with liver disease will be identified earlier, and receive care that is equitable, responsive, of high quality and effective.

How the framework fits with the 6Cs

The competency framework, which contains nine core liver care competencies (Box 1), is person centred and encompasses the core values of the 6Cs (Department of Health, 2012b). We hope it will promote high-quality liver care for all patients and their families/carers and help to achieve many of the action points set out in Compassion in Practice (DH, 2012b), as follows:

  • Helping people to stay independent, maximise wellbeing and improve health outcomes: by improving nurses’ competency in identifying risk factors, offering brief advice, initiating and supporting lifestyle changes;
  • Positive experience of care: nurses with a better knowledge and understanding of liver care will be able to give more information to patients to improve their choices;
  • High-quality care and measuring impact: by setting professional standards for effective care, and making a positive impact on care by improving nursing knowledge;
  • Building and strengthening leadership: by considering NHS drivers and outlining how to actively improve and promote liver services;
  • Ensuring the right staff and skills in the right place:by enabling the knowledge, skills and attitudes required to develop patient-centred liver care;
  • Positive staff experience: by improving knowledge and skills to develop high-quality care.

Box 1. The nine competencies

A competent practitioner:

  • Provides empathy and understanding and works with patients (and their family/carers), particularly those with chronic liver disease
  • Signposts and supports patients (and families/carers) in understanding their condition through education and health promotion
  • Undertakes a comprehensive clinical assessment, including risk profiling, and follows up with appropriate action, including referral to specialists, for relevant acute and chronic conditions
  • Assesses in collaboration with patients (and family/ carers), their healthcare needs, taking into account the impact of their age, vulnerability, lifestyle, cultural and ethnic background
  • Develops and evaluates a self-management plan with patients who have predisposing factors for liver disease
  • Works alongside and with patients (and families/carers) to address the psychological and social impact of the condition 
  • Provides specific diagnostic/treatment options safely, including:  
    • Undertaking phlebotomy and cannulation in patients with difficult access associated with their liver disease
    • Nutrition and fluid management/hydration in patients with liver disease
    • Pharmacological treatment and side-effects
    • Non-invasive diagnostics and treatment options
    • Invasive diagnostics and treatment options
  • Uses early warning tools/ approaches to identify patients’ changing and deteriorating condition, and takes appropriate action
  • Actively improves and promotes liver services across the appropriate care pathway

Demonstrating competence

Producing the right evidence to demonstrate competency in nursing to meet registration requirements as well as the many other clinical competencies, such as those concerning infection control or nutrition, can seem daunting.

However, in everyday practice, nurses undertake activities that can be used for this purpose. These include explaining procedures to patients, working with junior colleagues to explain symptoms such as ascites and its treatment, and seeing patients in GP practices, discussing lifestyle and risk factors together and motivating patients to make positive changes. Nurses can also use a single piece of evidence to demonstrate more than one competence.

The framework lists the types of evidence that can be incorporated, including:

  • Evidence of supervised practice such as signed observation of undertaking a procedure;
  • Projects;
  • Practice developments/changes in practice;
  • Critical incidents;
  • Assessments and appraisals;
  • Certificates of attendance with reflections on learning.

Implementing the framework

While implementing any competency framework can seem a major undertaking, involving the whole nursing team can allow learning needs for the service to be identified and highlight areas for improvement in the team’s performance. Identified areas can then be supported by using the framework, therefore combining the integration of performance and capability (Garside et al, 2013).

Being clear about what level of competency is expected for different nursing bands and, more importantly, is achievable by those nurses is crucial and can be achieved through a training needs analysis (Gould et al, 2004). Projects that are embraced by the whole team are more likely to succeed, while progressing in small achievable blocks and sharing successes with the team develops ownership of the implementation. Identifying members of the team to champion the framework helps not only with implementation but also with assessment in practice through preceptorship and mentorship of staff.

The framework can become a workable tool to enable new and established staff to develop and demonstrate their skills and knowledge; for example, a weekly teaching session given by members of the nursing team to nursing and other colleagues provides the nurses and those they teach with evidence of achievement of a part of the framework. While protected time for teaching can be difficult to find, small opportunities for learning and achieving competencies can be developed through team working in practice, ward rounds, referrals to other teams such as palliative care, and escalating care of at-risk patients to the specialist liver team. The framework provides examples of how different nurses and grades might meet the competency framework (Box 2). Individuals and nursing teams can work together to identify and implement an achievable competency when looking after people with or at risk of liver disease.

Box 2. Example of evidence of competency

Competency 1 - level 6 Competence

Provides empathy and understanding and works with patients (and their family/carers) and particularly those with chronic liver disease as experts in their own condition. Evidence to achieve competency includes:

  • Plans, implements and evaluates an agreed care plan with the patient and/or their carers
  • Able to demonstrate understanding of patients’ care needs and advocate for patients on ward rounds or at relevant multidisciplinary meetings
  • Gives appropriate information to patients or their carers and signposts them to other sources of information such as the British Liver Trust
  • Able to write a reflective account of an episode of care that may be challenging for their own personal and professional development
  • Able to support junior nurses in assessing and implementing a care plan that focuses on a specific aspect of care
  • Able to undertake or contribute to relevant liver nursing audits, disseminate outcomes and change practice where relevant
  • Identifies own learning needs to support patients


A healthy liver is as important as a healthy heart, bones or teeth. The liver disease framework is an excellent tool with which nurses can identify their own or their team’s learning needs, and develop the skills and knowledge they need.

Competency frameworks can identify gaps in workforce provision and support expansion of services, and can also be used by other health professionals to develop their own portfolio of competencies. They are designed to be flexible and relevant to each individual, and can easily be built upon as nurses develop their experience and skills.

Key points

  • Nurses play a key role in the fight against liver disease
  • Competency frameworks can give nurses the skills to deliver high-quality care and develop their knowledge and understanding
  • A newly developed liver disease competency framework can be used by all nurses, regardless of clinical background
  • The framework reflects the 6Cs approach to nursing practice
  • Different types of evidence can be used to demonstrate competence

Boost your CPD and work towards your next revalidation with our learning unit on liver disease

Nursing Times subscribers have free access to a range of learning units, including one on Liver Disease: Risk Factors and Treatment. Once you have been through the learning unit, you will be able to:

  • Identify patients at risk of liver disease and its complications
  • Describe lifestyle changes that can reduce patients’ risk of liver disease
  • Explain the most common causes of liver disease
  • Discuss how to diagnose chronic liver disease
  • Describe treatment options for patients with chronic liver disease
  • Identify when patients with or at risk of liver disease need specialist referral
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