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Caring for people with liver disease: a competence framework for nursing
Revised edition
RCN CompetencesRCN Competences
This publication has been supported by industry
RCN Legal Disclaimer
This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK.
The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this website information and guidance.
Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN
© 2015 Royal College of Nursing. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers.
Acknowledgements
Members of the Specialist Nurses External Reference Group
As part of the National Liver Disease Strategy, a Specialist Nurses External Reference Group was created to undertake various projects.
Helen Caldwell, Nurse Consultant in Hepatology, Royal Liverpool University Hospital, Liverpool
Michelle Clayton, Lecturer in Liver Care, University of Leeds and Liver Recipient Transplant Coordinator, St James’s University Hospital, Leeds
Amanda Clements, Hepatology Nurse Consultant, South West Liver Unit Derriford Hospital, Plymouth
Sandra Crompton, Liver Nurse Practitioner, Bolton NHS Foundation Trust
Elizabeth Farrington, Advanced Nurse Practitioner Hepatology, Royal Cornwall Hospital, Truro
Vicki Finlay, Professional Officer, Department of Health, Quarry House Leeds
Lynda Greenslade, Clinical Nurse Specialist in Hepatology, Royal Free Hospital NHS Foundation Trust, London
Richard Hall, Support Group Co-ordinator, British Liver Trust
Helen Hampton, Primary Care Hepatitis Nurse Specialist, Cornwall NHS
Anne Moger, Nurse Adviser, Department of Health, Wellington House, London
Debbie Morton, Alcohol CNS, Liverpool PCT, Liverpool
Lynn Owens, Nurse Consultant, Liverpool PCT, Liverpool
Ray Poll, Nurse Consultant in Viral Hepatitis, Royal Hallamshire Hospital, Sheffield
Mushi Rahman, Liver Disease Team, Department of Health, Wellington House, London
Sam Readhead, Viral Hepatitis Specialist Nurse, Frimley Park Hospital, Surrey
Norgine Pharmaceuticals Ltd have provided financial support by way of sponsorship for the production and distribution of this framework. Norgine Pharmaceuticals Ltd
had no editorial input into the content of this framework other than a review for medical accuracy.
Reviewers
British Association for the Study of the Liver
British Association for the Study of the Liver Nursing Forum
British Liver Nurses Forum
British Liver Trust
British Society of Gastroenterology
Children’s Liver Disease Foundation
The Hepatitis C Trust
RCN (general consultation)
Liver4Life
To provide feedback contact:
Michelle Clayton m.clayton@leeds.ac.uk
Lynda Greenslade lynda.greenslade@nhs.net
publications.feedback@rcn.org.uk
We would like to take this opportunity to thank Dr Kim Manley for her invaluable input, support and advice in the development of this framework.
Our thanks also go to the many liver nursing colleagues and other health care professionals (too many to mention individually), that contributed to the development of the framework through generously sharing their thoughts and ideas during its creation. And finally we would like to thank Lynda Greenslade and Michelle Clayton of the Specialist Nurses External Reference Group for their hard work in bringing together the completed Caring for people with liver disease: a competence framework for nursing (revised edition).
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RCN Competences: Caring for people with liver disease: a competence framework for nursing
Foreword 4
Key stakeholders 5
1. Introduction to the framework 5
2. Context for developing the framework 7
3. What is a competence framework? 8
4. The aim of Caring for people with liver disease: a competence framework for nursing and its relationship to the RCN career and competence and other relevant frameworks 9
5. Using Caring for people with liver disease: a competence framework for nursing 12
6 How to produce evidence to demonstrate competence 15
7. Overview of the competence framework 16
8. Detailed definition of Caring for people with liver disease: a competence framework for nursing 17
9. Quality assurance of the framework 19
10. Caring for people with liver disease: a competence framework for nursing 19
Appendix 1: Nurse Census of roles 62
Appendix 2: Examples of evidence to meet Caring for people with liver disease: a competence framework for nursing 63
Appendix 3: Blank competence sheet to produce own evidence for the Caring for people with liver disease: a competence framework for nursing 67
Appendix 4: References 69
Appendix 5: Useful contacts 70
Appendix 6: The six Cs and how they fit into Caring for people with liver disease: a competence framework for nursing 71
Contents
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Foreword
Delivery of high quality care that produces better outcomes for patients needs a high quality workforce: skilled and competent practitioners who are fit to deliver care in the future health and social care system.
Patients and carers have told us that they want to be able to access safe and effective care when they need it and in the right place, delivered by the right person. They want to be empowered to ensure that they exercise maximum choice and control over the services they receive, working in partnership with professionals – ‘no decision without me’.
In conjunction with the Royal College of Nursing (RCN), we have developed a competence framework that describes the knowledge, skills and attitudes that are required to deliver patient-centred liver care. The work has been supported by a range of key stakeholders including professional representatives from the British Society of Gastroenterology (BSG), British Liver Trust (BLT), The Hepatitis C Trust, British Association for the Study of the Liver Nurses Forum (BASLNF) and the British Liver Nurses Forum (BLNF). Competence frameworks are focused on outcomes and are an indispensible tool for those commissioning, managing and developing the workforce. They inform the development of education and training programmes as well as assessment strategies.
I commend this framework to you and hope that you use it to develop the workforce so that the quality and efficiency of services provided for people at risk of or with a diagnosis of liver disease are improved across the liver care spectrum, from prevention and early identification through to end of life.
Professor Martin Lombard National Clinical Director National Liver Disease Strategy
The ethos of Caring for people with liver disease: a competence framework for nursing has been to develop a set of competences that all nurses can use regardless of their area of clinical practice. The framework will help to equip the nurse to identify individuals at risk of liver disease, promote healthy livers and lifestyle as well as care for individuals with existing liver disease. Liver disease is increasing and the full impact has not yet been felt; it was once a minority killer, however liver disease is now becoming commonplace and is the fifth biggest killer in the United Kingdom. Age is no barrier to liver disease and, as such, raising awareness of risk factors across the age spectrum is essential. There is a great need to reverse this growing problem and the promotion of a healthy liver as a way of life to this generation and the next is a key concept.
Nurses are integral to making an impact on liver disease; nurses can make every contact count by identifying risk factors for the three major types of liver disease – alcohol, hepatitis B and C and obesity leading to non-alcoholic fatty liver disease (NAFLD); and by offering health promotion and education to help individuals to make informed choices. Some nurses will also need to be able to offer care to patients with existing liver disease and this competence framework has also been devised to support quality standards for care. Liver patients can be challenging and can have a complexity that requires nurses to draw upon multiple skills and talents. I hope that this publication will equip a nurse with the required skills and knowledge base to help make a difference for the individual with, or at risk, of liver disease by the delivery of effective quality care. Caring for people with liver disease: a competence framework for nursing aims to turn a little known and thought of disease into an everyday thought, which will help to encourage identification and prevention of liver disease development.
All nurses – regardless of clinical background – have the skills and talents to integrate liver health into the health care arena as a healthy liver is essential in maintaining a healthy life.
Michelle Clayton RGN, MSc, PGC in Clinical Education, BSc (Hons), Steering committee member, RCN Gastrointestinal Nursing Forum, Chair of the Specialist Nurses External Reference Group, National Liver Disease Strategy
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Key stakeholders
Introduction to the framework
This competence framework describes the professional standards expected of practitioners when caring for people with liver disease – adults and young people – across England.
Liver disease is now the fifth most common cause of death in the United Kingdom (Williams et al, 2014). What was once thought to be a rare disease is emerging to be a major killer and its prevalence has risen exponentially year on year in recent times, see Table 1. There are three major culprits that have led to this incredible rise: alcohol, viral hepatitis and obesity leading to non-alcoholic fatty liver disease (NAFLD). These three areas are essentially preventable causes and have been attributed to changes in lifestyle. One of the challenges in caring for patients is to raise awareness amongst all health care professionals in primary and secondary care as well as the general public. Public attention surrounding liver disease is not always positive due to its links to health inequalities and also the stigmatisation of this disease being as ‘self-inflicted’.
Table 1: England – liver disease mortality trend dramatic increase relative to other major disease groups.WHO/Europe, European HFA Database, January 2012
1
300
250
200
150
100
50
0
-50
-100
Movements in mortality 1971-2007
Deaths per million of population
% c
hang
e vs
197
1
1971
Year
Road
1981 1991 2001 2007
Liver Diabetes Cancer Respiratory Heart Stroke
Liver4Life
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of Health, England and the Royal College of Nursing, Gastrointestinal Nurses Forum.
The framework focuses on the general needs of people with liver disease and is intended to be used with other local policies and pathways around the scope of practice undertaken by nurses working at all levels.
Caring for people with liver disease: a competence framework for nursing is an essential document for all nurses whatever their clinical background and setting. The document has been produced to provide a framework on which skills, knowledge and understanding can be assessed. A recent survey of nurses from the RCN Gastrointestinal Nurses forum, British Liver Nurses’ Forum and British Association for the Study of Liver Disease Nurses Forum (2015) felt that the framework helped liver nurses plan their appraisals, identify development needs in their role, develop new roles and help to upskill ward teams. The competence framework should be seen as a flexible document that allows individual liver nurses to utilise those competences that are specific to them and does not have to be undertaken as a whole. It is important to recognise that the competence levels do not translate to agenda for change banding and a nurse’s competence level may vary in different competences.
The competence document may also be useful for those health care professionals (HCPs) i.e. GPs, social workers,dietitians and drug and alcohol workers who are also working with patients with or at risk of liver disease in primary or secondary care and may be useful as part of their professional learning and development. The document can also be used by student nurses to improve their knowledge, understanding and skill acquisition of caring for people with or at risk of liver disease. See page 9.
Nurses are key to the prevention of liver disease. Nurses in every area of clinical practice can identify individuals at risk of liver disease, for example, screening for hepatitis B and C, alcohol consumption and obesity, and help them to make informed choices through health promotion and education. The role of brief advice is a key component, whether in primary, secondary or tertiary care, and identification of risk factors, verbal and written information and signposting to support services can be invaluable in helping to reducing the risk of liver disease. Having a healthy liver should be just as important as a healthy heart, bones or teeth. Tackling obesity is already high on the public health agenda with campaigns to encourage and empower patients to make healthier choices in relation to eating, exercise and weight management (NICE, 2014). Some causes of liver disease, for example hepatitis B and C, are now highly treatable and can prevent liver disease from developing if detected early enough and individuals are referred for treatment (NICE, 2012). Whether in primary or secondary care, nurses who care for individuals with such conditions as diabetes and metabolic syndrome can also help to promote a healthy liver.
Age is no barrier to liver disease and as such, raising awareness of risk factors in the form of health education and promotion from an early age should be encouraged i.e. obesity in children and safe limits for drinking alcohol in the older population. This is an extremely important public health role as there is a great need to reverse the growing problem that we have and to promote a healthy liver as a way of life to the next generation. Established liver disease is generally life-limiting and the treatment options available, such as liver transplantation, is a limited resource. In England and Wales there was a 25 per cent increase in liver deaths between 2001 and 2009 (National End of Life Care Intelligence Network, 2012). Liver patients are known to die younger than the general population and the majority die in a hospital setting (NCEPOD, 2013). This is the opposite of most major disease processes where dying in hospital is in the minority. Therefore end of life planning and subsequent care delivery is another important area in which nurses in both primary and secondary care settings have a key role.
The National Liver Disease Strategy for England identified, with expert nurses working within the specialty, the need for a framework to ensure patients with liver diseases or risk factors to the disease were recognised. This document encapsulates the requirements and professional standards which will help nurses aspire to providing quality liver care and improving outcomes. This was a a joint development between a selected group of liver nurses on behalf of the Department
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The National Liver Disease Strategy for England (Department of Health, unpublished at present) aimed to transform the way health and social care services supported people with liver disease to deliver optimum outcomes. Those with liver disease would be identified earlier, diagnosed with improved accuracy and receive treatment that is equitable, responsive, high-quality and effective with the overall aim of reducing premature mortality associated with liver disease. This should be from the right person, at the right time, in the right place, within evidence-based standards of care and treatment, ensuring dignity and respect are at the heart of the patient journey. It aimed to ensure that all communities had appropriate prevention strategies for liver disease that include improved partnership working to address major lifestyle drivers and programmes to identify those most at risk. Further work has been undertaken by the Lancet Commission for Liver Disease (Williams et al, 2014) which has made recommendations to address the premature mortality and health inequalities that exist for people with or at risk of liver disease.
The NHS is judged on its performance in reducing deaths from liver disease through the NHS Outcomes Framework. Everyone in the NHS – and many outside it – have their part to play in making this happen. Through the NHS Outcomes Framework, the NHS Commissioning Board is held to account by the Secretary of State for making improvements to quality and outcomes in the public’s health. The NHS Commissioning Board hold Clinical Commissioning Groups to account on the services they commission for their local populations. The services, treatment and care provided to those with liver disease is a vital part of this.
Public Health England is also judged on the contribution it makes to reducing the number of people developing liver disease and reducing deaths from liver disease, through the Public Health Outcomes Framework. All health care professionals working within the NHS – both in primary and secondary care – can help to contribute to improvements in the public’s health, not just by treating those who already have liver disease, but also by helping to prevent it developing in those at risk.
In recognising the significant burden of liver disease, it is essential to ensure that a workforce is competent and confident to deliver high quality services to patients with a diagnosis of, or at risk, of developing liver disease is coherently developed. Williams et al (2014) has made a number of recommendations on a robust and coherent workforce and appropriate hospital services to care for people with liver disease.
A national census of nurses specialising in the care of people with liver disease (see appendix 1) was undertaken in late 2012, this was recognised to be a snapshot. As a growing specialty it is recognised that the demographics of this workforce will be constantly changing and adapting to the change in liver disease provision. However, this piece of work helped to identify areas that liver nurses work in and the diversity of nurses working in liver services.
Nurses who work in the arena of liver disease are at present a disparate group and encompass expertise in a wide range of disease processes, from the more common areas of viral hepatitis, alcohol-related liver disease and non-alcoholic fatty liver disease (NAFLD) to those who cover general hepatology including autoimmune hepatitis, haemochromatosis and hepatocellular carcinoma. The Lancet Commission (Williams et al, 2014) recognises the important contribution that liver nurses play but has identified that there is a need for further access to liver specific education. There is also a small group of specialised nurses that care for patients pre- and post-liver transplant.
Currently there is no umbrella organisation specifically for liver nurses, and this mirrors the medical profession who also do not have a single organisation. Some liver nurses are affiliated with either the British Association for the Study of the Liver Nurse Forum (BASLNF) or the British Liver Nurses Forum (BLNF). The RCN Gastrointestinal Nurses Forum also has a role representing nurses who care for people with liver disease.
The competence framework was commissioned around key areas highlighted by this group to complement the RCN core career and competence framework (RCN, 2009). The Department of Health commissioned Dr Kim Manley, formally of the Royal College of Nursing, who has a wide interest in the development of person-centred care to develop Caring for people with liver disease: a competence framework for nursing. Once the key areas were identified, Dr Manley developed the framework which was then reviewed by the Specialist Nurses External Reference Group to develop the liver context. A UK-wide consultation with a wide range of stakeholder groups and experts enabled completion of this competence framework. This revised edition of this framework was undertaken by the RCN Gastrointestinal Nurses forum who commissioned a survey to gather nurses’ views and experience of using the framework to guide amendments and changes in this revised edition.
Context for developing the framework
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What is a competence framework?
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For the purpose of this document competence can be defined as:
“The state of having the knowledge, judgement, skills, energy, experience and motivation required to respond adequately to the demands of one’s professional responsibilities (Roach, 1992)”.
Competences are the essential building blocks that shape nursing work in all clinical and practice settings. As practitioners acquire skills, knowledge, understanding and confidence in their field of liver practice they are able to demonstrate how they meet increasingly challenging levels of competence.
This document provides a resource for all grades of staff to enable learning and development around promoting healthy livers and lifestyles.
The framework aims to identify the competences required to meet the specific needs of people with liver disease, as well as provide support to registered nurses, health care assistants and assistant practitioners wishing to grow their expertise and progress their career in caring for this client group.
The competence framework is presented across bands 1-8 of the Skills for Health career framework and therefore provides both a competence and career framework for those wishing to specialise in the care of people with liver disease.
The competences are written from an outcome approach to competence, making clear the actions and activities expected in the workplace. This is in common with the NHS Knowledge and Skills Framework (KSF) against which the specific competences are also mapped
The Skills for Health career framework uses similar language and terminology to the NHS job evaluation (JE) scheme but they have different levels and meanings:
“The two systems are not interchangeable and the career framework should only be used to create career pathways for staff working in the NHS. The JE Scheme should only be used to measure the demands of jobs in order to give them a banding within the NHS pay scale.”
(NHS Employers, 2011)
Appendix 6 on page 71 demonstrates NHS England’s six Cs and how they fit into Caring for people with liver disease: a competence framework for nursing.
The framework aims to integrate high quality liver care for all individuals and their family/ carers. This care will be person-centred and encompassing the core values of the six Cs.
The RCN Principles of Nursing Practice can be aligned to the six Cs as a UK framework for delivering safe and effective nursing care.
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The aim of this framework and its relationship to the RCN career and competence and other relevant frameworks
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This publication aims to complement and not duplicate the RCN’s Integrated core career and competence framework for registered nurses publication which outlines what is expected of registered practitioners of nursing across all client groups and specialities (RCN, 2009). The RCN’s Integrated core career and competence framework for registered nurses identifies the competences required for achieving person-centred, safe and effective care by registered nurses, drawing on those KSF dimensions of particular relevance to nursing rather than other members of the health care team.
Through not duplicating general competences common to all client groups and settings, Caring for people with liver disease: a competence framework for nursing enables the unique aspects of the specialty to be accentuated for learning and development purposes as well as for making clear expectations of each level of the career pathway.
For this reason, in depth competences around using evidence-based practice, research, quality improvement, learning and development and leadership are not included as this would be duplication.
Other relevant frameworks include:
l RCN Principles of Nursing Practice (2010) which identify what the public can expect of nursing regardless of who in the nursing team is the most immediate provider of care. They have been developed with patient and user groups across the UK and identify eight overarching principles
l NICE guidelines, interventional procedures and appraisals in relation to people with liver disease (see www.nice.co.uk website for a wide range of guidance on liver conditions). Evidence-based guidelines and standards continue to be developed and refined and provide the most up-to-date and appraised evidence base to inform specific interventions. Relevant guidelines are identified in the context of the competence framework.
The competence framework, although making reference to highly specialised interventions such as liver transplantation and end of life care pathways, does not identify detailed performance indicators in relation to these areas. Instead the focus is on making clear what is expected in terms of professional standards for the vast majority of people experiencing liver disease.
The competence levels in this document were originally aligned to the career trajectory of Benner’s From novice to expert (1982). Health care assistants (HCAs) are at the first level of the career trajectory which equates to levels 1, 2, 3 and 4 of the career framework for health (Skills for Health, 2005).
Levels 1-4 can also be used by student nurses to help improve their knowledge, understanding and skill acquisition in caring for people with, or at risk, of liver disease.
Registered practitioner/competent nurse (level 5 of the career framework for health)This level defines the entry point for registered nurses to the specialty of liver disease or registered nurses working in other environments that encounter people with, or at risk of, liver disease. At this level, the registered practitioner caring for the patient with liver disease or individual at risk of liver disease will be developing expertise to undertake assessment and management of patients. They will demonstrate working knowledge of the key specialist treatments and interventions appropriate to this group. Generally, these nurses work on a regular, but not necessarily full-time, basis with people who have or are at risk of liver disease.
With experience, the nurse’s interpersonal skills develop so that they can initiate discussions on the impact of liver disease on personal relationships and daily living activities. They will learn when and how to refer patients directly to other health care professionals, such as dietitians, drug and alcohol services and social workers.
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Levels 1-4 Non-registered practitioner: this level could relate to health care assistants or student nurses working in a drug or alcohol environment, on a gastroenterology ward or liver unit, with liver outpatients or related to hepatobiliary conditions.
Level 5 Registered practitioner: this level could encompass any registered nurse who cares for a patient with liver disease or risk factors for liver disease in primary or secondary care and could relate to any clinical background or setting.
Level 6 Senior practitioner: this level could encompass nurses within drug and alcohol services, viral hepatitis, nurses with experience of caring for liver patients over a number of years, junior ward sister level or newly appointed specialist nurse.
Level 7 Advanced level practitioner: this level could encompass the experienced clinical nurse specialist, ward manager, practice development nurse and liver recipient transplant co-ordinator.
Level 8 Consultant practitioner: this level could encompass a nurse who may have developed or is leading a service, for example, nurse consultant in viral hepatitis or lead nurse for hepatology.
Experienced/proficient nurse (level 6 of the career framework for health)At this level the registered practitioner in the liver service will have developed expertise to use detailed theoretical and practical knowledge in liver management. Some knowledge will involve a critical understanding of theories, principles and pathophysiology. The practitioner will be able to demonstrate mastery of methods and tools in complex care, and demonstrate innovation in terms of methods used while having the ability to devise and sustain arguments to solve problems.
Senior registered practitioner (level 7 of the career framework for health)Often regarded as specialist, or advanced practice or for those in a managerial role, this is the extension and expansion of the registered practitioner role. Liver nurses practising at this level of clinical practice work according to local protocols to co-ordinate the comprehensive care of patients, who could equally be cared for by doctors. These nurses can work autonomously without asking the advice of a doctor. Any nurse working at this level is required to work within the boundaries of their own knowledge and competence, and refer to or seek advice/opinions from medical colleagues for cases beyond their clinical expertise. Selected treatments will expand some nursing roles such as supporting patients through treatment for hepatitis C, and continuity of care through independent prescribing.
The expected workload of senior registered practitioners differs between settings, depending on local need, resources and infrastructure. This may include specialist nurses roles and also nurses managing patients in secondary care or primary care settings.
Consultant practitioner (level 8 of the career framework for health)Previously defined as higher level of practice, this level may reflect the role of the nurse consultant but not always. Nurses working at this level have been employed to satisfy the individual needs of the service in which they are located. All posts need to conform to a common core of expectations outlined by the NHS Executive, which are:
l expert practice
l professional leadership and consultancy
l education, training and development
l practice and service development, research and evaluation.
Taken from Skills for Health (2005) Career Framework for Health.
For each of the competences, the performance indicators, knowledge, understanding and practical know-how are identified for levels 1-8 of the clinical career framework. Each level of the identified performance, knowledge, understanding, practical know-how and attitudes and behaviours builds on the previous level of expectations. Further discussion on these indicators can be found in section five of this document and section six gives examples of what evidence to collect. The framework recognises that there is a need for a range of competences in every team as well as a range of practitioners operating at different levels.
The clinical career framework levels used within this competence framework do not reflect the Agenda for Change banding levels.
Therefore a staff nurse at band 5 (Agenda for Change) who has worked within the area of liver disease for a number of years may have varying levels of competence either at level 5, 6 or 7 within different competences.
For example, for competence 7.2: nutrition and fluid management/hydration in patients with liver disease, the staff nurse may achieve level 6 as they have worked with liver patients for a number of years and can fulfil the performance and knowledge and understanding criteria.
Within this document, levels of competence are as follows:Table 2: The levels of competence and examples of roles
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Whereas a practice nurse may be a band 7 (Agenda for Change), but may achieve a level 5 in competence 5 (develops and evaluates a self-management plan with the patient who has predisposing factors to liver disease) as the practice nurse may have a broad understanding of chronic diseases but not in-depth liver disease knowledge.
The competence framework is designed to allow nurses from many clinical backgrounds to tailor their development of competence in working with patients with varying degrees of liver health. This can be achieved by nurses (in conjunction with their manager) being able to choose some or all of the relevant competences to demonstrate development of key skills, knowledge and understanding for this patient group. Successful demonstration of competence can be used as evidence of meeting professional development needs.
Practitioners will always need to be aware of local guidelines and protocols as well as working within the scope of professional practice when initiating treatment and interventions. Liver disease management is a dynamic and rapidly changing professional arena, therefore all health care professionals need to remain up-to-date and utilise contemporary evidence-based practice.
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Using Caring for people with liver disease: a competence framework for nursing
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The framework is intended to support the learning and development needs of staff and health care organisations as well as enable career progression and role clarity, making clear the professional standards expected for patients and service users.
Caring for people with liver disease: a competence framework for nursing includes a number of examples of how to use a competence in practice. The examples relate to different liver nursing roles such as senior staff nurse/junior sister, practice nurse, specialist nurse – see Appendix 2 (p. 63) onwards.
These are intended only as a guide in order to achieve an individual competence. There will be many other examples of liver nursing care that could be used as evidence to achieve the competence.
It would be envisaged that some of the competences could be shared across a team of nurses working at the desired level; this may be used to support quality standards for care. The competence framework may be individually tailored to a specific liver nursing role. This may assist in the development of innovative liver nursing roles in the future.
It is not envisaged that all nurses working in primary and secondary care will need to meet all of the competences. Caring for people with liver disease: a competence framework for nursing has been developed to allow nurses to select relevant competences to their role and scope of practise. However as nurses progress through the career trajectory, there should be emphasis on attainment of all the levels and all relevant competences that complement the higher role and scope of practice.
Organisations should be encouraged to use the framework to help identify any competence gaps in service provision. Individuals and teams should use it as a developmental framework both collectively and individually. Higher Education Institutes may draw on the framework for curriculum development. Commissioners of both services and education may also find this framework a useful tool.
With all competence documents there is specific terminology used. In relation to Caring for people with liver disease: a competence framework for nursing the following headings in table 3 are used.
Competence Identifying the specific aspect of care.
Level The levels used relate to Skills for Health career framework. Nurses using this document may be at different levels for different competences.
KSF Demonstrates the skills cross-referenced to dimensions with the knowledge and skills framework.
Performance criteria
Describes the skills required for each competence. In order to achieve a higher level, the individual will have had to demonstrate achievement at the previous level for performance, knowledge and understanding, knows how to and attitudes and behaviours.
Knowledge and
understanding
Describes specific areas that are pertinent to the competence.
Knows how to Describes the tacit knowledge required in each competence.
Attitudes and behaviours
Each level has a number of required attitudes and behaviours to support the individual’s competence development.
Contextual factors
Each competence contains a list of generic and specific resources.
It is important to recognise that each level is integral to the next and as such individuals need to demonstrate progression by achieving each level before moving on to the next.
Each competence is designed as a building block to develop performance, knowledge, understanding, attitudes and behaviours from a fundamental level through to specialist and/or advanced practice. As such each of these areas link together in order to build the individual’s competence and contribute to their professional development.
In relation to individual competence, the performance indicators help to identify the actions that would establish whether the competence is met but are also intended to be used flexibly in reviewing competence as they may be influenced by the context. The knowledge and understanding, as well as, the practical know-how required to achieve the performance indicators are identified in relation to each competence.
Table 3: Definitions of the terminology used in the framework
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How to implement the framework into practice
The framework is a flexible document that can be utilised in all areas working with people with, or at risk of, of liver disease. Sections of the framework can be selected to complete rather than undertaking the whole document. You and your team should identify the relevant competences to your area and then identify the levels of competence that you and your staff wish to achieve. One tip would be to start small and build over time.
The framework could be embedded into the ward or team philosophy and can be used to identify learning needs for individuals or the team. It can also become part of the personal development plan/appraisal process where areas of competence can be identified to complement learning and development. The framework can be used to identify gaps in service provision.
In light of the new revalidation process for nurses and midwives to practise (Nursing and Midwifery Council, 2015) this framework will help you to achieve some of the requirements identified. For example, demonstrating up-to-date practice and professional development and reflecting on professional standards of practice and behaviors.
This framework can be used by those working within a clinical team including on wards, outpatients, ITU, endoscopy, A&E or as an individual. A suggested format for implementation is set out below.
Assess
• Identify key members of the team across all bands.
• Review competence framework and identify appropriate levels of competence for each band (see Table 2, page 10).
• Choose one competence to pilot over a number of different levels.
• Publicise what you are doing and how this will help your area of clinical practice.
• Consider how to embed into the ward/team philosophy.
Plan
• Identify training needs that arise from the chosen competence.
• Identify an appropriate timeframe.
• Preparation of materials for ward/individuals that will meet NMC requirements for portfolio, for example download the document and reproduce the chosen competence.
• Consider what evidence is needed and how will it be assessed.
Implement
• Working with identified mentor/practice educator/supervisor/ward sister etc.
• Collect, demonstrate and/or show evidence for each competence identified.
• Ensure that evidence which shows the competence has been met is signed and dated and kept by the ward/individual
Evaluate
• Meeting with mentor/practice educator/supervisor/ward sister to review progress and evidence collected.
• Identify any gaps in learning.
• Competence can be used to complement PDP/appraisal processes.
• Reflect on the process. Consider sustainability and use of a yearly audit to review progress.
Examples in Practice
Example 1
As part of the trust alcohol team you work in A&E delivering brief interventions. As part of raising awareness about alcohol and the use of brief advice you want to roll out the Alcohol Use Disorders Identification Test (AUDIT) tool in your trust. You target A&E and your assessment unit to start and start training sessions:
Teaching includes what the AUDIT score means:
risk category AUDIT score
Abstainer 0
Lower risk 1-7
Increasing risk 8-15
Higher risk 16-19
Possible dependence
20-40
Adapted from Barbor et al, 2001
Assessment of competence would entail using a combination of methods, for example, self-assessment, observation of practice, structured reflection, peer review, document audit and clinical supervision. These methods are practice development tools that assist individuals and teams to achieve continuous development. However, developing a portfolio of multiple sources of evidence against competence standards may also be used to support both academic and professional accreditation.
14
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Teaching reveals an increase in AUDIT scoring by 76 per cent and this is improves again at six months to 81 per cent. This results in more referrals to the alcohol team and a reduction in A&E referrals by GPs.
This would fit competence 2. (signposts and supports patients (families and carers) in their understanding of their condition through patient education and health promotion) the evidence produced would be able to be used to support levels five and six.
Example 2
You manage a nursing team on a busy GI ward with a large liver population and you have a large number of new staff who are new to caring for patients with liver disease. This is a good opportunity to implement the competence framework. You put together a working group of ward staff from different bands to look at how to implement the framework.
As a team you identify what is expected from a:
• health care assistant
• band five staff nurse
• band six
• band seven ward manager
Once the competences required are identified your team can start delivering teaching on the competences.
You may not need all of them and in this example you could use competence 3 (undertakes a comprehensive clinical assessment including risk profiling and follows up with appropriate action, including referral to specialists, for relevant acute and chronic health care conditions) as well as competence 7 (provides specific diagnostic / treatment options safely). You will have identified at what level you will expect each member of the team to achieve and demonstrate in your planning. Both competences include specific nursing care that would include managing:
• a variceal bleed
• a jaundiced patient
• a patient who is malnourished
• a patient with ascites
This identifies the learning needs (identifying and managing the complications of chronic liver disease). Once education has been delivered then the nurse can start to develop the skills, knowledge and understanding needed to demonstrate competence and attain the appropriate evidence.
Evidence sheets can be found in Appendix 3 (p. 67)
15
R O Y A L C O L L E G E O F N U R S I N G
How to produce evidence to demonstrate competence
6
You are responsible for developing your own portfolio of evidence for each competence in order to demonstrate that you have achieved it at the identified/desirable level.
How to produce evidence to demonstrate competenceForms of evidence that you can use include case histories, self-appraisal via a reflective diary, 360-degree feedback, verification of practice and structured observation of practice. So, when you gather evidence it is important to consider the following:
l ensure that you understand what the competence statement is asking of you
l review any existing work that could be used
l identify whether the existing evidence is appropriate
l consider what else you may need to do in developing evidence; for example, are you familiar with a reflective model?
Will someone be giving you feedback on your practice? Do you have further development needs and have you considered how you might address them? Think about using evidence that covers several competences; for example, one case study may demonstrate that you have used a variety of knowledge and skills in treating a patient and in this instance you should be able to triangulate evidence against several competences.
For example, if you attend a study day in preparation for carrying out a particular intervention but you have not practised the skill in a clinical setting, your certificate of attendance is not evidence of competence and you will have to consider making arrangements for supervised practice. However, if you have undergone training and have evidence of supervised practice and use new knowledge and skills on a regular basis the evidence should be enough, consider what else you may need to do in developing evidence, such as feedback on your practice; if you have further development needs, are they recorded in a personal development plan?
How do I get started?You will need to look at the competence statements, and decide where you fit on the career trajectory in terms of development and what you already do. Table 2 may help you to clarify where you fit in the career trajectory.
What is evidence?There is a variety of material that you can collect to capture evidence of competence. This may include:
l evidence of supervised practice such as signed observation of undertaking a procedure
l projects
l practice developments/changes in practice
l critical incidents
l assessments and appraisals
l publications and presentations
l audits
l teaching packages
l posters
l certificates of attendance with reflections on learning
l evidence of group work
l policy and protocol development
l evidence of membership of advisory groups
l research and evidence-based reviews
l witness statements, when focused and well structured.
The strength of the competence framework lends itself to the assessment of nursing practice at a local level in partnership with multidisciplinary colleagues. However, assessment may also take place through higher education university courses, and formal examination. Practitioners who carry out the assessments should have adequate expertise and training in the assessment and mentoring process, together with a higher level knowledge of aesthetic practice.
See Appendix 2 (p. 63) for examples of how to use evidence to support attainment of the competence.
16
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Overview of the competence framework
7
Caring for people with liver disease: a competence framework for nursing is structured around nine competences. These are not placed in any hierarchal order as they are interdependent. However, they do start with a person-centred approach where there is a high regard for the person with liver disease as someone with expertise about themselves; then move through the assessment, intervention and evaluation processes; concluding with a key nursing function – care pathway co-ordination and management.
The nine liver care competences are:
1. Provides empathy and understanding and works with the patient (and their family/carers) particularly those with chronic liver disease as experts in their own condition.
2. Signposts and supports patients (and family/carers) in their understanding of their condition through patient education and health promotion.
3. Undertakes a comprehensive clinical assessment including risk profiling and follows up with appropriate action, including referral to specialists, for relevant acute and chronic health care conditions.
4. Assesses, in collaboration with the patient (young people, adults, family/carers), their health care needs, taking into account the impact of their age, vulnerability, their lifestyle, cultural and ethnic background.
5. Develops and evaluates a self-management plan with the patient who has predisposing factors to liver disease.
6. Works alongside and with the patient (and families/carers) to address the psychological and social impact of their condition.
7. Provides specific diagnostic/treatment options safely:
7.1. undertaking phlebotomy and cannulation in the patient with difficult access associated with their liver disease
7.2. nutrition and fluid management/hydration in patients with liver disease
7.3. pharmacological treatment and side-effects
7.4. non-invasive diagnostics and treatment options
7.5. invasive diagnostics and treatment options.
8. Uses early warning tools/approaches to identify the patient’s changing and deteriorating condition, and takes appropriate action.
9. Actively improves and promotes liver services across the appropriate care pathway.
17
R O Y A L C O L L E G E O F N U R S I N G
Detailed definition of Caring for people with liver disease: a competence framework for nursing
8
Competence 1
Provides empathy and understanding and works with the patient (and their family/carers) particularly those with chronic liver disease as experts in their own condition.
This competence will assist the liver nurse in developing understanding, knowledge and person-centred care for the individual with liver disease. To acknowledge the role of the liver patient as an expert in their own condition and to foster partnership working.
Competence 2
Signposts and supports patients (and families/carers) in their understanding of their condition through patient education and health promotion.
This competence embraces the wide spectrum of causes of liver disease and works with patients and their carers to support and develop understanding of risk factors or the individual’s existing liver disease.
Competence 3
Undertakes a comprehensive clinical assessment including risk profiling and follows up with appropriate action, including referral to specialists, for relevant acute and chronic health care conditions.
This competence helps to develop the knowledge and skills required to identify changes in liver health status and develop understanding of liver pathophysiology linked to the individual’s liver disease process.
Competence 4
Assesses, in collaboration with the patient (young people, adults, family/carers), their health care needs, taking into account the impact of their age, vulnerability, their lifestyle, cultural and ethnic background.
This competence recognises the diversity of individuals with liver disease and considers the impact of a range of factors including cultural, ethnic background and life choices on their liver condition.
Competence 5
Develops and evaluates a self-management plan with the patient who has predisposing factors to liver disease.
This competence encourages close partnership working with the individual with predisposing factors to liver disease, to empower them to make choices in managing their changing liver health.
Competence 6
Works alongside and with the patient (and families/carers) to address the psychological and social impact of their condition.
This competence addresses the wide spectrum of psychological and social impacts that individuals and their families/carers may have to deal with in relation to their liver disease.
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R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Competence 7
Provides specific diagnostic/treatment options safely: this competence embraces a range of therapeutic interventions that some patients with liver disease may experience during their care.
7.1 Undertaking phlebotomy and cannulation in the patient with difficult access associated with their liver disease. This competence considers a range of strategies to enable successful phlebotomy or cannulation in the difficult to access individual with liver disease.
7.2 Nutrition and fluid management/hydration in patients with liver disease. This competence will assist a nurse to demonstrate an in-depth knowledge and understanding of the role of nutrition and its importance in liver disease.
7.3 Pharmacological treatment and side-effects. This competence addresses the complexity of medication in individuals with liver disease and it recognises the contribution of the nurse as a non-medical prescriber.
7.4 Non-invasive diagnostics and treatment options. This competence introduces a broad range of non invasive liver specific investigations and the role of the liver nurse to support the patient at this time.
7.5 Invasive diagnostics and treatment options. This competence introduces a broad range of invasive diagnostics and treatment options and the role of the nurse to support the patient through the diagnostic journey.
Competence 8
Uses early warning tools/approaches to identify the patient’s changing and deteriorating condition, and takes appropriate action.
This competence alerts the nurse to early warning tools used for general deterioration and raises awareness of specific issues in relation to the deteriorating liver patient.
Competence 9
Actively improves and promotes liver services across the appropriate care pathway.
This competence is designed to support development and/or improvement of liver services in both primary and/or secondary care.
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R O Y A L C O L L E G E O F N U R S I N GR O Y A L C O L L E G E O F N U R S I N G
Quality assurance of the framework
9
As with all information and evidence, more becomes available daily. It is therefore vital that this framework is periodically reviewed and updated – a criterion of all good accreditation processes. An annual risk assessment will enable any risks to be identified and a cycle of document review will ensure it continues to be relevant to nurses caring for people with liver disease in a changing context. This will be undertaken by the RCN Gastrointestinal Nurses Forum.
Caring for people with liver disease: a competence framework for nursing
10
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R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
Prov
ides
em
path
y an
d un
ders
tand
ing
and
wor
ks w
ith
the
pati
ent (
and
thei
r fam
ily/c
arer
s) a
nd p
arti
cula
rly
thos
e w
ith
chro
nic
liver
dis
ease
as
expe
rts
in th
eir o
wn
cond
itio
n 1 1-
4Pr
ovid
es
empa
thy
and
unde
rsta
ndin
g an
d w
orks
w
ith th
e pa
tient
(and
th
eir f
amily
/ ca
rers
) and
pa
rtic
ular
ly
thos
e w
ith
chro
nic
liver
di
seas
e as
ex
pert
s in
thei
r ow
n co
nditi
on.
Core
1
Core
6
HW
B1
HW
B3
HW
B4
a. A
sks
ques
tion
s an
d ac
tive
ly
liste
ns.
b. E
stab
lishe
s th
e pa
tien
t’s
pref
eren
ces
and
boun
dari
es fo
r sh
arin
g pe
rson
al h
ealt
h in
form
atio
n,
for e
xam
ple
prot
ecti
ng th
eir p
riva
cy
and
confi
dent
ialit
y.
c. P
erso
nalis
es c
are.
d. R
espe
cts
and
ackn
owle
dges
a
pati
ent o
r fam
ily m
embe
r/ca
rer a
s an
exp
ert i
n th
eir o
wn
cond
itio
n,
part
icul
arly
if th
ey h
ave
chro
nic
liv
er d
isea
se.
e. E
mpa
this
es w
ith
and
is re
spon
sive
to
the
need
s of
pat
ient
s w
ith
acut
e an
d ch
roni
c liv
er d
isea
se.
f. R
ecog
nise
s th
at p
atie
nts
wit
h ch
roni
c liv
er d
isea
se m
ay
have
men
tal h
ealt
h is
sues
and
ch
ange
s in
moo
d du
e to
hep
atic
en
ceph
alop
athy
or f
or e
xam
ple
Wer
nick
e’s/
Kor
sako
ff’s
psy
chos
is/
alco
hol w
ithd
raw
al.
• t
he P
rinc
iple
s of
nur
sing
pra
ctic
e
• t
he D
epar
tmen
t of H
ealt
h (D
H) g
uida
nce
on th
e Ex
pert
Pat
ient
• t
he c
halle
nges
pos
ed w
hen
cari
ng fo
r pe
ople
wit
h ch
roni
c liv
er d
isea
se a
nd
the
impa
ct o
n th
e fa
mily
/car
er
• t
he im
pact
of h
epat
ic e
ncep
halo
path
y on
men
tal h
ealt
h, m
ood,
per
sona
lity,
m
emor
y an
d un
ders
tand
ing
of th
eir
dise
ase.
• A
war
e of
role
lim
itat
ions
and
w
hen
to o
btai
n he
lp.
• P
erso
n ce
ntre
d an
d co
mpa
ssio
nate
.
• L
iste
ns.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• C
onfid
enti
al.
• P
ride
in w
ork.
• R
espe
ctfu
l.
Gen
eric
• N
MC
docu
men
ts a
nd g
uida
nce.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
and
gui
danc
e.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Liv
er N
urse
s Fo
rum
(BA
SLN
F).
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f life
car
e.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2)
Dea
ths
from
Liv
er D
isea
se. I
mpl
icat
ions
for e
nd o
f lif
e ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
NH
S.
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as, C
QU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a re
view
of p
atie
nts
who
die
d w
ith
alco
hol-r
elat
ed li
ver d
isea
se,
Lond
on, N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fir
st
24 h
ours
• N
HS
Engl
and
(201
3) T
he 6
Cs
5Pr
ovid
es
empa
thy
and
unde
rsta
ndin
g an
d w
orks
w
ith th
e pa
tient
(and
th
eir f
amily
/ ca
rers
) and
pa
rtic
ular
ly
thos
e w
ith
chro
nic
liver
di
seas
e as
ex
pert
s in
thei
r ow
n co
nditi
on.
Core
1
Core
6
HW
B1
HW
B3
HW
B4
HW
B5
HW
B6
a. D
iscu
sses
car
e/tr
eatm
ent o
ptio
ns
and
offe
rs c
hoic
es to
reac
h jo
int a
nd
info
rmed
dec
isio
n m
akin
g.
b. C
o-de
velo
ps, i
mpl
emen
ts a
nd
eval
uate
s pe
rson
al c
are
plan
s,
trea
ting
the
pati
ent a
s an
indi
vidu
al.
c. E
ncou
rage
s fe
edba
ck fr
om th
e pa
tien
t, th
eir f
amily
and
car
ers.
d. W
orks
col
labo
rati
vely
wit
h ot
her
mem
bers
of t
he in
terd
isci
plin
ary
team
to p
rovi
de a
sea
mle
ss s
ervi
ce.
e. A
cts
to e
nsur
e th
at th
e vo
ice
of
pati
ents
and
car
ers,
par
ticu
larl
y th
ose
who
are
vul
nera
ble
due
to
thei
r con
diti
on, t
heir
nee
ds a
nd
view
s ar
e he
ard
and
acte
d on
.
• th
e N
ursi
ng a
nd M
idw
ifery
Cou
ncil
(NM
C)
Nur
sing
Cod
e of
Con
duct
• lo
cal p
roto
cols
, sta
ndar
ds a
nd
guid
elin
es fo
r pat
ient
car
e in
rela
tion
to
acu
te a
nd c
hron
ic li
ver d
isea
se,
incl
udin
g tr
eatm
ent
• th
e di
ffer
ence
s be
twee
n ac
ute
and
chro
nic
liver
dis
ease
• p
atie
nts’
ow
n un
ders
tand
ing
of th
e im
pact
of c
o-m
orbi
diti
es o
n th
emse
lves
e.
g. a
lcoh
ol a
nd o
besi
ty to
geth
er, v
iral
he
pati
tis
and
alco
hol u
se; a
lcoh
ol
and
depr
essi
on
• p
rinci
ples
of t
he e
xper
t pat
ient
phi
loso
phy
• ro
le a
nd c
ontr
ibut
ions
of e
ach
mem
ber
of th
e in
terd
isci
plin
ary
team
.
Kno
ws
how
to:
• b
e re
spon
sive
to p
atie
nt fe
edba
ck a
nd
addr
ess
conc
erns
app
ropr
iate
ly.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• S
uppo
rtiv
e.
• E
ncou
ragi
ng.
• Em
pow
erin
g.
• P
rovi
des
choi
ces.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• F
lexi
ble.
• N
on-ju
dgm
enta
l.
• P
assi
onat
e ab
out p
atie
nt c
are.
21
R O Y A L C O L L E G E O F N U R S I N G
1-4
Prov
ides
em
path
y an
d un
ders
tand
ing
and
wor
ks
with
the
patie
nt (a
nd
thei
r fam
ily/
care
rs) a
nd
part
icul
arly
th
ose
with
ch
roni
c liv
er
dise
ase
as
expe
rts
in th
eir
own
cond
ition
.
Core
1
Core
6
HW
B1
HW
B3
HW
B4
a. A
sks
ques
tion
s an
d ac
tive
ly
liste
ns.
b. E
stab
lishe
s th
e pa
tien
t’s
pref
eren
ces
and
boun
dari
es fo
r sh
arin
g pe
rson
al h
ealt
h in
form
atio
n,
for e
xam
ple
prot
ecti
ng th
eir p
riva
cy
and
confi
dent
ialit
y.
c. P
erso
nalis
es c
are.
d. R
espe
cts
and
ackn
owle
dges
a
pati
ent o
r fam
ily m
embe
r/ca
rer a
s an
exp
ert i
n th
eir o
wn
cond
itio
n,
part
icul
arly
if th
ey h
ave
chro
nic
liv
er d
isea
se.
e. E
mpa
this
es w
ith
and
is re
spon
sive
to
the
need
s of
pat
ient
s w
ith
acut
e an
d ch
roni
c liv
er d
isea
se.
f. R
ecog
nise
s th
at p
atie
nts
wit
h ch
roni
c liv
er d
isea
se m
ay
have
men
tal h
ealt
h is
sues
and
ch
ange
s in
moo
d du
e to
hep
atic
en
ceph
alop
athy
or f
or e
xam
ple
Wer
nick
e’s/
Kor
sako
ff’s
psy
chos
is/
alco
hol w
ithd
raw
al.
• t
he P
rinc
iple
s of
nur
sing
pra
ctic
e
• t
he D
epar
tmen
t of H
ealt
h (D
H) g
uida
nce
on th
e Ex
pert
Pat
ient
• t
he c
halle
nges
pos
ed w
hen
cari
ng fo
r pe
ople
wit
h ch
roni
c liv
er d
isea
se a
nd
the
impa
ct o
n th
e fa
mily
/car
er
• t
he im
pact
of h
epat
ic e
ncep
halo
path
y on
men
tal h
ealt
h, m
ood,
per
sona
lity,
m
emor
y an
d un
ders
tand
ing
of th
eir
dise
ase.
• A
war
e of
role
lim
itat
ions
and
w
hen
to o
btai
n he
lp.
• P
erso
n ce
ntre
d an
d co
mpa
ssio
nate
.
• L
iste
ns.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• C
onfid
enti
al.
• P
ride
in w
ork.
• R
espe
ctfu
l.
Gen
eric
• N
MC
docu
men
ts a
nd g
uida
nce.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
and
gui
danc
e.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Liv
er N
urse
s Fo
rum
(BA
SLN
F).
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f life
car
e.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2)
Dea
ths
from
Liv
er D
isea
se. I
mpl
icat
ions
for e
nd o
f lif
e ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
NH
S.
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as, C
QU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a re
view
of p
atie
nts
who
die
d w
ith
alco
hol-r
elat
ed li
ver d
isea
se,
Lond
on, N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fir
st
24 h
ours
• N
HS
Engl
and
(201
3) T
he 6
Cs
5Pr
ovid
es
empa
thy
and
unde
rsta
ndin
g an
d w
orks
w
ith th
e pa
tient
(and
th
eir f
amily
/ ca
rers
) and
pa
rtic
ular
ly
thos
e w
ith
chro
nic
liver
di
seas
e as
ex
pert
s in
thei
r ow
n co
nditi
on.
Core
1
Core
6
HW
B1
HW
B3
HW
B4
HW
B5
HW
B6
a. D
iscu
sses
car
e/tr
eatm
ent o
ptio
ns
and
offe
rs c
hoic
es to
reac
h jo
int a
nd
info
rmed
dec
isio
n m
akin
g.
b. C
o-de
velo
ps, i
mpl
emen
ts a
nd
eval
uate
s pe
rson
al c
are
plan
s,
trea
ting
the
pati
ent a
s an
indi
vidu
al.
c. E
ncou
rage
s fe
edba
ck fr
om th
e pa
tien
t, th
eir f
amily
and
car
ers.
d. W
orks
col
labo
rati
vely
wit
h ot
her
mem
bers
of t
he in
terd
isci
plin
ary
team
to p
rovi
de a
sea
mle
ss s
ervi
ce.
e. A
cts
to e
nsur
e th
at th
e vo
ice
of
pati
ents
and
car
ers,
par
ticu
larl
y th
ose
who
are
vul
nera
ble
due
to
thei
r con
diti
on, t
heir
nee
ds a
nd
view
s ar
e he
ard
and
acte
d on
.
• th
e N
ursi
ng a
nd M
idw
ifery
Cou
ncil
(NM
C)
Nur
sing
Cod
e of
Con
duct
• lo
cal p
roto
cols
, sta
ndar
ds a
nd
guid
elin
es fo
r pat
ient
car
e in
rela
tion
to
acu
te a
nd c
hron
ic li
ver d
isea
se,
incl
udin
g tr
eatm
ent
• th
e di
ffer
ence
s be
twee
n ac
ute
and
chro
nic
liver
dis
ease
• p
atie
nts’
ow
n un
ders
tand
ing
of th
e im
pact
of c
o-m
orbi
diti
es o
n th
emse
lves
e.
g. a
lcoh
ol a
nd o
besi
ty to
geth
er, v
iral
he
pati
tis
and
alco
hol u
se; a
lcoh
ol
and
depr
essi
on
• p
rinci
ples
of t
he e
xper
t pat
ient
phi
loso
phy
• ro
le a
nd c
ontr
ibut
ions
of e
ach
mem
ber
of th
e in
terd
isci
plin
ary
team
.
Kno
ws
how
to:
• b
e re
spon
sive
to p
atie
nt fe
edba
ck a
nd
addr
ess
conc
erns
app
ropr
iate
ly.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• S
uppo
rtiv
e.
• E
ncou
ragi
ng.
• Em
pow
erin
g.
• P
rovi
des
choi
ces.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• F
lexi
ble.
• N
on-ju
dgm
enta
l.
• P
assi
onat
e ab
out p
atie
nt c
are.
Pro
vide
s em
path
y an
d un
ders
tand
ing
and
wor
ks w
ith
the
pati
ent (
and
thei
r fa
mil
y/ca
rers
) and
par
ticu
larl
y th
ose
wit
h ch
roni
c li
ver
dise
ase
as e
xper
ts in
thei
r ow
n co
ndit
ion
(con
tinu
ed)
1 Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
6Pr
ovid
es
empa
thy
and
unde
rsta
ndin
g an
d w
orks
w
ith th
e pa
tient
(and
th
eir f
amily
/ ca
rers
) and
pa
rtic
ular
ly
thos
e w
ith
chro
nic
liver
di
seas
e as
ex
pert
s in
thei
r ow
n co
nditi
on.
Core
1
Core
6
HW
B1
HW
B3
HW
B4
HW
B5
HW
B6
a. S
uppo
rts
team
mem
bers
to c
o-de
velo
p,
impl
emen
t and
eva
luat
e pe
rson
al c
are
plan
s.
b. A
cts
as a
role
mod
el to
ens
ure
that
team
m
embe
rs e
nabl
e th
e pa
tien
ts’ v
oice
to b
e he
ard
and
acte
d on
.
• ad
voca
cy n
eeds
for t
hose
who
are
less
abl
e to
ac
t for
them
selv
es d
ue to
thei
r liv
er c
ondi
tion
le
adin
g to
cha
lleng
ing
beha
viou
r, d
epre
ssio
n or
in
abili
ty to
art
icul
ate
thei
r nee
ds d
ue to
hep
atic
en
ceph
alop
athy
or o
ther
cog
niti
ve im
pair
men
t
• ac
ute
and
long
-ter
m c
ompl
icat
ions
rela
ted
to
liver
dis
ease
• st
rate
gies
pat
ient
s ca
n us
e fo
r man
agin
g co
-mor
bidi
ties
• lo
cal a
nd n
atio
nal s
trat
egy
for p
atie
nts
wit
h liv
er
dise
ase
and
how
to c
ontr
ibut
e
• Pa
tien
t Rep
orte
d O
utco
me
Mea
sure
s
(PR
OM
S) a
nd P
atie
nt R
epor
ted
Expe
rien
ce
Mea
sure
s (P
REM
S).
Kno
ws
how
to:
• bu
ild a
nd fo
ster
an
equi
tabl
e
nurs
e-pa
tien
t rel
atio
nshi
p
• w
ork
wit
h pa
tien
ts w
ith
chal
leng
ing
beha
viou
r an
d co
llabo
rati
vely
dev
elop
car
e pl
ans
• di
ffus
e an
ger a
nd c
halle
ngin
g be
havi
our
• de
velo
p ca
re p
lans
in c
onju
ncti
on w
ith
lo
cal g
uide
lines
.
• M
odel
s be
st p
ract
ice.
• A
ctiv
ely
prom
otes
bet
ter h
ealt
h fo
r pat
ient
s.
• Ch
alle
nges
oth
ers.
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
ch
arit
ies
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
G
roup
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy
of th
e Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy
of L
iver
Dis
ease
s (A
ASL
D)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral
and
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
Spec
ific
• D
H (2
001)
Exp
ert P
atie
nt.
• Pa
tien
t Saf
ety
Firs
t cam
paig
n.
• N
atio
nal o
ccup
atio
nal s
tand
ards
for
heal
th a
nd s
ocia
l car
e
HSC
31 a
nd H
SC35
.
7Pr
ovid
es
empa
thy
and
unde
rsta
ndin
g an
d w
orks
w
ith th
e pa
tient
(and
th
eir f
amily
/ ca
rers
) and
pa
rtic
ular
ly
thos
e w
ith
chro
nic
liver
di
seas
e as
ex
pert
s in
thei
r ow
n co
nditi
on.
Core
1
Core
6
HW
B1
HW
B3
HW
B4
HW
B5
HW
B6
a. If
app
ropr
iate
, inv
ites
the
pati
ent t
o sh
are
thei
r exp
erie
nce
as a
reso
urce
for t
each
ing
nurs
es a
nd o
ther
s.
b. D
evel
ops
pati
ent p
athw
ays
in c
olla
bora
tion
w
ith
pati
ents
and
use
r gro
ups.
c. O
vers
ees
and
mon
itor
s th
e qu
alit
y of
car
e.
• lo
cal u
ser n
etw
orks
and
teac
hing
opp
ortu
niti
es
• cl
inic
al in
dica
tors
• re
leva
nt N
HS
polic
ies.
• R
ole
mod
el.
• Pr
ovid
es s
tron
g le
ader
ship
.
• Ch
alle
nges
ass
umpt
ions
and
ta
ken
for g
rant
ed w
ays
of
wor
king
.
• Ch
ampi
ons
pers
on-c
entr
ed
appr
oach
es.
22
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Sig
npos
ts a
nd s
uppo
rts
pati
ents
(an
d fa
mil
ies/
care
rs) i
n th
eir
unde
rsta
ndin
g of
thei
r co
ndit
ion
thro
ugh
pati
ent e
duca
tion
and
he
alth
pro
mot
ion
2 Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
1-4
Sign
post
s pa
tient
s (a
nd
fam
ilies
/ ca
rers
) to
info
rmat
ion
abou
t the
ir
cond
ition
.
HW
B1
HW
B2
HW
B3
HW
B5
HW
B6
Core
1
Core
3
a. S
ignp
osts
pat
ient
s, fa
mili
es
and
care
rs to
furt
her i
nfor
mat
ion
and
orga
nisa
tion
s.
• ra
nge
of a
ppro
ved
info
rmat
ion
sour
ces
avai
labl
e in
loca
l are
a
• o
rgan
isat
ions
and
age
ncie
s pr
ovid
ing
supp
ort
• w
hen
to a
lert
regi
ster
ed n
urse
s ab
out
info
rmat
ion
requ
este
d an
d pr
ovid
ed to
en
able
follo
w th
roug
h.
Kno
ws
how
to:
• a
cces
s fu
rthe
r sup
plie
s
• re
cogn
ise
own
boun
dari
es, c
ompe
tenc
e an
d re
spon
sibi
lity.
• A
war
e of
role
lim
itat
ions
and
w
hen
to o
btai
n he
lp.
• P
erso
n ce
ntre
d an
d co
mpa
ssio
nate
.
• L
iste
ns.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• C
onfid
enti
al.
• P
ride
in w
ork.
• R
espe
ctfu
l.
Gen
eric
• N
MC
docu
men
ts a
nd g
uida
nce.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
and
gu
idan
ce.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Liv
er
Nur
ses
Foru
m (B
ASL
NF)
.
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f life
car
e.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fr
om L
iver
Dis
ease
. Im
plic
atio
ns fo
r en
d of
life
car
e.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le
peop
le in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as, C
QU
INS,
PR
OM
S et
c.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a re
view
of
pat
ient
s w
ho d
ied
wit
h al
coho
l-rel
ated
live
r di
seas
e, L
ondo
n, N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fi
rst 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
5Si
gnpo
sts
and
supp
orts
pa
tient
s (a
nd
fam
ilies
/ ca
rers
) in
thei
r un
ders
tand
ing
of th
eir
cond
ition
th
roug
h pa
tient
ed
ucat
ion
and
heal
th
prom
otio
n.
HW
B1
HW
B2
HW
B3
HW
B5
HW
B6
Core
1
Core
3
a. A
sses
ses
know
ledg
e an
d un
ders
tand
ing
of p
atie
nt’s
and
ca
rer’
s ow
n co
ndit
ion,
cau
ses,
ri
sk fa
ctor
s an
d co
nseq
uenc
es.
b. P
rovi
des
tailo
red
educ
atio
n to
pat
ient
and
fam
ily/c
arer
s on
co
ndit
ion,
trea
tmen
ts a
nd s
ide-
effe
cts.
c. P
rovi
des
info
rmat
ion
abou
t lif
esty
le fa
ctor
s, c
onse
quen
ces
and
serv
ices
ava
ilabl
e to
sup
port
lif
esty
le c
hang
es.
d. R
efer
to o
ther
app
ropr
iate
he
alth
car
e pr
ofes
sion
als
if
requ
ired
.
• ri
sk fa
ctor
s, s
uch
as, d
rugs
, obe
sity
, alc
ohol
• in
form
atio
n, s
uch
as, D
H D
rink
wis
e, e
duca
tion
an
d su
ppor
t res
ourc
es, s
ervi
ces
and
spec
ialis
t st
aff a
vaila
ble
• d
iffer
ent c
omm
unic
atio
n an
d en
gage
men
t ap
proa
ches
to p
rovi
ding
edu
cati
on
and
info
rmat
ion
• h
ealt
h pr
omot
ion,
sex
ual h
ealt
h st
rate
gies
and
e-
lear
ning
reso
urce
s av
aila
ble,
suc
h as
from
the
PHE
Alc
ohol
Lea
rnin
g R
esou
rces
• p
osit
ive
lifes
tyle
app
roac
hes
and
advi
ce
• h
ow to
giv
e br
ief a
dvic
e an
d in
terv
enti
ons
for
pati
ents
wit
h al
coho
l mis
use,
con
tinu
ed IV
DU
use
an
d w
eigh
t man
agem
ent.
Kno
ws
how
to:
• ta
ilor i
nfor
mat
ion
and
educ
atio
n to
the
pers
on
• o
btai
n ed
ucat
iona
l inf
orm
atio
n or
dir
ect p
atie
nts/
fam
ilies
/car
ers t
o av
aila
ble
reso
urce
s, se
rvic
es a
nd
staf
f, in
clud
ing
the
volu
ntar
y se
ctor
• w
ork
wit
hin
thei
r lev
el o
f com
pete
nce.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• E
mpa
thet
ic.
• E
ncou
ragi
ng.
• S
uppo
rtiv
e.
• W
orks
in p
artn
ersh
ip w
ith
othe
rs.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• F
lexi
ble.
• N
on-ju
dgm
enta
l.
• P
assi
onat
e ab
out p
atie
nt c
are.
23
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
1-4
Sign
post
s pa
tient
s (a
nd
fam
ilies
/ ca
rers
) to
info
rmat
ion
abou
t the
ir
cond
ition
.
HW
B1
HW
B2
HW
B3
HW
B5
HW
B6
Core
1
Core
3
a. S
ignp
osts
pat
ient
s, fa
mili
es
and
care
rs to
furt
her i
nfor
mat
ion
and
orga
nisa
tion
s.
• ra
nge
of a
ppro
ved
info
rmat
ion
sour
ces
avai
labl
e in
loca
l are
a
• o
rgan
isat
ions
and
age
ncie
s pr
ovid
ing
supp
ort
• w
hen
to a
lert
regi
ster
ed n
urse
s ab
out
info
rmat
ion
requ
este
d an
d pr
ovid
ed to
en
able
follo
w th
roug
h.
Kno
ws
how
to:
• a
cces
s fu
rthe
r sup
plie
s
• re
cogn
ise
own
boun
dari
es, c
ompe
tenc
e an
d re
spon
sibi
lity.
• A
war
e of
role
lim
itat
ions
and
w
hen
to o
btai
n he
lp.
• P
erso
n ce
ntre
d an
d co
mpa
ssio
nate
.
• L
iste
ns.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• C
onfid
enti
al.
• P
ride
in w
ork.
• R
espe
ctfu
l.
Gen
eric
• N
MC
docu
men
ts a
nd g
uida
nce.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
and
gu
idan
ce.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Liv
er
Nur
ses
Foru
m (B
ASL
NF)
.
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f life
car
e.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fr
om L
iver
Dis
ease
. Im
plic
atio
ns fo
r en
d of
life
car
e.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le
peop
le in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as, C
QU
INS,
PR
OM
S et
c.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a re
view
of
pat
ient
s w
ho d
ied
wit
h al
coho
l-rel
ated
live
r di
seas
e, L
ondo
n, N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fi
rst 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
5Si
gnpo
sts
and
supp
orts
pa
tient
s (a
nd
fam
ilies
/ ca
rers
) in
thei
r un
ders
tand
ing
of th
eir
cond
ition
th
roug
h pa
tient
ed
ucat
ion
and
heal
th
prom
otio
n.
HW
B1
HW
B2
HW
B3
HW
B5
HW
B6
Core
1
Core
3
a. A
sses
ses
know
ledg
e an
d un
ders
tand
ing
of p
atie
nt’s
and
ca
rer’
s ow
n co
ndit
ion,
cau
ses,
ri
sk fa
ctor
s an
d co
nseq
uenc
es.
b. P
rovi
des
tailo
red
educ
atio
n to
pat
ient
and
fam
ily/c
arer
s on
co
ndit
ion,
trea
tmen
ts a
nd s
ide-
effe
cts.
c. P
rovi
des
info
rmat
ion
abou
t lif
esty
le fa
ctor
s, c
onse
quen
ces
and
serv
ices
ava
ilabl
e to
sup
port
lif
esty
le c
hang
es.
d. R
efer
to o
ther
app
ropr
iate
he
alth
car
e pr
ofes
sion
als
if
requ
ired
.
• ri
sk fa
ctor
s, s
uch
as, d
rugs
, obe
sity
, alc
ohol
• in
form
atio
n, s
uch
as, D
H D
rink
wis
e, e
duca
tion
an
d su
ppor
t res
ourc
es, s
ervi
ces
and
spec
ialis
t st
aff a
vaila
ble
• d
iffer
ent c
omm
unic
atio
n an
d en
gage
men
t ap
proa
ches
to p
rovi
ding
edu
cati
on
and
info
rmat
ion
• h
ealt
h pr
omot
ion,
sex
ual h
ealt
h st
rate
gies
and
e-
lear
ning
reso
urce
s av
aila
ble,
suc
h as
from
the
PHE
Alc
ohol
Lea
rnin
g R
esou
rces
• p
osit
ive
lifes
tyle
app
roac
hes
and
advi
ce
• h
ow to
giv
e br
ief a
dvic
e an
d in
terv
enti
ons
for
pati
ents
wit
h al
coho
l mis
use,
con
tinu
ed IV
DU
use
an
d w
eigh
t man
agem
ent.
Kno
ws
how
to:
• ta
ilor i
nfor
mat
ion
and
educ
atio
n to
the
pers
on
• o
btai
n ed
ucat
iona
l inf
orm
atio
n or
dir
ect p
atie
nts/
fam
ilies
/car
ers t
o av
aila
ble
reso
urce
s, se
rvic
es a
nd
staf
f, in
clud
ing
the
volu
ntar
y se
ctor
• w
ork
wit
hin
thei
r lev
el o
f com
pete
nce.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• E
mpa
thet
ic.
• E
ncou
ragi
ng.
• S
uppo
rtiv
e.
• W
orks
in p
artn
ersh
ip w
ith
othe
rs.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• F
lexi
ble.
• N
on-ju
dgm
enta
l.
• P
assi
onat
e ab
out p
atie
nt c
are.
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
See
abov
e.Se
e ab
ove.
See
abov
e.Se
e ab
ove.
See
abov
e.•
Key
qual
ity
assu
red
pati
ent a
nd c
arer
in
form
atio
n an
d su
ppor
t fro
m k
ey
char
itie
s an
d or
gani
sati
ons,
suc
h as
: –
Bri
tish
Liv
er T
rust
– Ch
ildre
n’s
Live
r Dis
ease
Fou
ndat
ion
– A
lcoh
ol C
once
rn–
The
Hep
atit
is C
Tru
st–
Hep
atit
is B
Fou
ndat
ion
UK
– H
aem
ochr
omat
osis
Soc
iety
– W
ilson
’s D
isea
se S
uppo
rt
Gro
up (U
K)–
PBC
Foun
dati
on–
Rar
e D
isea
ses
UK
– PS
C Su
ppor
t–
Roy
al c
olle
ges,
suc
h as
, Phy
sici
ans,
G
ener
al P
ract
itio
ners
, Sur
geon
s,
Ana
esth
etis
ts–
Bri
tish
Soc
iety
of G
astr
oent
erol
ogy
(BSG
)–
Bri
tish
Ass
ocia
tion
for t
he S
tudy
of
the
Live
r (B
ASL
)–
Euro
pean
Ass
ocia
tion
for t
he S
tudy
of
the
Live
r (EA
SL)
– A
mer
ican
Ass
ocia
tion
for t
he S
tudy
of
Liv
er D
isea
ses
(AA
SLD
)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral
and
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
Sig
npos
ts a
nd s
uppo
rts
pati
ents
(an
d fa
mil
ies/
care
rs) i
n th
eir
unde
rsta
ndin
g of
thei
r co
ndit
ion
thro
ugh
pati
ent e
duca
tion
and
he
alth
pro
mot
ion
(con
tinu
ed)
2
24
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Sig
npos
ts a
nd s
uppo
rts
pati
ents
(an
d fa
mil
ies/
care
rs) i
n th
eir
unde
rsta
ndin
g of
thei
r co
ndit
ion
thro
ugh
pati
ent e
duca
tion
and
hea
lth
prom
otio
n (c
onti
nued
)2 Le
vel
Com
pete
nce
KS
FP
erfo
rman
ce c
rite
ria
Kno
wle
dge
and
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
6Si
gnpo
sts
and
supp
orts
pa
tient
s (a
nd
fam
ilies
/ ca
rers
) in
thei
r un
ders
tand
ing
of th
eir
cond
ition
th
roug
h pa
tient
ed
ucat
ion
and
heal
th
prom
otio
n.
HW
B1
HW
B2
HW
B3
HW
B5
HW
B6
Core
1
Core
3
a. R
ecog
nise
s pa
tien
ts in
divi
dual
trea
tmen
t ch
oice
s.
b. S
uppo
rts
pati
ents
sen
siti
vely
and
em
path
etic
ally
whe
n:
– u
nder
goin
g ri
sk p
rofil
ing
– re
ceiv
ing
thei
r res
ults
and
dia
gnos
is, w
hich
m
ay in
clud
e gi
ving
bad
new
s, ta
king
into
ac
coun
t whe
ther
the
pati
ent i
s an
adu
lt o
r a
youn
g pe
rson
.
c. P
rovi
des
cult
ural
ly s
ensi
tive
pat
ient
and
car
er
info
rmat
ion
abou
t con
diti
on, l
ocal
and
nat
iona
l in
form
atio
n, s
uppo
rt g
roup
s an
d ch
arit
ies.
• lo
cal g
uida
nce
and
refe
rral
pat
hway
s
• ad
opti
ng p
osit
ive
lifes
tyle
app
roac
hes
and
mod
ifica
tion
s
• re
quir
emen
ts fo
r goo
d in
form
atio
n st
anda
rds
and
the
qual
ity
assu
ranc
e an
d re
view
pro
cess
es
for p
atie
nt in
form
atio
n do
cum
enta
tion
• he
alth
edu
cati
on s
kills
• kn
owle
dge
of in
form
atio
n so
urce
s –
web
site
s,
leafl
ets,
cha
riti
es, k
ite-
mar
ked
info
rmat
ion
• lo
cal a
nd n
atio
nal c
hari
ties
• de
term
inan
ts o
f hea
lth,
suc
h as
, pov
erty
, cul
ture
, re
ligio
n et
c
• cu
ltur
al a
nd s
ocia
l ris
k fa
ctor
s su
ch a
s Kh
at
chew
ing,
her
bal a
nd C
hine
se m
edic
atio
ns,
spec
ific
nutr
itio
nal s
uppl
emen
ts a
nd o
ther
su
bsta
nces
use
d to
boo
st p
hysi
cal p
erfo
rman
ce
that
may
cau
se li
ver d
isea
se
• ph
arm
acol
ogic
al s
ide
effe
cts
of tr
eatm
ents
.
Kno
ws
how
to:
• re
cogn
ise
and
use
pati
ent/
serv
ice
user
in
form
atio
n th
at is
qua
lity
assu
red
• us
e br
ief i
nter
vent
ions
and
mot
ivat
iona
l in
terv
iew
ing
arou
nd d
rugs
, alc
ohol
, wei
ght
man
agem
ent,
dep
ress
ion
and
liver
dis
ease
• de
velo
p co
llabo
rati
ve a
gree
men
ts a
roun
d co
mm
itm
ent t
o he
alth
rela
ted
beha
viou
rs
• si
gnpo
st s
uppo
rt s
ervi
ces
such
as
Wei
ght
Wat
cher
s, A
lcoh
olic
s A
nony
mou
s, T
he H
epat
itis
C
Trus
t and
oth
ers
• re
fer t
o sp
ecia
list s
ervi
ces.
• Em
pow
erin
g.
• M
odel
s be
st p
ract
ice.
• A
ctiv
ely
prom
otes
bet
ter h
ealt
h fo
r pa
tien
ts.
Spec
ific
• D
rink
wis
e.
• W
eigh
t Wat
cher
s.
• A
lcoh
olic
Ano
nym
ous.
• A
lcoh
ol P
olic
y U
K.
• P
HE
Alc
ohol
Lea
rnin
g R
esou
rces
.
• G
uide
lines
for t
he d
iagn
osis
and
tr
eatm
ent o
f cho
lang
ioca
rcin
oma.
• E
urop
ean
Ass
ocia
tion
for t
he S
tudy
of
The
Liv
er G
uide
lines
Asc
ites
, SB
P,
HE
and
HR
S.
• A
mer
ican
Ass
ocia
tion
for t
he S
tudy
of
Liv
er D
isea
ses,
Gui
delin
es fo
r liv
er
dise
ases
.
• N
ICE
clin
ical
gui
delin
es 1
41 (2
012)
A
cute
upp
er g
astr
oint
esti
nal
blee
ding
: man
agem
ent.
• N
ICE
Gui
danc
e on
Alc
ohol
, Cir
rhos
is
and
NA
FLD
.
25
R O Y A L C O L L E G E O F N U R S I N G
Sig
npos
ts a
nd s
uppo
rts
pati
ents
(an
d fa
mil
ies/
care
rs) i
n th
eir
unde
rsta
ndin
g of
thei
r co
ndit
ion
thro
ugh
pati
ent e
duca
tion
and
hea
lth
prom
otio
n (c
onti
nued
)2 Le
vel
Com
pete
nce
KS
FP
erfo
rman
ce c
rite
ria
Kno
wle
dge
and
un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
7Si
gnpo
sts
and
supp
orts
pa
tient
s (a
nd
fam
ilies
/ ca
rers
) in
thei
r un
ders
tand
ing
of th
eir
cond
ition
th
roug
h pa
tient
ed
ucat
ion
and
heal
th
prom
otio
n.
HW
B1
HW
B2
HW
B3
HW
B5
HW
B6
Core
1
Core
3
a. In
terp
rets
com
plex
inve
stig
atio
n re
sult
s an
d pr
oced
ures
and
exp
lain
s th
ese
to p
atie
nts.
b. E
nsur
es p
atie
nt (a
nd fa
mily
/car
ers
whe
re re
leva
nt) u
nder
stan
ds ri
sk p
rofil
ing
impl
icat
ions
and
resu
lts,
and
dis
cuss
es o
ptio
ns
avai
labl
e.
c. W
orks
wit
h sp
ecia
lists
incl
udin
g sp
ecia
list
coun
sello
rs, p
allia
tive
car
e ex
pert
s w
here
ap
prop
riat
e.
d. E
nsur
es ti
mel
y re
ferr
al to
oth
er c
linic
al c
are
prov
ider
s w
here
app
ropr
iate
, and
follo
w u
p.
e. C
ontr
ibut
es to
qua
lity
assu
ranc
e an
d ac
cred
itat
ion
proc
esse
s ar
ound
pat
ient
in
form
atio
n.
• ri
sk p
rofil
ing
test
s av
aila
ble,
thei
r im
plic
atio
ns
and
resu
lts
• na
tion
al s
tand
ards
and
loca
l gui
delin
es
• ne
w o
r em
ergi
ng th
erap
ies
• co
mpl
ex tr
eatm
ent g
roup
s, s
uch
as,
co-in
fect
ion,
mul
tipl
e ae
tiol
ogie
s, a
nd
pre-
tran
spla
nt a
nd p
ost t
rans
plan
t iss
ues
• av
aila
ble
reso
urce
s an
d su
ppor
t ser
vice
s lo
cally
, re
gion
ally
and
nat
iona
lly a
nd th
eir a
ccre
dita
tion
an
d qu
alit
y as
sura
nce
proc
esse
s.
Kno
ws
how
to:
• re
fer t
o sp
ecia
list c
ouns
ellin
g an
d pa
lliat
ive
care
se
rvic
es
• qu
alit
y as
sure
and
acc
redi
t pat
ient
info
rmat
ion
liter
atur
e.
• R
ole
mod
el.
• Pr
ovid
es s
tron
g le
ader
ship
.
• Ch
alle
nges
ass
umpt
ions
and
ta
ken
for g
rant
ed w
ays
of w
orki
ng.
• Ch
ampi
ons
pers
on-c
entr
ed
appr
oach
es.
See
abov
e.
26
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Und
erta
kes
a co
mpr
ehen
sive
cli
nica
l ass
essm
ent i
nclu
ding
ris
k pr
ofili
ng a
nd fo
llow
s up
wit
h ap
prop
riat
e ac
tion
, inc
ludi
ng r
efer
ral t
o sp
ecia
list
s, fo
r re
leva
nt a
cute
and
chr
onic
hea
lth
care
con
diti
ons
3 Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cr
iter
iaK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
1-4
Und
erta
kes
nurs
ing
obse
rvat
ions
, re
cord
s ac
cura
tely
an
d re
port
s al
l ch
ange
s.
Core
1
Core
6
HW
B1
HW
B3
HW
B4
HW
B6
a. U
nder
take
s an
d re
cord
s nu
rsin
g ob
serv
atio
ns.
b. M
easu
res
and
reco
rds
wei
ght
accu
rate
ly.
c. T
akes
ap
prop
riat
e ac
tion
in
clud
ing
whe
n re
cord
ings
fall
outs
ide
agre
ed
para
met
ers.
• th
e no
rmal
par
amet
ers
of n
ursi
ng
obse
rvat
ions
for p
atie
nts
wit
h liv
er d
isea
se.
Kno
ws
how
to:
• re
cord
nur
sing
obs
erva
tion
s an
d
take
app
ropr
iate
act
ion/
refe
rral
for
abno
rmal
resu
lts
• th
e im
port
ance
of r
epor
ting
and
reco
rdin
g si
gns
and
sym
ptom
s su
ch a
s na
usea
, vom
iting
, pr
uritu
s an
d al
tere
d m
enta
l sta
te
• re
cogn
ise
dete
rior
atio
n an
d re
port
to
appr
opri
ate
regi
ster
ed p
ract
itio
ner a
nd n
eed
for p
ossi
ble
end
of li
fe c
are.
• A
war
e of
role
lim
itat
ions
and
whe
n to
ob
tain
hel
p.
• Pe
rson
cen
tred
and
com
pass
iona
te.
• Li
sten
s.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• Co
nfide
ntia
l.
• Pr
ide
in w
ork.
• R
espe
ctfu
l.
Gen
eric
• N
MC
docu
men
ts a
nd g
uida
nce.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
and
gui
danc
e.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Liv
er N
urse
s Fo
rum
(B
ASL
NF)
.
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f life
car
e.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2)
Dea
ths
from
Liv
er D
isea
se. I
mpl
icat
ions
for e
nd o
f life
car
e.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
th
e re
form
ed N
HS.
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as, C
QU
INS,
PR
OM
S et
c.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al 2
014)
.
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a re
view
of p
atie
nts
who
di
ed w
ith
alco
hol-r
elat
ed li
ver d
isea
se, L
ondo
n, N
CEPO
D.
• N
HS
IQ (
Impr
ovin
g qu
alit
y).
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s).
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3).
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fir
st
24 h
ours
.
• N
HS
Engl
and
(201
3) T
he 6
Cs.
27
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
1-4
See
abov
e.Se
e ab
ove.
See
abov
e.Se
e ab
ove.
See
abov
e.•
Key
qual
ity
assu
red
pati
ent a
nd c
arer
in
form
atio
n an
d su
ppor
t fro
m k
ey
char
itie
s an
d or
gani
sati
ons,
suc
h as
: –
Bri
tish
Liv
er T
rust
– Ch
ildre
n’s
Live
r Dis
ease
Fou
ndat
ion
– A
lcoh
ol C
once
rn–
The
Hep
atit
is C
Tru
st–
Hep
atit
is B
Fou
ndat
ion
UK
– H
aem
ochr
omat
osis
Soc
iety
– W
ilson
’s D
isea
se S
uppo
rt G
roup
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy
of th
e Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy
of L
iver
Dis
ease
s (A
ASL
D)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral
and
Ente
ral N
utri
tion
(BA
PEN
).
• N
HS
Engl
and
The
Info
rmat
ion
Stan
dard
.
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
.
• Sk
ills
for H
ealt
h.
Und
erta
kes
a co
mpr
ehen
sive
cli
nica
l ass
essm
ent i
nclu
ding
ris
k pr
ofili
ng a
nd fo
llow
s up
wit
h ap
prop
riat
e ac
tion
, inc
ludi
ng r
efer
ral t
o sp
ecia
list
s, fo
r re
leva
nt a
cute
and
chr
onic
hea
lth
care
con
diti
ons
(con
tinu
ed)
3
28
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
5U
nder
take
s a
com
preh
ensi
ve
phys
ical
as
sess
men
t an
d fo
llow
s up
with
ap
prop
riat
e ac
tion,
in
clud
ing
refe
rral
to
med
ical
sp
ecia
lists
for
rele
vant
acu
te
and
chro
nic
heal
th c
are
cond
ition
s.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
a. U
nder
take
s an
d re
cord
s nu
rsin
g as
sess
men
t an
d hi
stor
y ta
king
.
b. Id
enti
fies
sign
s of
live
r dis
ease
in s
tool
s,
urin
e an
d sk
in.
c. Id
enti
fies
indi
vidu
als
at ri
sk, s
uch
as, d
rugs
, al
coho
l, ob
esit
y, c
o-m
orbi
diti
es, d
epre
ssio
n.
d. A
sses
ses
nutr
itio
nal s
tatu
s.
e. Id
enti
fies
sign
s an
d sy
mpt
oms
of a
lter
ed
men
tal s
tate
incl
udin
g ce
rebr
al o
edem
a fo
r ac
ute
liver
failu
re.
f. A
cts
on fi
ndin
gs o
f nur
sing
ass
essm
ent.
g. E
xpla
ins
rele
vant
inve
stig
atio
ns to
pat
ient
s an
d se
rvic
e us
ers.
h. U
ses
loca
l gui
delin
es fo
r the
car
e of
peo
ple
wit
h liv
er d
isea
se.
i. U
se o
f inf
ecti
on c
ontr
ol a
nd p
reve
ntio
n po
licie
s w
hen
cari
ng fo
r pat
ient
s.
j. R
efer
s to
app
ropr
iate
spe
cial
ist t
eam
.
k. D
irec
ts th
e pa
tien
t to
spec
ialis
t hel
p.
l. Ca
rrie
s ou
t inv
esti
gati
ons
rela
ted
to ri
sk
profi
ling
unde
r loc
al g
uida
nce.
• fu
ncti
ons
of th
e liv
er
• no
rmal
and
abn
orm
al li
ver a
nato
my
and
phys
iolo
gy
• ch
ange
s to
the
stoo
ls, u
rine
and
ski
n in
live
r di
seas
e e.
g. ja
undi
ce, b
ruis
ing,
scr
atch
mar
ks,
palm
ar e
rthy
ema,
asc
ites
, liv
er fl
ap (a
ster
ixis
)
• so
me
of th
e ef
fect
s of
dru
gs m
etab
olis
ed b
y
the
liver
• ef
fect
of l
iver
dis
ease
on
othe
r bod
y sy
stem
s,
such
as,
men
tal f
unct
ion,
car
diov
ascu
lar a
nd
rena
l fun
ctio
n
• sp
ecifi
c ac
ute
and
chro
nic
com
plic
atio
ns a
nd
thei
r man
agem
ent i
nclu
ding
:
– pr
urit
us
– sk
in ra
shes
as
side
eff
ects
of d
rug
trea
tmen
ts
espe
cial
ly in
rela
tion
to v
iral
hep
atit
is
– hy
pote
nsio
n du
e to
dru
g re
late
d, s
uch
as,
Prop
rano
lol,
and
non-
drug
rela
ted
reas
ons
such
as
deco
mpe
nsat
ed li
ver d
isea
se
– ja
undi
ce
– bi
liary
com
plic
atio
ns, s
uch
as, c
hole
cyst
itis
an
d/or
cho
lang
itis
– po
rtal
hyp
erte
nsio
n an
d oe
soph
agea
l var
ices
– as
cite
s/sp
onta
neou
s ba
cter
ial p
erit
onit
is
– he
pato
rena
l fai
lure
– he
pati
c en
ceph
alop
athy
– ri
sk o
f cer
ebra
l oed
ema
in a
cute
live
r fai
lure
– se
psis
whi
ch o
ften
pre
cipi
tate
s va
rice
al
blee
ding
or h
epat
ic e
ncep
halo
path
y
– ca
rdio
vasc
ular
and
resp
irat
ory
com
plic
atio
ns
– co
agul
opat
hy
– re
cogn
ise
the
sign
s an
d sy
mpt
oms
of a
lcoh
ol
and
/or d
rug
wit
hdra
wal
• al
tere
d pa
thop
hysi
olog
y an
d di
ffere
nt m
anag
emen
t of
dec
ompe
nsat
ed li
ver d
isea
se a
nd a
cute
on
chro
nic
liver
dis
ease
and
thei
r com
plic
atio
ns
• al
tere
d pa
thop
hysi
olog
y in
acu
te li
ver f
ailu
re a
nd
its
man
agem
ent a
nd s
igni
fican
ce o
f det
erio
rati
on
• im
port
ance
of n
utri
tion
in c
hron
ic li
ver d
isea
se
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• Su
ppor
tive
.
• En
cour
agin
g.
• Pr
ovid
es c
hoic
es.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• Fl
exib
le.
• N
on-ju
dgm
enta
l.
• Pa
ssio
nate
abo
ut p
atie
nt c
are.
• St
arts
to d
emon
stra
te a
tten
tion
to
det
ail.
• A
ctiv
e in
ow
n le
arni
ng.
• O
pen
to re
ceiv
ing
feed
back
.
• O
pen
min
ded.
• R
eflec
tive
.
Spec
ific
• Lo
cal p
roto
cols
and
gui
delin
es
• S
tand
ards
for c
linic
al p
ract
ice
and
trai
ning
(joi
nt s
tate
men
ts) f
rom
:
– R
oyal
Col
lege
of A
naes
thet
ists
– R
oyal
Col
lege
of P
hysi
cian
s
– Th
e In
tens
ive
Care
Soc
iety
– Th
e R
esus
cita
tion
Cou
ncil
• N
ICE
Gui
danc
e on
Alc
ohol
• N
ICE
Gui
danc
e on
Liv
er
• N
HS
Blo
od a
nd T
rans
plan
t Pol
icie
s Li
ver T
rans
plan
t: s
elec
tion
cri
teri
a an
d re
cipi
ent r
egis
trat
ion
• N
ICE
(201
3) Q
ualit
y st
anda
rd e
nd o
f lif
e ca
re.
• R
CN (2
012)
Adv
ance
d N
urse
P
ract
itio
ner:
An
RCN
gui
de to
the
adva
nced
nur
se ro
le a
ccre
dita
tion
.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
• N
ICE
(201
4) S
afe
staf
fing
for
nurs
ing
in a
dult
inpa
tien
t war
ds in
ac
ute
hosp
ital
s.
• P
refe
rred
Pri
orit
ies
of C
are
Und
erta
kes
a co
mpr
ehen
sive
cli
nica
l ass
essm
ent i
nclu
ding
ris
k pr
ofili
ng a
nd fo
llow
s up
wit
h ap
prop
riat
e ac
tion
, inc
ludi
ng r
efer
ral t
o sp
ecia
list
s, fo
r re
leva
nt a
cute
and
chr
onic
hea
lth
care
con
diti
ons
(con
tinu
ed)
3
29
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
5Se
e ab
ove.
See
abov
e.Se
e ab
ove.
• im
pact
of p
rurit
us o
n w
ell b
eing
and
sle
ep p
atte
rns
• th
e lif
esty
le ri
sk fa
ctor
s th
at m
ay in
fluen
ce d
isea
se
seve
rity
e.g
. sm
okin
g, a
lcoh
ol, o
besi
ty, d
epre
ssio
n
• ty
pes
of in
vest
igat
ion
e.g.
live
r bio
psy,
ult
raso
und
scan
ning
, how
to in
terp
ret r
esul
ts, a
ppro
pria
te
trea
tmen
t opt
ions
and
loca
l gui
delin
es
• w
hen
to re
fer t
o sp
ecia
list l
iver
team
• al
tere
d bo
dy im
age
• en
d of
life
car
e in
rela
tion
to p
atie
nts
wit
h ch
roni
c liv
er d
isea
se.
Kno
ws
how
to:
• un
dert
ake
a co
mpr
ehen
sive
clin
ical
ass
essm
ent o
f pa
tien
ts w
ith
liver
dis
ease
• id
enti
fy s
igns
of l
iver
dis
ease
in s
tool
s an
d ur
ine
• co
mm
unic
ate
the
purp
ose,
resu
lts
and
mea
ning
of
rele
vant
inve
stig
atio
ns
• co
mm
unic
ate
to p
atie
nts,
fam
ily/c
arer
s an
d st
aff
the
need
for i
nfec
tion
pre
vent
ion
and
cont
rol
• re
cogn
ise
sign
s of
live
r dis
ease
and
impl
emen
t ap
prop
riate
act
ions
and
/or r
efer
ral t
o sp
ecia
list
team
s.
See
abov
e.Se
e ab
ove.
Und
erta
kes
a co
mpr
ehen
sive
cli
nica
l ass
essm
ent i
nclu
ding
ris
k pr
ofili
ng a
nd fo
llow
s up
wit
h ap
prop
riat
e ac
tion
, inc
ludi
ng r
efer
ral t
o sp
ecia
list
s, fo
r re
leva
nt a
cute
and
chr
onic
hea
lth
care
con
diti
ons
(con
tinu
ed)
3
30
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
6U
nder
take
s a
com
preh
ensi
ve
phys
ical
as
sess
men
t an
d fo
llow
s up
with
ap
prop
riat
e ac
tion,
in
clud
ing
refe
rral
to
med
ical
sp
ecia
lists
fo
r rel
evan
t ch
roni
c he
alth
car
e co
nditi
ons.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
a. U
nder
take
s a
com
preh
ensi
ve p
hysi
cal
asse
ssm
ent a
nd p
atie
nt ri
sk p
rofil
ing
incl
udin
g th
e ea
rly
dete
ctio
n of
oth
er d
isea
ses
and
the
iden
tific
atio
n of
co-
mor
bidi
ties
.
b. P
rovi
des
expe
rt c
are
and
inte
r-pr
ofes
sion
al
colla
bora
tive
pra
ctic
e an
d co
nsul
tati
on to
in
divi
dual
pat
ient
s an
d se
rvic
e us
ers
acro
ss
spec
ific
pati
ent p
athw
ays
base
d on
hol
isti
c as
sess
men
t, n
atio
nal g
uide
lines
, spe
cial
ist
com
pete
nces
and
bes
t pra
ctic
e, d
ocum
enti
ng
this
car
e as
an
acco
unta
ble
prac
titi
oner
.
c. D
iscu
sses
wit
h pa
tien
ts a
nd fa
mily
/car
er
the
sign
ifica
nce
of m
edic
al in
vest
igat
ions
, tes
t re
sult
s, p
rogn
osis
and
trea
tmen
t opt
ions
.
d. M
onit
ors
and
advi
ses
on n
utri
tion
al in
take
an
d su
pple
men
ts in
col
labo
rati
on w
ith
diet
icia
n to
pro
vide
opt
imal
nut
riti
on.
e. Im
plem
ents
and
doc
umen
ts a
n ap
prop
riat
e m
anag
emen
t pla
n.
f. Es
tabl
ishe
s pa
tien
t con
cord
ance
wit
h tr
eatm
ent a
nd re
cogn
ises
pat
ient
’s in
divi
dual
tr
eatm
ent c
hoic
es.
g. K
eeps
up
to d
ate
wit
h be
st p
ract
ice
for
spec
ific
pati
ent p
athw
ays
thro
ugh
nati
onal
sp
ecia
list f
orum
s, jo
urna
ls a
nd n
etw
orki
ng.
• re
leva
nt N
ICE
guid
elin
es a
nd s
tand
ards
• e
arly
sig
ns a
nd s
ympt
oms
of o
ther
maj
or
dise
ases
, suc
h as
dia
bete
s, h
eart
dis
ease
and
en
docr
ine
dise
ase
• im
pact
of p
regn
ancy
on
the
liver
• si
gns
of li
ver d
isea
se a
nd th
e im
pact
of
co-m
orbi
diti
es
• in
terp
reti
ng c
hang
es to
blo
od c
hem
istr
y in
live
r di
seas
e, s
uch
as li
ver e
nzym
es, s
ynth
etic
func
tion
s su
ch a
s IN
R/p
roth
rom
bin
tim
es a
nd a
lbum
in
• in
vest
igat
ions
suc
h as
Dop
pler
sca
n, e
ndos
copy
, en
dosc
opic
retr
ogra
de c
hola
ngio
panc
reto
grap
hy
(ER
CP),
mag
neti
c re
sona
nce
imag
ing
(MR
I)
• in
dep
th u
nder
stan
ding
of a
lter
ed
path
ophy
siol
ogy,
suc
h as
am
mon
ia le
vels
in
hepa
tic
ence
phal
opat
hy a
nd e
ffec
ts o
f spl
anch
nic
circ
ulat
ion
on p
orta
l hyp
erte
nsio
n an
d re
leva
nce
to c
urre
nt m
anag
emen
t str
ateg
ies
• kn
owle
dge
of p
reci
pita
ting
fact
ors
of h
epat
ic
ence
phal
opat
hy a
nd p
reve
ntat
ive
mea
sure
s
• p
atie
nt c
ompl
ianc
e, a
dher
ence
and
con
cord
ance
• m
easu
rem
ents
of s
ever
ity
and
surv
ival
bas
ed o
n bl
ood
resu
lts,
suc
h as
UKE
LD, M
ELD
, Chi
lds
Pugh
sc
ore
and
othe
r phy
sica
l fac
tors
suc
h as
asc
ites
an
d he
pati
c en
ceph
alop
athy
• en
d of
life
car
e an
d it
s m
anag
emen
t.
Kno
ws
how
to:
• u
nder
take
a d
etai
led,
com
preh
ensi
ve p
hysi
cal
asse
ssm
ent i
n ac
cord
ance
wit
h lo
cal g
uide
lines
• re
cogn
ise
sign
s an
d sy
mpt
oms
and
im
plem
ent a
ppro
pria
te a
ctio
ns fo
r co
mpl
icat
ions
of l
iver
dis
ease
• in
terp
ret a
rang
e of
blo
od re
sult
s
• co
mm
unic
ate
to p
atie
nts
the
impa
ct o
f co
-mor
bidi
ties
on
thei
r liv
er d
isea
se
• d
iffer
enti
ate
betw
een
hepa
tic
ence
phal
opat
hy
and
alco
hol w
ithd
raw
al
• as
sess
for s
igns
and
sym
ptom
s of
acu
te a
lcoh
ol
wit
hdra
wal
uti
lisin
g a
valid
ated
sev
erit
y sc
ale
• V
alue
s le
arni
ng.
• W
orks
in p
artn
ersh
ip.
• E
mpo
wer
ing.
• E
mbr
aces
diff
eren
t per
spec
tive
s.
• A
naly
tica
l.
• A
tten
tion
to d
etai
l.
• M
odel
s be
st p
ract
ice.
Und
erta
kes
a co
mpr
ehen
sive
cli
nica
l ass
essm
ent i
nclu
ding
ris
k pr
ofili
ng a
nd fo
llow
s up
wit
h ap
prop
riat
e ac
tion
, inc
ludi
ng r
efer
ral t
o sp
ecia
list
s, fo
r re
leva
nt a
cute
and
chr
onic
hea
lth
care
con
diti
ons
(con
tinu
ed)
3
31
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
6•
iden
tify
pre
and
pos
t mor
bid
men
tal h
ealt
h is
sues
• m
onit
or o
ptim
al n
utri
tion
al s
tatu
s
• ac
t as
a m
ento
r to
othe
rs.
7U
nder
take
s a
com
preh
ensi
ve
phys
ical
as
sess
men
t an
d fo
llow
s up
with
ap
prop
riat
e ac
tion,
in
clud
ing
refe
rral
to
med
ical
sp
ecia
lists
fo
r rel
evan
t ch
roni
c an
d ac
ute
heal
th c
are
cond
ition
s.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
a. A
sses
ses,
dia
gnos
es a
nd tr
eats
peo
ple
wit
h on
-goi
ng li
ving
dis
ease
and
its
com
plic
atio
ns.
b. U
nder
take
s a
med
ical
his
tory
, com
plet
es a
de
taile
d ph
ysic
al a
nd n
ursi
ng e
xam
inat
ion,
fo
rmul
ates
a d
iagn
osis
, ini
tiat
es in
vest
igat
ions
an
d/or
trea
tmen
ts a
nd re
fers
to s
peci
alis
t te
ams
as a
ppro
pria
te.
c. D
iagn
oses
new
or w
orse
ning
com
plic
atio
ns
of a
cute
and
chr
onic
live
r dis
ease
.
d. Id
enti
fies
earl
y si
gns
of o
ther
dis
ease
s.
e. P
rovi
des
the
pati
ent w
ith
info
rmat
ion
on h
ow to
man
age
and
mon
itor
spe
cific
sy
mpt
oms.
f. Im
plem
ents
end
of l
ife c
are
for t
he p
atie
nt
and
thei
r fam
ily, p
rovi
des
supp
ort a
nd re
fers
to
the
appr
opri
ate
heal
th p
rofe
ssio
nals
.
• a
ll ca
uses
of l
iver
dis
ease
incl
udin
g th
ose
rela
ted
to o
ccup
atio
n an
d tr
avel
• c
ompl
icat
ions
of a
cute
and
chr
onic
live
r dis
ease
• d
esig
n, im
plem
ent a
nd e
valu
ate
a m
anag
emen
t pl
an th
at in
clud
ed th
e sp
ecifi
c si
gns
and
sym
ptom
s or
sid
e ef
fect
s: s
uch
as:
– pr
urit
us
– sk
in ra
shes
as
side
eff
ects
of d
rug
trea
tmen
ts
espe
cial
ly in
rela
tion
to v
iral
hep
atit
is
– hy
pote
nsio
n du
e to
dru
g re
late
d, s
uch
as
prop
rano
lol,
and
non-
drug
rela
ted
reas
ons
such
as
dec
ompe
nsat
ed li
ver d
isea
se
– ja
undi
ce
– bi
liary
com
plic
atio
ns s
uch
as c
hole
cyst
itis
and
/or
cho
lang
itis
– po
rtal
hyp
erte
nsio
n an
d oe
soph
agea
l var
ices
– as
cite
s/sp
onta
neou
s ba
cter
ial p
erit
onit
is
– he
pato
rena
l fai
lure
– he
pati
c en
ceph
alop
athy
– ri
sk o
f cer
ebra
l oed
ema
in a
cute
live
r fai
lure
– se
psis
whi
ch o
ften
pre
cipi
tate
s va
rice
al b
leed
ing
or h
epat
ic e
ncep
halo
path
y
– ca
rdio
vasc
ular
and
resp
irat
ory
com
plic
atio
ns
– co
agul
opat
hy
– re
cogn
ise
the
sign
s an
d sy
mpt
oms
of a
lcoh
ol
and
/or d
rug
wit
hdra
wal
• tr
eatm
ent r
egim
es, i
nclu
ding
elig
ibili
ty a
nd
suit
abili
ty c
rite
ria
for d
iffer
ent l
iver
dis
ease
s
• o
ptio
ns fo
llow
ing
failu
re o
f tre
atm
ent,
suc
h as
ea
rly
refe
rral
for l
iver
tran
spla
ntat
ion
asse
ssm
ent
in c
hron
ic li
ver d
isea
se
• p
allia
tion
of s
ympt
oms
such
as
chem
o-em
bolis
atio
n or
par
acen
tesi
s an
d pl
anni
ng fo
r en
d of
life
car
e.
(con
tinu
ed)
• R
ole
mod
el.
• In
terp
rofe
ssio
nal w
orki
ng.
• C
olla
bora
tive
.
• In
clus
ive.
• S
tron
g cl
inic
al le
ader
ship
.
• C
halle
nges
ass
umpt
ions
.
• C
ham
pion
s pe
rson
-cen
tred
ap
proa
ches
.
• C
halle
nges
ass
umpt
ion
and
take
n fo
r gra
nted
way
s of
wor
king
.
• A
ctiv
ely
prom
otes
bet
ter h
ealt
h fo
r pat
ient
s.
Und
erta
kes
a co
mpr
ehen
sive
cli
nica
l ass
essm
ent i
nclu
ding
ris
k pr
ofili
ng a
nd fo
llow
s up
wit
h ap
prop
riat
e ac
tion
, inc
ludi
ng r
efer
ral t
o sp
ecia
list
s, fo
r re
leva
nt a
cute
and
chr
onic
hea
lth
care
con
diti
ons
(con
tinu
ed)
3
32
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
7Se
e ab
ove.
See
abov
e.Se
e ab
ove.
Kno
ws
how
to:
• u
nder
take
a d
etai
led
clin
ical
and
nu
rsin
g as
sess
men
t
• u
nder
take
an
abdo
min
al a
sses
smen
t and
oth
er
syst
ems
as a
ppro
pria
te.
• e
xpla
in s
igni
fican
ce o
f any
inve
stig
atio
ns
to p
atie
nts
• in
itia
te in
vest
igat
ions
app
ropr
iate
ly
• a
ct o
n in
vest
igat
ions
and
inte
rpre
t res
ults
in
clud
ing
liver
scr
een
• fo
rmul
ate
an a
ppro
pria
te m
anag
emen
t pla
n in
clud
ing,
whe
re a
ppro
pria
te, e
nd o
f life
car
e
• id
enti
fy a
cute
alc
ohol
wit
hdra
wal
and
saf
ely
prov
ide
phar
mac
olog
ical
man
agem
ent o
f sy
mpt
oms
duri
ng a
n ep
isod
e of
acu
te
alco
hol w
ithd
raw
al
• a
dmin
iste
r tre
atm
ent w
ithi
n th
eir s
peci
alis
t rol
e as
a n
on-m
edic
al p
resc
ribe
r
• re
cogn
ise,
man
age
and
refe
r pat
ient
s in
rela
tion
to
thei
r co-
mor
bidi
ties
• a
sses
s co
mpe
tenc
e of
nur
ses
unde
rtak
ing
cl
inic
al a
sses
smen
ts
• a
ct a
s a
role
mod
el.
See
abov
e.Se
e ab
ove.
Und
erta
kes
a co
mpr
ehen
sive
cli
nica
l ass
essm
ent i
nclu
ding
ris
k pr
ofili
ng a
nd fo
llow
s up
wit
h ap
prop
riat
e ac
tion
, inc
ludi
ng r
efer
ral t
o sp
ecia
list
s, fo
r re
leva
nt a
cute
and
chr
onic
hea
lth
care
con
diti
ons
(con
tinu
ed)
3
33
R O Y A L C O L L E G E O F N U R S I N G
Ass
esse
s, in
col
labo
rati
on w
ith
the
pati
ent (
youn
g pe
ople
, adu
lts,
fam
ily/
care
rs),
thei
r he
alth
car
e ne
eds,
taki
ng in
to a
ccou
nt th
e im
pact
of
thei
r ag
e, v
ulne
rabi
lity
, the
ir li
fest
yle,
cul
tura
l and
eth
nic
back
grou
nd4 Le
vel
Com
pete
nce
KS
FP
erfo
rman
ce c
rite
ria
Kno
wle
dge
and
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
5As
sess
es, i
n co
llabo
ratio
n w
ith th
e pa
tient
thei
r he
alth
car
e ne
eds,
taki
ng
into
acc
ount
th
eir a
ge,
vuln
erab
ility
, th
eir l
ifest
yle,
cu
ltura
l an
d et
hnic
ba
ckgr
ound
.
Core
1
HW
B2
HW
B5
HW
B6
HW
B7
Core
6
a. U
nder
take
s a
holis
tic
heal
th c
are
ne
eds
asse
ssm
ent.
b. Id
enti
fies
pati
ents
at r
isk
from
live
r dis
ease
.
c. E
xplo
res
the
pati
ent’
s cu
rren
t life
styl
e, h
opes
an
d ex
pect
atio
ns.
d. D
iscu
sses
the
pati
ent’
s cu
ltur
al/f
amily
/et
hnic
bac
kgro
und
and
iden
tifie
s pe
rson
al
pref
eren
ces.
e. Id
enti
fies
vuln
erab
le in
divi
dual
s.
f. M
aint
ains
con
fiden
tial
ity
in re
lati
on to
pa
tien
t inf
orm
atio
n an
d da
ta.
g. D
ocum
ents
com
preh
ensi
ve a
sses
smen
t.
h. U
ses
all a
vaila
ble
reso
urce
s to
pro
vide
in
form
atio
n an
d to
asc
erta
in th
e pa
tien
t un
ders
tand
s th
eir i
llnes
s/tr
eatm
ent o
ptio
ns in
th
eir p
refe
rred
lang
uage
.
i. Es
tabl
ishe
s pa
tien
t con
cord
ance
wit
h tr
eatm
ent a
nd re
cogn
ises
pat
ient
’s in
divi
dual
tr
eatm
ent c
hoic
es.
• th
e im
plic
atio
ns o
f diff
eren
t life
st
ages
, life
styl
es a
nd ri
sk fa
ctor
s on
th
e de
velo
pmen
t and
pro
gres
sion
of
acut
e an
d ch
roni
c liv
er c
ondi
tion
s an
d at
end
of l
ife
• d
iffer
ent c
ultu
res
and
fait
hs a
nd
the
pote
ntia
l im
pact
of t
hese
upo
n th
e pa
tien
t’s
pers
onal
bel
iefs
and
vi
ewpo
ints
• th
e ra
nge
of re
sour
ces
for i
nfor
mat
ion
and
supp
ort w
here
the
pati
ent c
ould
be
refe
rred
• o
btai
ning
con
sent
from
the
pati
ent
• le
gal a
nd e
thic
al a
spec
ts o
f con
sent
.
Kno
ws
how
to:
• u
nder
take
hol
isti
c as
sess
men
t in
clud
ing
lifes
tyle
, sex
ual h
ealt
h,
soci
al a
nd m
enta
l hea
lth
need
s
• u
se a
lcoh
ol s
cree
ning
tool
• c
onsu
lts,
com
mun
icat
es a
nd re
fers
to
appr
opri
ate
supp
ort
• re
cogn
ise
vuln
erab
ility
acr
oss
the
ag
e sp
ectr
um
• a
cces
s ex
pert
ise
in re
lati
on to
car
ing
for v
ulne
rabl
e in
divi
dual
s
• a
cces
s an
inte
rpre
ter/
cultu
ral m
edia
tor.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• S
uppo
rtiv
e.
• E
ncou
ragi
ng.
• P
rovi
des
choi
ces.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• F
lexi
ble.
• N
on-ju
dgm
enta
l.
• P
assi
onat
e ab
out p
atie
nt c
are.
Gen
eric
• N
MC
docu
men
ts a
nd g
uida
nce.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
and
gui
danc
e.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Liv
er N
urse
s Fo
rum
(BA
SLN
F).
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f life
car
e.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2)
Dea
ths
from
Liv
er D
isea
se. I
mpl
icat
ions
for e
nd o
f lif
e ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le
peop
le in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as, C
QU
INS
, PR
OM
S e
tc.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a re
view
of
pati
ents
who
die
d w
ith
alco
hol-r
elat
ed li
ver d
isea
se,
Lond
on, N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fi
rst 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
34
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Ass
esse
s, in
col
labo
rati
on w
ith
the
pati
ent (
youn
g pe
ople
, adu
lts,
fam
ily/
care
rs),
thei
r he
alth
car
e ne
eds,
taki
ng in
to a
ccou
nt th
e im
pact
of
thei
r ag
e, v
ulne
rabi
lity
, the
ir li
fest
yle,
cul
tura
l and
eth
nic
back
grou
nd (c
onti
nued
)4 Le
vel
Com
pete
nce
KS
FP
erfo
rman
ce c
rite
ria
Kno
wle
dge
and
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
6As
sess
es, i
n co
llabo
ratio
n w
ith th
e pa
tient
thei
r he
alth
car
e ne
eds,
taki
ng
into
acc
ount
th
eir a
ge,
vuln
erab
ility
, th
eir l
ifest
yle,
cu
ltura
l an
d et
hnic
ba
ckgr
ound
.
Core
1
HW
B2
HW
B5
HW
B6
HW
B7
Core
6
a. E
xplo
res
the
impa
ct o
f the
pat
ient
’s
agre
emen
t or r
esis
tanc
e to
trea
tmen
t opt
ions
on
thei
r liv
er c
ondi
tion
with
rega
rd to
thei
r cu
ltura
l and
eth
nic
back
grou
nd a
nd li
fe c
hoic
es.
• c
ultu
re, r
elig
ion
and
ethn
icit
y on
hea
lth
belie
fs
• li
fest
yle
impa
ct o
n liv
er h
ealt
h in
clud
ing
chao
tic
lifes
tyle
, dru
gs, a
lcoh
ol a
nd o
besi
ty
• im
pact
of l
iver
dis
ease
on
life
styl
e an
d se
xual
hea
lth
• c
linic
al g
over
nanc
e
Kno
ws
how
to:
• a
sses
s lif
esty
le fa
ctor
s in
col
labo
rati
on w
ith
th
e pa
tien
t
• h
ow to
ass
ess
drin
king
his
tory
and
use
tool
s to
as
sess
risk
s to
pat
ient
com
plia
nce
and
safe
ty
• m
anag
e re
fusa
l of c
are/
trea
tmen
t by
pati
ent,
fa
mily
or c
arer
s, a
nd re
fer t
o a
heal
th c
are
prof
essi
onal
whe
re a
ppro
pria
te.
• M
odel
s be
st p
ract
ice.
• B
uild
s re
lati
onsh
ip w
ith
peer
s.
• S
hare
s id
eas.
• F
acili
tate
s in
volv
emen
t of
stak
ehol
ders
.
• M
edic
o-le
gal i
mpl
icat
ion.
• W
orks
in p
artn
ersh
ip.
• E
mpo
wer
ing.
• E
mbr
aces
diff
eren
t per
spec
tive
s.
Gen
eric
(con
tinu
ed)
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
ch
arit
ies
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
G
roup
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy
of th
e Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy
of L
iver
Dis
ease
s (A
ASL
D)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral
and
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
Spec
ific
• E
qual
ity
impa
ct a
sses
smen
ts.
• M
IND
.
• N
HS
Publ
ic H
ealt
h En
glan
d - s
exua
l he
alth
.
• N
ICE
CG 1
00 A
lcoh
ol-u
se d
isor
ders
: ph
ysic
al c
ompl
icat
ions
ww
w.
guid
ance
.nic
e.or
g.uk
/CG
100.
(con
tinu
ed)
7As
sess
es, i
n co
llabo
ratio
n w
ith th
e pa
tient
thei
r he
alth
car
e ne
eds,
taki
ng
into
acc
ount
th
eir a
ge,
vuln
erab
ility
, th
eir l
ifest
yle,
cu
ltura
l an
d et
hnic
ba
ckgr
ound
.
Core
1
HW
B2
HW
B5
HW
B6
HW
B7
Core
6
a. A
sses
s, d
iagn
ose
and
trea
t pat
ient
s w
ith
on-g
oing
live
r dis
ease
.
b. M
anag
e an
d m
onit
or c
ompl
icat
ions
.
c. A
sses
ses
pati
ents
retu
rnin
g fo
r on-
goin
g fo
llow
-up.
d. R
efer
s pa
tien
ts to
oth
er m
embe
rs o
f the
m
ulti
-dis
cipl
inar
y te
am w
hen
appr
opri
ate.
e. A
udit
s as
sess
men
t doc
umen
tati
on in
co
llabo
rati
on w
ith
the
mul
ti-d
isci
plin
ary
team
.
f. Pa
rtic
ipat
es in
mul
ti-d
isci
plin
ary
pa
tien
t con
fere
nces
.
g. K
eeps
pat
ient
s’ g
ener
al p
ract
itio
ners
, an
d co
mm
unit
y te
ams/
serv
ices
info
rmed
of
on-g
oing
con
sult
atio
n, h
ealt
h ca
re n
eeds
and
as
sess
men
t pro
gres
s.
• re
ferr
al s
yste
ms
and
com
mun
icat
ion
syst
ems
wit
h ge
nera
l pra
ctit
ione
rs, c
omm
unit
y te
ams
and
scho
ol n
urse
s.
Kno
ws
how
to:
• se
t-up
, org
anis
e an
d ru
n nu
rse-
led
clin
ics
• es
tabl
ish
tele
phon
e su
ppor
t and
cou
nsel
ling
syst
ems.
• R
ole
mod
el.
• Co
llabo
rati
ve.
• In
clus
ive.
• Pa
rtic
ipat
ive.
• Ch
alle
nges
ass
umpt
ions
.
• Ch
ampi
ons
pers
on-c
entr
ed
appr
oach
es.
• Ch
alle
nges
ass
umpt
ion
and
take
n fo
r gra
nted
way
s of
wor
king
.
• A
ctiv
ely
prom
otes
bet
ter h
ealt
h
for p
atie
nts.
35
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
7Se
e ab
ove.
See
abov
e.Se
e ab
ove.
See
abov
e.Se
e ab
ove.
• N
ICE
CG 1
15 A
lcoh
ol u
se d
isor
ders
: di
agno
sis,
ass
essm
ent a
nd
man
agem
ent o
f har
mfu
l dri
nkin
g an
d al
coho
l dep
ende
nce
ww
w.g
uida
nce.
nice
.org
.uk/
CG11
5.
• N
ICE
PH 2
4 A
lcoh
ol-u
se d
isor
ders
–
prev
enti
ng th
e de
velo
pmen
t of
haza
rdou
s an
d ha
rmfu
l dri
nkin
g.
ww
w.g
uida
nce.
nice
.org
.uk/
PH24
.
Ass
esse
s, in
col
labo
rati
on w
ith
the
pati
ent (
youn
g pe
ople
, adu
lts,
fam
ily/
care
rs),
thei
r he
alth
car
e ne
eds,
taki
ng in
to a
ccou
nt th
e im
pact
of
thei
r ag
e, v
ulne
rabi
lity
, the
ir li
fest
yle,
cul
tura
l and
eth
nic
back
grou
nd (c
onti
nued
)4
36
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Dev
elop
s an
d ev
alua
tes
a se
lf-m
anag
emen
t pla
n w
ith
the
pati
ent w
ho h
as p
redi
spos
ing
fact
ors
to li
ver
dise
ase
5 Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
5D
evel
ops
and
eval
uate
s a
self-
man
agem
ent
plan
with
th
e pa
tient
w
ho h
as
pred
ispo
sing
fa
ctor
s to
live
r di
seas
e.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
a. A
sses
smen
t of p
atie
nt ri
sk
fact
ors
for l
iver
dis
ease
.
b. D
iscu
sses
wit
h th
e pa
tien
t th
eir r
isk
fact
ors.
c. D
evel
ops
and
reco
rds
a se
lf-m
anag
emen
t pla
n w
ith
the
pati
ent/
fam
ily/c
arer
s.
d. U
ses
pati
ent-
held
reco
rd/
diar
ies.
e. Im
plem
ents
app
ropr
iate
br
ief a
dvic
e an
d in
terv
enti
ons.
f. D
ocum
ents
inte
rven
tion
s an
d sh
ares
info
rmat
ion
wit
h th
e m
ulti
-dis
cipl
inar
y te
am,
as a
ppro
pria
te.
g. E
valu
ates
sel
f m
anag
emen
t pla
n an
d go
als
set.
h. D
emon
stra
tes
skill
s in
med
iati
on, c
onfli
ct
reso
luti
on a
nd a
dvoc
acy.
• th
e ne
eds
of p
atie
nts
who
hav
e pr
edis
posi
ng
fact
ors
to li
ver d
isea
se s
uch
as a
lcoh
ol, v
iral
, ob
esit
y, g
enet
ic p
redi
spos
itio
n, d
iabe
tes,
se
xual
hea
lth
• av
aila
ble
reso
urce
s an
d w
here
and
how
to
acce
ss th
em
• ho
w c
ultu
ral,
ethn
ic a
nd re
ligio
us b
ackg
roun
ds
influ
ence
life
styl
e ch
oice
s
• th
e im
pact
of l
ivin
g w
ith
a ch
roni
c co
ndit
ion
in
rela
tion
to s
elf-
man
agem
ent a
nd a
dher
ence
• ti
mel
y di
scus
sion
of e
nd o
f life
car
e.
Kno
ws
how
to:
• w
ork
colla
bora
tive
ly w
ith
the
pati
ent
• de
velo
p an
d m
aint
ain
a se
lf-m
anag
emen
t pla
n th
at a
chie
ves
the
pote
ntia
l of t
he in
divi
dual
and
m
aint
ains
thei
r mot
ivat
ion
and
confi
denc
e
• de
velo
p go
als
colla
bora
tive
ly th
at a
re S
MA
RT
(spe
cific
, mea
sura
ble,
ach
ieva
ble,
real
isti
c an
d ti
me-
spec
ific)
• be
nchm
ark
arou
nd th
e ac
tivi
ties
of d
aily
livi
ng
and
impr
ovem
ent s
trat
egie
s
• ho
w a
nd w
here
to c
onfid
enti
ally
reco
rd a
nd
repo
rt in
form
atio
n, th
e el
ectr
onic
reco
rd a
nd
data
base
s, a
nd d
ata
that
can
sup
port
qua
lity
impr
ovem
ent t
hrou
gh s
hari
ng a
nd p
eer-
revi
ew
• re
fer t
o pa
lliat
ive
care
ser
vice
s an
d ke
ep G
P pr
acti
ce a
nd re
late
d co
mm
unit
y te
ams
info
rmed
.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• Su
ppor
tive
.
• En
cour
agin
g.
• Pr
ovid
es c
hoic
es.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• Fl
exib
le.
• N
on-ju
dgm
enta
l.
• Pa
ssio
nate
abo
ut p
atie
nt c
are.
Gen
eric
•
NM
C do
cum
ents
and
gui
danc
e.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
and
gui
danc
e.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Liv
er N
urse
s Fo
rum
(BA
SLN
F).
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f life
car
e.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2)
Dea
ths
from
Liv
er D
isea
se. I
mpl
icat
ions
for e
nd o
f lif
e ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le
peop
le in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as, C
QU
INS,
PR
OM
S et
c.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
).
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a re
view
of
pati
ents
who
die
d w
ith
alco
hol-r
elat
ed li
ver d
isea
se,
Lond
on, N
CEPO
D.
• N
HS
IQ (
Impr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fi
rst 2
4 ho
urs.
• N
HS
Engl
and
(201
3) T
he 6
Cs.
(con
tinu
ed)
37
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
6D
evel
ops
and
eval
uate
s a
self-
man
agem
ent
plan
with
th
e pa
tient
w
ho h
as
pred
ispo
sing
fa
ctor
s to
live
r di
seas
e.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
a. W
orks
col
labo
rati
vely
wit
h th
e pa
tien
t and
/or
car
ers
to a
sses
s th
eir l
evel
of u
nder
stan
ding
of
thei
r con
diti
on.
b. Id
enti
fies
in c
olla
bora
tion
wit
h th
e pa
tien
t an
d/or
fam
ily/c
arer
s, w
ho h
ave
pred
ispo
sing
fa
ctor
s fo
r liv
er d
isea
se, t
heir
nee
ds a
nd g
ives
ap
prop
riat
e ad
vice
.
c. D
iscu
sses
var
ious
life
styl
e ch
oice
s w
ith
the
pati
ent a
nd p
ossi
ble
impl
icat
ions
for t
heir
im
med
iate
and
long
-ter
m h
ealt
h.
d. Id
enti
fies
agre
ed p
atie
nt g
oals
that
can
be
eval
uate
d an
d re
view
ed p
erio
dica
lly.
e. A
gree
s ap
prop
riat
e ri
sk p
rofil
ing
and
inve
stig
atio
ns a
s pa
rt o
f the
pat
ient
’s s
elf-
man
agem
ent p
lan.
f. In
tegr
ates
sup
port
str
ateg
ies
for p
atie
nts
wit
h de
teri
orat
ing
heal
th.
g. H
elps
pat
ient
to n
avig
ate
thei
r way
thro
ugh
the
heal
th c
are
syst
em to
ach
ieve
the
mos
t ap
prop
riat
e ca
re.
• th
e ba
rrie
rs to
con
tinu
ity
of c
are
and
how
they
ca
n be
ove
rcom
e
• lo
cal n
etw
orks
in th
e ho
spit
al a
nd th
e co
mm
unit
y, a
nd k
now
ledg
e of
how
to b
uild
go
od re
lati
onsh
ips
• lo
ng-t
erm
com
plic
atio
ns a
nd ri
sk p
rofil
ing
appr
oach
es
• de
teri
orat
ion
and
reco
gnit
ion
of c
hron
ic
live
r dis
ease
and
its
impa
ct o
n th
e pa
tien
t a
nd fa
mily
/car
ers
• ke
y ou
tcom
es th
at c
an b
e m
easu
red
and
mon
itore
d
• su
ppor
t str
ateg
ies
for t
hose
wit
h de
teri
orat
ing
heal
th.
Kno
ws
how
to:
• ev
alua
te th
e ou
tcom
es o
f car
e fo
r ind
ivid
uals
and
cl
ient
gro
ups
in re
lati
on to
bot
h cl
inic
al o
utco
mes
an
d th
e pa
tien
t’s
expe
rien
ce
• in
itia
tes
end
of li
fe d
iscu
ssio
ns w
ith
pati
ent i
n co
llabo
rati
on w
ith
mul
ti-d
isci
plin
ary
team
.
• M
odel
s be
st p
ract
ice.
• Em
pow
erin
g.
• Co
llabo
rati
ve.
• In
clus
ive.
• H
ones
t and
ope
n.
• W
orks
in p
artn
ersh
ip.
• Em
brac
es d
iffer
ent p
ersp
ecti
ves.
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
ch
arit
ies
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
Gro
up
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy
of th
e Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy
of L
iver
Dis
ease
s (A
ASL
D)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral
and
Ente
ral N
utri
tion
(BA
PEN
).
• N
HS
Engl
and
The
Info
rmat
ion
Stan
dard
.
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
.
• Sk
ills
for H
ealt
h.
Spec
ific
• N
atio
nal S
ervi
ce F
ram
ewor
ks –
Obe
sity
.
• D
H (2
006)
Our
Hea
lth, O
ur C
are,
Our
Say
.
• N
ICE
(201
4-5)
Gui
danc
e on
obe
sity
.
• D
H (2
001)
Exp
ert P
atie
nt.
• R
CN (2
010)
Pri
ncip
les
of
Nur
sing
Pra
ctic
e.
Dev
elop
s an
d ev
alua
tes
a se
lf-m
anag
emen
t pla
n w
ith
the
pati
ent w
ho h
as p
redi
spos
ing
fact
ors
to li
ver
dise
ase
(con
tinu
ed)
5
38
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
7D
evel
ops
and
eval
uate
s a
self-
man
agem
ent
plan
with
th
e pa
tient
w
ho h
as
pred
ispo
sing
fa
ctor
s to
live
r di
seas
e.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
a. E
nabl
es c
ontin
uity
of c
are
for t
hose
pa
tient
s w
ith c
ompl
ex h
ealth
nee
ds to
im
plem
ent t
heir
self-
man
agem
ent p
lan,
su
ch a
s in
the
com
mun
ity.
b. W
orks
col
labo
rati
vely
to m
anag
e th
e pa
tien
t’s
sym
ptom
s su
ch a
s as
cite
s, h
epat
ic
ence
phal
opat
hy b
etw
een
prim
ary
and
seco
ndar
y ca
re.
c. R
ecog
nise
s ea
rly
need
for d
iscu
ssio
n ab
out
pati
ents
pre
fere
nces
in e
nd o
f life
pla
nnin
g an
d ca
re.
d. D
evel
ops
a co
llabo
rati
ve p
lan
of c
are
wit
h pa
tien
t and
fam
ily fo
r man
agin
g en
d-st
age
liver
dis
ease
, pal
liati
on a
nd s
ympt
om c
ontr
ol
for e
nd o
f life
car
e.
• th
e pr
inci
ples
of c
are
in re
spec
t to
com
plex
he
alth
nee
ds
• lo
ng-t
erm
and
chr
onic
dis
ease
del
iver
y ca
re
path
way
s in
clud
ing
end
of li
fe c
are
• ch
oice
s av
aila
ble
to th
e pa
tien
t for
end
of l
ife c
are
arou
nd h
ome,
hos
pice
and
hos
pita
l.
Kno
ws
how
to:
• pl
an, d
eliv
er a
nd e
valu
ate
care
for p
eopl
e w
ith
pred
ispo
sing
fact
ors
of li
ver d
isea
se
• bu
ild a
nd s
tren
gthe
n co
mm
unit
y an
d ho
spit
al
rela
tion
ship
s to
cre
ate
seam
less
ser
vice
s
• in
nova
te a
nd im
prov
e se
rvic
es to
enh
ance
he
alth
-rel
ated
qua
lity
of li
fe
• re
cogn
ises
whe
n en
d of
life
car
e ne
eds
to b
e di
scus
sed
and
plan
ned
for
• le
ad p
atie
nt c
onfe
renc
es a
nd p
eer r
evie
w
• en
gage
wit
h pa
tien
t to
expl
ore
end
of li
fe c
hoic
es
• w
ork
wit
h th
e m
ulti
-dis
cipl
inar
y te
am a
nd
prim
ary
care
to p
lan
end
of li
fe c
are.
• R
ole
mod
el.
• In
terp
rofe
ssio
nal w
orki
ng.
• Ch
ampi
ons
pers
on-c
entr
ed
appr
oach
es.
• Ch
alle
nges
ass
umpt
ions
and
ta
ken
for g
rant
ed w
ays
of w
orki
ng.
• A
ctiv
ely
prom
otes
bet
ter h
ealt
h fo
r pat
ient
s.
• St
rong
clin
ical
lead
ersh
ip.
• V
isib
le in
pra
ctic
e se
ttin
gs.
See
abov
e.
Dev
elop
s an
d ev
alua
tes
a se
lf-m
anag
emen
t pla
n w
ith
the
pati
ent w
ho h
as p
redi
spos
ing
fact
ors
to li
ver
dise
ase
(con
tinu
ed)
5
39
R O Y A L C O L L E G E O F N U R S I N G
Wor
ks a
long
side
and
wit
h th
e pa
tien
t (an
d fa
mil
ies/
care
rs) t
o ad
dres
s th
e ps
ycho
logi
cal a
nd s
ocia
l im
pact
of t
heir
con
diti
on6 Le
vel
Com
pete
nce
KS
FP
erfo
rman
ce c
rite
ria
Kno
wle
dge
and
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
1-4
Prov
ides
si
mpl
e ps
ycho
logi
cal
and
soci
al
inte
rven
tions
an
d se
eks
supp
ort
appr
opri
atel
y.
KSF
Core
1
HW
B2
HW
B4
HW
B5
HW
B6
a. P
rovi
des
supp
ort a
nd e
ncou
rage
men
t by
fam
iliar
isin
g th
e pa
tien
t wit
h th
e w
ard
or c
linic
env
iron
men
t (su
ch a
s to
ilet
loca
tion
, mea
l tim
es, v
isit
ing
tim
es).
b. C
omm
unic
ates
trea
tmen
t pla
ns c
lear
ly
and
reco
gnis
es th
at h
ospi
talis
atio
n is
a
maj
or s
tres
s fa
ctor
for p
atie
nts.
c. L
iste
ns a
nd e
mpa
this
es w
ith
the
pati
ent,
doc
umen
ts in
form
atio
n an
d di
scus
ses
wit
h al
l inv
olve
d in
the
care
, an
d ta
kes
appr
opri
ate
acti
on.
d. S
eeks
sup
port
from
col
leag
ues
in
resp
onse
to d
istr
essi
ng c
onve
rsat
ions
.
• v
erba
l and
non
-ver
bal c
omm
unic
atio
n in
clud
ing
para
lingu
isti
cs s
uch
as s
ilenc
e, s
ighs
, clic
king
of t
he
tong
ue a
nd o
ther
non
-ver
bal u
tter
ance
s.
• A
war
e of
role
lim
itat
ions
and
w
hen
to o
btai
n he
lp.
• P
erso
n ce
ntre
d an
d co
mpa
ssio
nate
.
• L
iste
ns.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• C
onfid
enti
al.
• P
ride
in w
ork.
• R
espe
ctfu
l.
Gen
eric
• N
MC
docu
men
ts a
nd g
uida
nce.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
an
d gu
idan
ce.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Li
ver N
urse
s Fo
rum
(BA
SLN
F).
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f lif
e ca
re.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fr
om L
iver
Dis
ease
. Im
plic
atio
ns fo
r end
of l
ife c
are.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as,
CQU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(W
illia
ms
et a
l, 20
14)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a
revi
ew o
f pat
ient
s w
ho d
ied
wit
h al
coho
l-re
late
d liv
er d
isea
se,
Lond
on, N
CEPO
D.
5W
orks
al
ongs
ide
the
patie
nt a
nd
fam
ilies
/car
ers
to a
ddre
ss
psyc
holo
gica
l an
d so
cial
im
pact
of t
heir
co
nditi
on.
KSF
Core
1
HW
B2
HW
B4
HW
B5
HW
B6
a. Id
enti
fies
verb
al a
nd n
on-v
erba
l si
gns
of d
istr
ess,
sup
port
s th
e pa
tien
t,
disc
usse
s w
ith
the
med
ical
team
s an
d re
fers
to th
e ps
ycho
logy
team
or l
ocal
ps
ycho
logy
ser
vice
.
b. A
sses
ses
pati
ent a
nd id
enti
fies
soci
al
prob
lem
s th
at re
quir
e su
ppor
t.
c. Id
enti
fies
soci
al is
sues
, inc
ludi
ng
educ
atio
n, e
mpl
oym
ent,
hou
sing
and
w
elfa
re, a
nd m
akes
app
ropr
iate
refe
rral
to
soci
al w
orke
rs o
r non
-hea
lth
agen
cies
.
d. P
rovi
des
supp
ort a
nd id
enti
fies
psyc
holo
gica
l and
soc
ial n
eeds
in
rela
tion
to th
e im
pact
of t
he c
ondi
tion
in
gen
eral
e.g
. sti
gma
rela
ted
to c
hron
ic
liver
dis
ease
.
e. In
itia
tes
com
mun
icat
ion
duri
ng
asse
ssm
ent a
nd d
urin
g th
e pa
tien
t’s
jour
ney
usin
g op
en/c
lose
d qu
esti
ons
and
prov
ides
an
envi
ronm
ent f
or e
ffec
tive
co
mm
unic
atio
n.
f. Id
enti
fies
com
mun
icat
ion
prob
lem
s w
ithi
n fa
mily
rela
tion
ship
s an
d/or
par
tner
re
lati
onsh
ips.
g. R
aise
s co
ncer
ns to
app
ropr
iate
m
embe
rs o
f the
MD
T in
pri
mar
y or
se
cond
ary
care
.
• s
igns
and
sym
ptom
s of
alt
ered
men
tal s
tate
, mem
ory
loss
• c
ultu
ral e
xpre
ssio
ns/w
ays
of e
xpre
ssin
g di
stre
ss a
nd
pain
• c
ultu
ral v
aria
tion
s in
way
s of
com
mun
icat
ion
• d
iffer
ent c
omm
unic
atio
n st
rate
gies
• p
sych
olog
ical
sup
port
ser
vice
s or
oth
er re
sour
ces
avai
labl
e su
ch a
s bi
lingu
al h
ealt
h ad
voca
tes
• h
ow to
sup
port
pat
ient
s to
con
cord
wit
h tr
eatm
ent
• h
ow to
ena
ble
pati
ents
to m
anag
e ex
pect
atio
ns
• m
anag
e yo
ung
peop
le’s
and
adu
lts
need
for l
ong
term
car
e
• th
e im
pact
of s
afe
sexu
al h
ealt
h on
rela
tion
ship
s
• th
e ne
eds
of h
omel
ess
peop
le a
nd a
war
enes
s of
loca
l ho
mel
ess
care
pat
hway
s
• m
anag
ing
the
stig
ma
and
publ
ic a
ssum
ptio
ns a
roun
d ch
roni
c liv
er d
isea
se e
.g. j
aund
ice
and
asci
tes
• th
e so
cial
impa
ct o
f alt
ered
men
tal s
tate
in re
lati
on to
re
lati
onsh
ips,
em
ploy
men
t, s
elf c
are
• th
e ro
les
of p
sych
olog
ists
and
soc
ial w
orke
rs w
ithi
n th
e m
ulti
disc
iplin
ary
team
.
• th
e ps
ycho
logi
cal i
mpa
ct o
f alc
ohol
and
/ o
r dru
g m
isus
e
Kno
ws
how
to:
• a
sses
s so
cial
sup
port
and
men
tal h
ealt
h.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• S
uppo
rtiv
e.
• E
ncou
ragi
ng.
• E
mpo
wer
ing.
• P
rovi
des
choi
ces.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• F
lexi
ble.
• N
on-ju
dgm
enta
l.
• P
assi
onat
e ab
out p
atie
nt c
are.
40
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Wor
ks a
long
side
and
wit
h th
e pa
tien
t (an
d fa
mil
ies/
care
rs) t
o ad
dres
s th
e ps
ycho
logi
cal a
nd s
ocia
l im
pact
of t
heir
con
diti
on (c
onti
nued
)6 Le
vel
Com
pete
nce
KS
FP
erfo
rman
ce c
rite
ria
Kno
wle
dge
and
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
6W
orks
al
ongs
ide
the
patie
nt a
nd
fam
ilies
/car
ers
to a
ddre
ss
psyc
holo
gica
l an
d so
cial
im
pact
of t
heir
co
nditi
on.
KSF
Core
1
HW
B2
HW
B4
HW
B5
HW
B6
a. A
sses
ses
pati
ent a
nd id
enti
fies
pote
ntia
l or
actu
al p
sych
olog
ical
pro
blem
s.
b. Id
enti
fies
stre
ngth
s an
d w
eakn
ess,
and
an
indi
vidu
al’s
cop
ing
stra
tegi
es w
hen
this
ha
s be
en c
alle
d in
to q
uest
ion;
reas
sure
s th
e in
divi
dual
and
mak
es a
n ap
prop
riat
e re
ferr
al
to th
e ps
ycho
logy
team
or l
ocal
psy
chol
ogy/
psyc
hiat
ry s
ervi
ce.
c. C
reat
es a
nd e
valu
ates
a c
are
plan
bas
ed o
n ac
hiev
able
goa
ls, s
tren
gths
and
wea
knes
ses,
co
ping
str
ateg
ies,
fam
ily a
nd s
ocia
l sup
port
.
d. Id
enti
fies
indi
vidu
als
wit
h lo
ng-t
erm
co
mpl
icat
ions
aff
ecti
ng m
enta
l cap
acit
y su
ch a
s ce
rebr
al a
trop
hy, c
hron
ic h
epat
ic
ence
phal
opat
hy, W
erni
cke’
s en
ceph
alop
athy
or
Kor
sako
ff’s
psy
chos
is.
e. D
emon
stra
tes
the
abili
ty to
inve
stig
ate
pers
onal
bac
kgro
und
and
iden
tify
fam
ily
dyna
mic
s th
at m
ight
hav
e an
impa
ct o
n he
alth
.
f. Id
enti
fies
com
mun
icat
ion
prob
lem
s w
ithi
n fa
mily
rela
tion
ship
s an
d/or
par
tner
re
lati
onsh
ips
and
take
s ap
prop
riat
e ac
tion
.
g. A
dvis
es, s
uppo
rts
and
sign
post
s pa
tien
t and
fa
mily
/car
ers
to c
omm
unit
y se
rvic
es a
vaila
ble
h. M
akes
refe
rral
s w
here
app
ropr
iate
.
Kno
wle
dge
and
unde
rsta
ndin
g of
:
• s
igns
and
sym
ptom
s of
alt
ered
men
tal s
tate
, m
emor
y lo
ss a
nd th
resh
olds
for r
efer
ral t
o ps
ycho
logy
team
or l
ocal
men
tal h
ealt
h se
rvic
e
• th
e cr
iter
ia a
nd th
resh
olds
for r
efer
ral t
o ps
ychi
atry
ser
vice
s
• c
ompl
exit
y of
psy
chol
ogic
al n
eeds
of y
oung
pe
ople
and
adu
lts
in re
lati
on to
long
term
car
e
• s
trat
egie
s us
ed to
sup
port
and
mee
t the
nee
ds
and/
or e
xpec
tati
ons
of h
omel
ess
peop
le.
Kno
ws
how
to:
• m
anag
e ex
tern
al fa
ctor
s e.
g. fa
mily
dyn
amic
s.
• M
odel
s be
st p
ract
ice.
• P
artn
ersh
ip.
• In
clus
ive.
• E
mbr
aces
diff
eren
t per
spec
tive
s.
• V
alue
s ot
hers
.
• D
evel
ops
trus
t.
• W
illin
g to
lear
n fr
om o
wn
prac
tice
.
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er
Dis
ease
: Ris
k fa
ctor
s an
d tr
eatm
ent
(fre
e ac
cess
)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is
care
Bun
dle:
Fir
st 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
ch
arit
ies
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
G
roup
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy
of th
e Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy
of L
iver
Dis
ease
s (A
ASL
D)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral
and
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
41
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
7W
orks
al
ongs
ide
the
patie
nt a
nd
fam
ilies
/car
ers
to a
ddre
ss
psyc
holo
gica
l an
d so
cial
im
pact
of t
heir
co
nditi
on.
KSF
Core
1
Core
3
HW
B2
HW
B4
HW
B5
HW
B6
a. A
sses
ses
anxi
ety
and
depr
essi
on u
sing
risk
pr
ofilin
g to
ols
copi
ng s
trat
egie
s; im
plem
ents
ca
re a
nd c
arri
es o
ut a
n ev
alua
tion
bas
ed o
n th
e pr
oble
ms
iden
tifie
d.
b. U
nder
take
s as
sess
men
t th
at in
clud
es
men
tal h
ealt
h; id
enti
fies
men
tal h
ealt
h is
sues
and
psy
cho-
soci
al is
sues
and
mak
es
appr
opri
ate
refe
rral
(s).
c. R
efer
s to
and
wor
ks c
lose
ly w
ith
so
cial
ser
vice
s.
d. R
ecog
nise
s th
e ne
eds
of fa
mily
/car
ers
who
car
e fo
r th
e pa
tien
t w
ith
liver
dis
ease
, of
fers
su
ppor
t an
d si
gnpo
sts
them
to
appr
opri
ate
agen
cies
.
• th
e em
otio
nal/
psyc
ho-s
ocia
l im
pact
of c
hron
ic
dise
ase
man
ifest
atio
n
• p
oten
tial
impa
ct o
f soc
ial d
epri
vati
on o
n he
alth
st
atus
and
live
r hea
lth
• c
olla
bora
tive
wor
king
wit
h ps
ycho
soci
al
spec
ialis
ts to
del
iver
car
e
• ri
sk p
rofil
ing
tool
s fo
r dep
ress
ion
and
anxi
ety
such
as
PhQ
9 (r
ecom
men
ded
by N
SG 9
1, N
ICE)
, CO
RE
and
HA
DS
ques
tion
nair
es
• in
terv
enti
ons,
e.g
. cog
niti
ve b
ehav
iour
al
ther
apy
(CB
T)
• m
otiv
atio
nal t
echn
ique
s
• ri
sk a
sses
smen
t for
lone
wor
ker/
sett
ing
Kno
ws
how
to:
• ta
ke a
full
com
preh
ensi
ve h
isto
ry, i
dent
ify
actu
al a
nd p
oten
tial
pro
blem
s an
d ta
ke
appr
opri
ate
acti
on
• u
nder
take
men
tal h
ealt
h an
d de
pres
sion
/anx
iety
as
sess
men
ts a
nd u
se a
sses
smen
t too
ls
• m
aint
ain
clos
e re
lati
onsh
ips
wit
h ps
ycho
soci
al
spec
ialis
ts a
nd s
ocia
l car
e se
rvic
es
• R
ole
mod
el.
• C
olla
bora
tive
.
• C
halle
nges
ass
umpt
ions
and
take
n fo
r gra
nted
way
s of
wor
king
.
• A
ctiv
e pr
omot
es b
ette
r hea
lth
fo
r pat
ient
s.
• V
alue
s le
arni
ng.
• S
tron
g cl
inic
al le
ader
ship
.
Spec
ific
• D
H, L
ong
Term
Con
ditio
ns –
Impr
ovin
g Ac
cess
to P
sych
olog
ical
The
rapi
es.
• T
he P
sych
olog
ical
Car
e of
Med
ical
P
atie
nts:
A P
ract
ical
Gui
de (2
003)
. R
epor
t of a
join
t wor
king
par
ty o
f the
R
oyal
Col
lege
of P
hysi
cian
s an
d th
e R
oyal
Col
lege
of P
sych
iatr
ists
.
• N
ICE
Gui
danc
e on
anx
iety
an
d de
pres
sion
.
• G
over
nmen
t Gui
danc
e Li
ving
Will
and
Ad
vanc
ed D
irect
ives
info
rmat
ion.
Wor
ks a
long
side
and
wit
h th
e pa
tien
t (an
d fa
mil
ies/
care
rs) t
o ad
dres
s th
e ps
ycho
logi
cal a
nd s
ocia
l im
pact
of t
heir
con
diti
on (c
onti
nued
)
6
42
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y:7.
1 U
nder
taki
ng p
hleb
otom
y an
d ca
nnul
atio
n in
the
pati
ent w
ith
diffi
cult
acc
ess
asso
ciat
ed w
ith
thei
r li
ver
dise
ase
It is
reco
gnis
ed th
at in
som
e or
gani
sati
ons
phle
boto
my
and
cann
ulat
ions
may
be
unde
rtak
en b
y Co
mpe
tenc
e Le
vel 1
-5. T
his
com
pete
nce
spec
ifica
lly
rela
tes
to li
ver p
atie
nts
wit
h di
fficu
lt a
cces
s.7 Le
vel
Com
pete
nce
KS
FP
erfo
rman
ce c
rite
ria
Kno
wle
dge
and
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
6Pr
ovid
es
spec
ific
diag
nost
ic/
trea
tmen
t op
tions
saf
ely
with
rega
rds
to:
unde
rtak
ing
phle
boto
my
and
cann
ulat
ion
in th
e pa
tient
w
ith d
ifficu
lt ac
cess
as
soci
ated
w
ith th
eir l
iver
di
seas
e.
HW
B7
Core
2
Core
3
G1
a. A
sses
ses
the
clin
ical
nee
d fo
r ven
epun
ctur
e/
cann
ulat
ion
taki
ng in
to c
onsi
dera
tion
th
at p
atie
nts
wit
h liv
er d
isea
se m
ay b
e im
mun
ocom
prom
ised
or h
ave
alte
red
coag
ulop
athy
/ pe
riph
eral
oed
ema.
b. L
iste
ns a
nd re
spon
ds to
the
pati
ent’
s an
d th
eir c
arer
/fam
ily’s
sug
gest
ions
and
is s
ensi
tive
to
fam
ily/c
arer
con
cern
s (p
arti
cula
rly
whe
n th
e pa
tien
t is
a yo
ung
pers
on) a
nd a
ckno
wle
dges
th
e ad
ult a
s an
exp
ert p
atie
nt.
c. C
olla
bora
tes
wit
h th
e pa
tien
t to
iden
tify
po
ints
of v
enou
s ac
cess
.
d. Id
enti
fies
alte
rnat
ive
appr
oach
es fo
r pat
ient
s w
ith
‘poo
r acc
ess’
and
oed
ema,
and
iden
tifie
s st
rate
gies
for p
atie
nts
to ta
ke th
eir o
wn
bloo
d.
e. S
elec
ts v
ein
info
rmed
by
a ra
nge
of fa
ctor
s,
e.g.
wit
h re
gard
s to
pai
n an
d as
epsi
s.
f. Pr
epar
es p
atie
nt u
sing
com
fort
ing
and
dist
ract
ing
stra
tegi
es, e
.g. u
se o
f top
ical
an
aest
heti
c cr
eam
or s
pray
, dis
trac
tion
and
co
mfo
rt.
g. A
gree
s w
ith
the
pati
ent w
hat t
o do
if
diffi
cult
y ta
king
blo
ods
or w
ith
cann
ulat
ion,
e.
g. n
umbe
r of t
imes
to tr
y.
h. U
nder
take
s bl
ood
inve
stig
atio
ns/
cann
ulat
ion
safe
ly a
nd id
enti
fies
the
pati
ent
verb
ally
or v
ia p
atie
nt id
enti
ficat
ion
brac
elet
.
i. R
ecor
ds, o
bser
ves
and
mon
itor
s ca
nnul
a si
te.
j. Su
ppor
ts th
e pa
tien
t who
regu
larl
y ta
kes
thei
r ow
n bl
ood.
k. W
here
app
licab
le tr
ains
and
sup
ervi
ses
othe
rs in
can
nula
tion
/phl
ebot
omy
tech
niqu
es
and
care
.
l. U
nder
take
s ca
nnul
atio
n/ph
lebo
tom
y us
ing
ultr
asou
nd te
chni
ques
or v
ein
illum
inat
ion.
• p
atie
nt s
afet
y an
d co
nsen
t
• lo
cal g
uida
nce
and
polic
ies
• a
nato
my
and
phys
iolo
gy o
f art
erie
s an
d ve
ins
• d
iffer
ent t
ypes
of c
annu
lati
on/b
utte
rflie
s or
ne
edle
siz
es
• n
eedl
e st
ick
guid
ance
/pol
icie
s
• th
e im
pact
of c
onti
nued
acc
ess
to v
eins
• d
istr
acti
on te
chni
ques
• w
hen
it is
app
ropr
iate
for t
he p
atie
nt to
take
thei
r ow
n bl
ood
• th
e in
crea
sed
risk
of k
eloi
d/sc
arri
ng/i
nfec
tion
/ps
ycho
logi
cal d
istr
ess
• p
ossi
ble
com
plic
atio
ns
• a
ids
to d
ilate
ven
ous
acce
ss
• a
lter
nati
ves
to c
annu
lati
ons
for p
atie
nts
wit
h
poor
acc
ess
• n
eedl
e ph
obia
s re
lati
ng to
the
pati
ent’
s pa
st
med
ical
his
tory
• th
e tr
eatm
ent a
nd m
anag
emen
t of i
ron
ov
erlo
ad d
isea
ses
• th
eore
tica
l kno
wle
dge
requ
ired
to u
nder
take
ul
tras
ound
and
use
vei
n ill
umin
atio
n de
vice
s
• c
rite
ria,
tech
niqu
es a
nd h
azar
ds w
hen
usin
g fe
mor
al/j
ugul
ar s
tabs
for b
lood
taki
ng
• o
wn
scop
e of
pra
ctic
e an
d lim
itat
ions
.
Kno
ws
how
to:
• re
cogn
ise,
man
age
and
deal
wit
h ne
edle
pho
bias
, it
s im
pact
on
fam
ilies
and
car
ers
• re
fer t
o sp
ecia
list h
elp
whe
n re
leva
nt
• re
cogn
ise
and
act o
n co
mpl
icat
ions
and
wit
h em
erge
ncy
situ
atio
ns.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• Pa
tien
t cen
tred
and
co
mpa
ssio
nate
.
• Li
sten
s.
• U
nder
stan
ding
.
• N
on-ju
dgm
enta
l.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• Co
nfide
ntia
l.
• W
orks
in p
artn
ersh
ip w
ith
othe
rs.
• Pe
rson
-cen
tred
app
roac
h.
• Th
inks
cre
ativ
ely.
• D
evel
ops
trus
t.
• Pr
ovid
es c
hoic
es.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• V
alue
s ot
hers
.
• Pr
ovid
es h
igh
supp
ort a
nd h
igh
chal
leng
e.
• Em
brac
es d
iffer
ent p
ersp
ecti
ves.
• M
odel
s be
st p
ract
ice.
Gen
eric
• N
MC
docu
men
ts a
nd g
uida
nce.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
an
d gu
idan
ce.
• R
CN G
astr
oint
estin
al N
ursi
ng F
orum
.
• B
ritis
h As
soci
atio
n fo
r the
Stu
dy o
f the
Li
ver N
urse
s Fo
rum
(BAS
LNF)
.
• B
ritis
h Li
ver N
urse
s Fo
rum
(BLN
F).
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth E
ngla
nd.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd
of li
fe c
are.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fro
m L
iver
D
isea
se. I
mpl
icat
ions
for e
nd o
f lif
e ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acity
Act
200
5.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ectio
n Ac
t 199
8.
• N
HS
Choi
ces.
• N
HS
Inst
itute
for I
nnov
atio
n an
d Im
prov
emen
t.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as,
CQU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(W
illia
ms
et a
l, 20
14)
• N
ECPO
D 2
013
Mea
surin
g th
e un
its:
a re
view
of p
atie
nts
who
die
d w
ith
alco
hol-r
elat
ed li
ver d
isea
se,
Lond
on, N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
ality
)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Live
r D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s)
43
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
(con
tinu
ed)
7Pr
ovid
es
spec
ific
diag
nost
ic/
trea
tmen
t op
tions
saf
ely
with
rega
rds
to:
unde
rtak
ing
phle
boto
my
and
cann
ulat
ion
in th
e pa
tient
w
ith d
ifficu
lt ac
cess
as
soci
ated
w
ith th
eir l
iver
di
seas
e.
HW
B7
Core
2
Core
3
G1
a. A
ccep
ts re
ferr
als
of c
ompl
ex/c
haot
ic p
atie
nts
if ap
prop
riat
e.
b. G
ains
info
rmed
con
sent
in th
e co
mpl
ex/
chao
tic
pati
ent.
c. U
nder
take
s an
d in
terp
rets
a ri
sk a
sses
smen
t fo
r the
pat
ient
.
d. U
nder
take
s ju
gula
r and
fem
oral
ve
nepu
nctu
re s
afel
y if
appr
opri
ate
acco
rdin
g to
loca
l pol
icy.
e. M
aint
ains
ow
n co
mpe
tenc
e in
thes
e pr
oced
ures
in
line
with
loca
l and
nat
iona
l gui
danc
e.
f. Tr
ains
, edu
cate
s an
d as
sess
es o
ther
hea
lth
care
pro
fess
iona
ls in
ult
raso
und
and
use
of v
ein
illum
inat
ion
devi
ces.
g. U
nder
take
s au
dit a
nd s
ervi
ce e
valu
atio
n su
ch
as c
ompl
icat
ions
and
infe
ctio
n ra
tes
or p
atie
nt
expe
rien
ce.
• a
ppro
pria
te a
sses
smen
t ski
lls
unde
rpin
ned
by re
leva
nt a
nato
my
and
phys
iolo
gy
• w
hen
it is
app
ropr
iate
to u
se ju
gula
r or
fem
oral
rout
es fo
r ven
epun
ctur
e
• th
e co
mpl
ex is
sues
that
pat
ient
s m
ay
pres
ent w
ith
• p
roto
col a
nd s
ervi
ce d
evel
opm
ent.
Kno
ws
how
to:
• c
annu
late
a p
atie
nt s
afel
y vi
a ju
gula
r or
fem
oral
ven
epun
ctur
e an
d po
ssib
le
com
plic
atio
ns
• in
terp
ret r
isk
asse
ssm
ent a
nd in
volv
es
othe
r hea
lth
care
pro
fess
iona
ls if
ap
prop
riat
e.
• C
ham
pion
s pa
tien
t-ce
ntre
d ap
proa
ch.
• R
ole
mod
el.
• V
alue
s le
arni
ng.
• C
olla
bora
tive
wor
king
acr
oss
serv
ices
.
Gen
eric
(con
tinu
ed)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fi
rst 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er in
form
atio
n an
d su
ppor
t fro
m k
ey c
hari
ties
and
org
anis
atio
ns,
such
as:
–
Bri
tish
Liv
er T
rust
– Ch
ildre
n’s
Live
r Dis
ease
Fou
ndat
ion
– A
lcoh
ol C
once
rn–
The
Hep
atit
is C
Tru
st–
Hep
atit
is B
Fou
ndat
ion
UK
– H
aem
ochr
omat
osis
Soc
iety
– W
ilson
’s D
isea
se S
uppo
rt
Gro
up (U
K)–
PBC
Foun
dati
on–
Rar
e D
isea
ses
UK
– PS
C Su
ppor
t–
Roy
al c
olle
ges,
suc
h as
, Phy
sici
ans,
Gen
eral
Pr
acti
tion
ers,
Sur
geon
s, A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Liv
er
(BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy o
f the
Liv
er
(EA
SL)
– A
mer
ican
Ass
ocia
tion
for t
he S
tudy
of L
iver
D
isea
ses
(AA
SLD
)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral a
nd E
nter
al
Nut
riti
on (B
APE
N)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
Spec
ific
• N
atio
nal G
uide
lines
Cen
tre
(201
3). C
G17
4 In
trav
enou
s flu
id th
erap
y fo
r adu
lts
in h
ospi
tal.
• L
ocal
pro
toco
ls a
nd g
uide
lines
in re
lati
on to
the
man
agem
ent o
f blo
od s
pilla
ges.
(con
tinu
ed)
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.1
Und
erta
king
phl
ebot
omy
and
cann
ulat
ion
in th
e pa
tien
t wit
h di
fficu
lt a
cces
s as
soci
ated
wit
h th
eir
live
r di
seas
e (c
onti
nued
)It
is re
cogn
ised
that
in s
ome
orga
nisa
tion
s ph
lebo
tom
y an
d ca
nnul
atio
ns m
ay b
e un
dert
aken
by
Com
pete
nce
Leve
l 1 -5
. Thi
s co
mpe
tenc
e sp
ecifi
call
y re
late
s to
live
r pat
ient
s w
ith
diffi
cult
acc
ess.
7
44
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
7Se
e ab
ove.
See
abov
e.Se
e ab
ove.
See
abov
e.Se
e ab
ove.
• R
CN (2
013)
Com
pete
nces
: an
educ
atio
n an
d tr
aini
ng c
ompe
tenc
e fr
amew
ork
for c
apill
ary
bloo
d sa
mpl
ing
and
vene
punc
ture
in
child
ren
and
youn
g pe
ople
.
• N
ICE
(200
2). G
uida
nce
on th
e us
e of
ult
raso
und
loca
ting
dev
ices
for
plac
ing
cent
ral v
enou
s ca
thet
ers.
TA
49.
• L
ocal
gui
danc
e on
ult
raso
und
tech
niqu
es o
r vei
n ill
umin
atio
n.
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.1
Und
erta
king
phl
ebot
omy
and
cann
ulat
ion
in th
e pa
tien
t wit
h di
fficu
lt a
cces
s as
soci
ated
wit
h th
eir
live
r di
seas
e (c
onti
nued
)It
is re
cogn
ised
that
in s
ome
orga
nisa
tion
s ph
lebo
tom
y an
d ca
nnul
atio
ns m
ay b
e un
dert
aken
by
Com
pete
nce
Leve
l 1 -5
. Thi
s co
mpe
tenc
e sp
ecifi
call
y re
late
s to
live
r pat
ient
s w
ith
diffi
cult
acc
ess.
7
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.2.
Nut
riti
on a
nd fl
uid
man
agem
ent/
hydr
atio
n in
pat
ient
s w
ith
live
r di
seas
e7 Le
vel
Com
pete
nce
KS
FP
erfo
rman
ce c
rite
ria
Kno
wle
dge
and
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
1-4
Prov
ides
sp
ecifi
c in
terv
entio
ns
safe
ly w
ith
rega
rds
to:
nutr
ition
an
d flu
id
man
agem
ent/
hy
drat
ion
in
patie
nts
with
liv
er d
isea
se.
Core
1
HW
B7
Core
3
a. M
easu
res
and
reco
rds
wei
ght a
ccur
atel
y.
b. U
nder
take
s re
gula
r obs
erva
tion
of fl
uid
bala
nce
and
bloo
d su
gar.
c. R
ecor
ds a
ccur
atel
y flu
id b
alan
ce a
nd
nutr
itio
nal i
nput
.
d. O
bser
ves
and
reco
rds
inpu
t and
out
put.
e. R
epor
ts o
n ab
norm
al m
easu
res
to s
enio
r st
aff m
embe
r.
f. R
ecog
nise
s im
port
ance
of fl
uid
man
agem
ent/
hy
drat
ion
and
nutr
itio
n.
g. H
elps
pat
ient
s to
eat
and
dri
nk.
h. D
ocum
ents
all
obse
rvat
ions
and
ac
tion
s ac
cura
tely
.
• w
eigh
t and
BM
I
• vu
lner
abili
ty to
wei
ght a
nd m
uscl
e lo
ss b
ecau
se o
f liv
er d
isea
se
• pa
tien
t diffi
cult
ies
in m
eeti
ng n
utri
tion
al
requ
irem
ents
due
to s
ympt
oms
such
as
earl
y sa
tiet
y, n
ause
a an
d ch
ange
s in
tast
e
• ne
ed to
mon
itor
uri
ne o
utpu
t.
• or
al fl
uid
and
nutr
itio
nal i
ntak
e ta
rget
s/re
stri
ctio
ns
• w
hen
to re
port
failu
re to
mee
t nut
riti
onal
re
quir
emen
ts a
nd w
ho to
repo
rt to
.
Kno
ws
how
to:
• m
aint
ain
fluid
bal
ance
cha
rts
• ca
lcul
ate
fluid
bal
ance
on
inpu
t and
out
put
fluid
bal
ance
.
• A
war
e of
role
lim
itat
ions
and
w
hen
to o
btai
n he
lp.
• P
erso
n ce
ntre
d an
d co
mpa
ssio
nate
.
• L
iste
ns.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• C
onfid
enti
al.
• P
ride
in w
ork.
• R
espe
ctfu
l.
Gen
eric
• N
MC
docu
men
ts a
nd g
uida
nce.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
an
d gu
idan
ce.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver N
urse
s Fo
rum
(BA
SLN
F).
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd
of li
fe c
are.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fr
om
Live
r Dis
ease
. Im
plic
atio
ns fo
r end
of
life
car
e.
45
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
5Pr
ovid
es
spec
ific
inte
rven
tions
sa
fely
with
re
gard
s to
:
nutr
ition
an
d flu
id
man
agem
ent/
hy
drat
ion
in
patie
nts
with
liv
er d
isea
se.
HW
B7
Core
2
Core
3
a. U
nder
take
s re
gula
r nut
riti
onal
scr
eeni
ng
usin
g ap
prop
riat
e nu
trit
iona
l too
l i.e
. MU
ST o
r ot
her l
ocal
gui
delin
e.
b. D
ocum
ents
and
revi
ews
nutr
itio
n an
d hy
drat
ion
stat
us o
n a
regu
lar b
asis
.
c. C
omm
ence
s a
food
cha
rt/d
iary
whe
n ap
prop
riat
e.
d. M
onit
ors
and
acts
on
effe
ctiv
enes
s of
nu
trit
iona
l int
erve
ntio
ns.
e. A
sses
ses
whe
ther
the
pati
ent i
s ab
le to
hy
drat
e th
emse
lves
or n
ot (c
onsi
ders
pat
ient
fo
r int
rave
nous
or n
asog
astr
ic fl
uids
).
f. Ed
ucat
es th
e pa
tien
t and
fam
ily a
bout
in
appr
opri
ate
high
sal
t foo
ds th
at s
houl
d no
t be
eat
en in
pat
ient
s w
ith
asci
tes.
g. A
sses
ses
pote
ntia
l for
refe
edin
g sy
ndro
me.
h. M
aint
ains
vig
ilanc
e w
hen
pati
ents
are
sel
f-ca
ring
(loo
king
aft
er th
emse
lves
).
i. R
efer
s to
die
titi
an in
a ti
mel
y m
anne
r and
is
able
to g
ive
the
rele
vant
nut
riti
onal
/med
ical
hi
stor
y re
quir
ed fo
r the
refe
rral
.
• n
utri
tiona
l gui
delin
es a
nd lo
cal s
cree
ning
tool
s•
nut
ritio
nal n
eeds
in p
atie
nts
with
live
r dis
ease
• re
cogn
ition
that
wei
ght/
BM
I may
not
refle
ct
the
patie
nts
nutr
ition
al s
tatu
s e.
g. m
ay s
till b
e m
alno
uris
hed
• a
war
enes
s of
inap
prop
riat
e di
etar
y re
stri
ctio
ns
such
as
low
fat o
r low
pro
tein
die
ts•
food
s hi
gh in
sal
t•
the
impo
rtan
ce o
f dai
ly w
eigh
t for
peo
ple
with
as
cite
s an
d ex
tern
al b
iliar
y dr
ains
•
und
erst
andi
ng o
f rat
iona
le fo
r use
of i
ntra
veno
us
fluid
e.g
. not
usi
ng s
alin
e so
lutio
ns fo
r peo
ple
with
asc
ites
• w
eigh
t and
wei
ght l
oss
if on
diu
retic
s•
alte
red
tast
e•
redu
ced
appe
tite
due
to a
scite
s an
d/or
jaun
dice
an
d G
I dis
turb
ance
• w
hy a
sto
ol c
hart
may
be
used
and
be
awar
e of
ch
ange
s in
bow
els
habi
ts a
ssoc
iate
d w
ith
liver
dis
ease
s•
app
ropr
iate
food
type
s an
d th
e ro
le o
f sm
all a
nd
regu
lar m
eals
(six
per
day
)•
spe
cial
die
tary
and
hyd
ratio
n re
quir
emen
ts
such
as
no a
dded
sal
t die
t, s
ip fe
eds,
vita
min
su
pple
men
tatio
n, u
se o
f flui
d re
stri
ctio
n e.
g.
hypo
natr
aem
ia, l
ate
even
ing
snac
ks•
refe
edin
g sy
ndro
me
• a
war
enes
s th
at if
pat
ient
det
oxify
ing
at ri
sk
of m
alnu
triti
on.
Kno
ws
how
to•
iden
tify
the
patie
nt a
t ris
k of
refe
edin
g sy
ndro
me.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• Su
ppor
tive
.
• En
cour
agin
g.
• Pr
ovid
es c
hoic
es.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• Fl
exib
le.
• N
on-ju
dgm
enta
l.
• Pa
ssio
nate
abo
ut p
atie
nt c
are.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
N
HS.
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as,
CQU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(W
illia
ms
et a
l, 20
14)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a
revi
ew o
f pat
ient
s w
ho d
ied
wit
h al
coho
l-rel
ated
live
r dis
ease
, Lo
ndon
, NCE
POD
.
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er
Dis
ease
: Ris
k fa
ctor
s an
d tr
eatm
ent
(fre
e ac
cess
)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is
care
Bun
dle:
Fir
st 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
ch
arit
ies
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
G
roup
(UK)
– PB
C Fo
unda
tion
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.2.
Nut
riti
on a
nd fl
uid
man
agem
ent/
hydr
atio
n in
pat
ient
s w
ith
live
r di
seas
e7
46
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.2.
Nut
riti
on a
nd fl
uid
man
agem
ent/
hydr
atio
n in
pat
ient
s w
ith
live
r di
seas
e7 Le
vel
Com
pete
nce
KS
FP
erfo
rman
ce c
rite
ria
Kno
wle
dge
and
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s (c
onti
nued
)
6Pr
ovid
es
spec
ific
inte
rven
tions
sa
fely
with
re
gard
s to
:
nutr
ition
an
d flu
id
man
agem
ent/
hy
drat
ion
in
patie
nts
with
liv
er d
isea
se.
HW
B7
Core
2
Core
3
a. R
ecog
nise
s th
e de
teri
orat
ing
nutr
itio
nal
stat
e of
the
liver
pat
ient
.
b. A
sses
ses
and
man
ages
the
pati
ent a
t ris
k of
re
feed
ing
synd
rom
e.
c. W
orks
clo
sely
wit
h ot
her M
DT
mem
bers
suc
h as
die
titi
an, d
iabe
tes
spec
ialis
t nur
se.
d. E
stim
ates
dry
wei
ght.
e. W
orks
wit
h pa
tien
t and
fam
ily/c
arer
to
impl
emen
t and
impr
ove
nutr
itio
nal i
ntak
e w
ith
goal
set
ting
.
f. U
ses
and
eval
uate
s a
rang
e of
nut
riti
onal
and
hy
drat
ion
stra
tegi
es.
g. W
orks
wit
h th
e pa
tien
t/fa
mily
to h
elp
them
un
ders
tand
the
impo
rtan
ce fo
r ent
eral
feed
ing
desp
ite
relu
ctan
ce.
h. In
stig
ates
ent
eral
feed
ing
as p
resc
ribe
d.
i. Su
ppor
ts th
e pa
tien
t and
fam
ily/c
arer
wit
h ho
me
ente
ral f
eedi
ng if
requ
ired
as
a lo
ng te
rm
nutr
itio
nal g
oal.
• p
rote
in e
nerg
y m
alnu
trit
ion
and
effe
cts
on
liver
pat
ient
s
• s
trat
egie
s to
redu
ce p
rote
in e
nerg
y m
alnu
trit
ion
such
as
late
eve
ning
sna
cks,
hig
h fa
t sup
plem
ents
i.e
. cal
ogen
/liq
uige
n
• v
itam
in s
uppl
emen
tati
on to
add
ress
/avo
id s
uch
as o
steo
poro
sis,
per
iphe
ral n
euro
path
y
• s
teat
orrh
oea
and
its
effe
cts
on w
eigh
t los
s
• d
ry w
eigh
t and
its
impo
rtan
ce fo
r rec
ogni
sing
m
alnu
trit
ion
• ty
pes
of e
nter
al fe
edin
g su
ch a
s na
soga
stri
c,
naso
jeju
nal t
ube
if ap
prop
riat
e.
• E
mpo
wer
ing.
• D
evel
opin
g tr
ust.
• V
alue
s ot
hers
.
• V
alue
s le
arni
ng.
• R
eflec
t on
and
lear
n fr
om
own
prac
tice
.
• M
odel
s be
st p
ract
ice.
• T
hink
s cr
eati
vely
.
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy
of th
e Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy
of L
iver
Dis
ease
s (A
ASL
D)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral
and
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
Spec
ific
• N
HS
Engl
and
Not
iona
l Pat
ient
s Sa
fety
an
d Al
erts
.•
RCN
- N
utrit
ion
and
Hyd
ratio
n.•
MU
ST to
ol.
• E
SPEN
gui
delin
es.
7Pr
ovid
es
spec
ific
diag
nost
ic/
trea
tmen
t op
tions
saf
ely
with
rega
rds
to:
nutr
ition
an
d flu
id
man
agem
ent/
hy
drat
ion
in
patie
nts
with
liv
er d
isea
se.
HW
B7
Core
2
Core
3
a. U
nder
take
s a
nutr
itio
nal n
eeds
reas
sess
men
t.
b. R
ecog
nise
s an
d ac
ts u
pon
dete
rior
atin
g nu
trit
iona
l sta
tus
e.g.
pat
ient
wit
h en
d st
age
chro
nic
liver
dis
ease
.
c. S
uppo
rts
pati
ent a
nd fa
mily
/car
er w
ith
mee
ting
and
eva
luat
ing
thei
r nut
riti
onal
and
hy
drat
ion
need
s.
d. In
vest
igat
e if
requ
ired
for o
ther
cau
ses
of
wei
ght l
oss.
• c
ompl
exit
y of
nut
riti
onal
nee
ds fo
r pat
ient
s w
ith
impi
ngin
g fa
ctor
s su
ch a
s us
e of
cor
tico
ster
oids
ca
usin
g la
bile
blo
od s
ugar
s; w
eigh
t los
s du
ring
an
tivi
ral t
hera
py
Kno
ws
how
to:
• c
omm
unic
ate
effe
ctiv
ely
wit
h th
e M
DT
and
prim
ary
care
• m
onit
or p
atie
nts
on h
ome
ente
ral f
eedi
ng a
nd
goal
ach
ieve
men
t
• h
ave
com
plex
dis
cuss
ions
wit
h pa
tien
ts w
ishi
ng
to d
isco
ntin
ue e
nter
al fe
edin
g
• s
uppo
rt th
e pa
tien
t reg
ardi
ng s
tigm
a re
late
d to
ha
ving
a lo
ng te
rm n
asog
astr
ic tu
be in
sit
u.
• R
ole
mod
el.
• V
isib
le in
pra
ctic
e se
ttin
gs.
• C
ham
pion
s pa
tien
t-ce
ntre
d ap
proa
ch.
• C
olla
bora
tive
wor
king
acr
oss
serv
ices
.
• S
tron
g cl
inic
al le
ader
ship
.
47
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd
beha
viou
rs
Cont
extu
al fa
ctor
s
5Pr
ovid
es s
peci
fic
inte
rven
tions
saf
ely
with
rega
rds
to:
phar
mac
olog
ical
tr
eatm
ent a
nd s
ide-
effe
cts
Core
1
HW
B7
Core
3
a. A
sses
ses
pati
ent’
s kn
owle
dge
and
unde
rsta
ndin
g of
thei
r med
icat
ion
and
its
effe
cts.
b. P
rovi
des
pati
ent i
nfor
mat
ion
abou
t m
edic
atio
ns a
nd th
eir s
ide-
effe
cts.
c. E
nsur
es p
atie
nt is
saf
e at
all
tim
es b
y ob
serv
ing,
mon
itor
ing
and
reco
rdin
g al
l ide
ntifi
ed s
ide-
effe
cts
and
taki
ng
appr
opri
ate
acti
ons.
d. Is
ale
rt to
med
icat
ions
that
sho
uld
not b
e us
ed w
ith
peop
le w
ith
liver
dis
ease
.
e. D
ocum
ents
non
-com
plia
nce
wit
h m
edic
atio
ns w
ithi
n m
edic
al a
nd n
ursi
ng
note
s.
f. En
sure
s pr
imar
y or
sec
onda
ry c
are
prov
ider
s re
ceiv
e pa
tien
t med
icat
ion
info
rmat
ion.
• ph
arm
acol
ogic
al th
erap
ies
used
in a
cute
and
chr
onic
liv
er d
isea
se in
clud
ing:
– dos
e re
gim
e
– con
trai
ndic
atio
ns e
.g. c
ontr
acep
tion
– dru
g in
tera
ctio
ns
– sid
e ef
fect
s
– man
agem
ent/
mon
itorin
g
• c
ore
med
icat
ion
used
suc
h as
spi
rono
lact
one,
lact
ulos
e,
prop
rano
lol,
azat
hiop
rine,
pre
dnis
olon
e an
d rif
axim
in
• a
war
enes
s of
med
icat
ions
use
d in
the
prop
hyla
xis
/ se
cond
ary
prev
entio
n of
com
plic
atio
ns o
f cirr
hosi
s (s
uch
as G
I ble
ed, S
BP
and
hepa
tic e
ncep
halo
path
y) s
uch
as
prop
rano
lol,
cipr
oflox
acin
, rifa
xim
in in
line
with
loca
l an
tibio
tic p
olic
y
• m
edic
atio
ns th
at a
re c
ontr
aind
icat
ed in
live
r dis
ease
e.g
. N
SAID
s, a
spiri
n
• im
pact
of a
nalg
esia
on
cons
tipat
ion
that
can
lead
to
hepa
tic e
ncep
halo
path
y
• m
edic
atio
ns th
at le
ad to
ove
r-di
ures
is e
.g. d
iure
tics
caus
ing
rena
l im
pairm
ent /
elec
trol
yte
imba
lanc
e an
d he
patic
enc
epha
lopa
thy
• s
afe
alco
hol w
ithdr
awal
regi
me.
• m
edic
atio
ns th
at c
an p
reci
pita
te h
epat
ic
ence
phal
opat
hy; s
edat
ives
suc
h as
bar
bitu
rate
s or
be
nzod
iaze
pine
s
Kno
ws
how
to:
• re
cogn
ise
pote
ntia
l effe
cts
on th
e pa
tient
of n
on
com
plia
nce
such
as
deve
lopm
ent o
f hep
atic
en
ceph
alop
athy
, inc
reas
e in
asc
ites,
gas
troi
ntes
tinal
bl
eedi
ng.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel
of c
ompe
tenc
e, a
ble
to id
enti
fy le
arni
ng
need
s.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• S
uppo
rtiv
e.
• E
ncou
ragi
ng.
• P
rovi
des
choi
ces.
• G
ives
and
rece
ives
fe
edba
ck.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• F
lexi
ble.
• N
on-ju
dgm
enta
l.
• P
assi
onat
e ab
out
pati
ent c
are.
Gen
eric
•
NM
C do
cum
ents
and
gui
danc
e.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
and
gu
idan
ce.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Li
ver N
urse
s Fo
rum
(BA
SLN
F).
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f lif
e ca
re.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fr
om L
iver
D
isea
se. I
mpl
icat
ions
for e
nd o
f lif
e ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as,
CQU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a
revi
ew o
f pat
ient
s w
ho d
ied
wit
h al
coho
l-re
late
d liv
er d
isea
se,
Lond
on, N
CEPO
D.
6Pr
ovid
es s
peci
fic
inte
rven
tions
saf
ely
with
rega
rds
to:
phar
mac
olog
ical
tr
eatm
ent a
nd s
ide-
effe
cts
Core
1
HW
B7
Core
3
a. R
evie
ws
and
build
s on
und
erst
andi
ng o
f th
e pa
tien
t and
fam
ily/c
arer
and
als
o ot
her
staf
f mem
bers
wit
h re
gard
to m
edic
atio
n an
d th
e si
de e
ffec
ts.
b. W
orks
wit
h th
e ph
arm
acis
t to
prov
ide
appr
opri
ate
info
rmat
ion
and
guid
ance
to
pati
ents
and
fam
ily/c
arer
and
als
o st
aff.
c. In
vest
igat
es a
nd a
ddre
sses
reas
ons
for
non
com
plia
nce
and
refe
rs to
app
ropr
iate
M
DT
mem
bers
.
d. C
o-or
dina
tes
and
acts
as
a po
int o
f co
ntac
t reg
ardi
ng in
itia
l med
icat
ion
enqu
irie
s.
• ho
w th
e m
edic
atio
n w
orks
in re
lati
on to
und
erly
ing
path
ophy
siol
ogy
e.g.
ald
oste
rone
ant
agon
isti
c pr
oper
ties
of s
piro
nola
cton
e
• re
ason
s w
hy p
atie
nts
may
be
non-
com
plia
nt a
nd w
ho
to re
fer t
o
• th
e in
dica
tion
of i
ndiv
idua
l med
icat
ions
, whe
n to
co
ntin
ue o
r dis
cont
inue
use
and
com
mun
icat
e w
ith
appr
opri
ate
MD
T m
embe
r e.g
. pre
vent
ion
of a
ntib
ioti
c re
sist
ance
, pre
vent
ion
of W
erni
cke’
s en
ceph
alop
athy
.
Kno
ws
how
to:
• co
mm
unic
ate
wit
h th
e pa
tien
t ris
ks a
nd b
enefi
ts o
f po
ssib
le tr
eatm
ent r
egim
es.
• M
odel
s be
st p
ract
ice.
• E
mpo
wer
ing.
• W
orks
in p
artn
ersh
ip
wit
h ot
hers
.
• O
pen
to re
ceiv
ing
feed
back
.
• C
halle
nges
oth
ers
to m
aint
ain
pati
ent
safe
ty.
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.3.
Pha
rmac
olog
ical
trea
tmen
t and
sid
e-ef
fect
s7
48
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
7P
rovi
des
spec
ific
diag
nost
ic/t
reat
men
t opt
ions
saf
ely:
(con
tinu
ed)
7.3.
Pha
rmac
olog
ical
trea
tmen
t and
sid
e-ef
fect
s (c
onti
nued
)
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd
beha
viou
rs
Cont
extu
al fa
ctor
s
7Pr
ovid
es s
peci
fic
diag
nost
ic/
trea
tmen
t opt
ions
sa
fely
with
re
gard
s to
:
phar
mac
olog
ical
tr
eatm
ent a
nd
side
-effe
cts
Core
1
HW
B7
Core
3
a. Is
an
inde
pend
ent/
supp
lem
enta
ry
non-
med
ical
pre
scrib
er (N
MP)
.
b. U
nder
take
s a
full
com
preh
ensi
ve a
sses
smen
t an
d hi
stor
y an
d in
itiat
es tr
eatm
ent a
ccor
ding
to
loca
l gui
danc
e or
pro
toco
l.
c. O
btai
ns in
form
ed c
onse
nt fr
om p
atie
nt a
nd
care
r to
pres
crib
e as
a N
MP.
d. M
onito
rs a
nd a
sses
ses
the
patie
nt’s
pro
gres
s as
app
ropr
iate
to th
e pa
tient
’s c
ondi
tion
and
the
med
icin
es p
resc
ribed
by
the
non-
med
ical
pr
escr
iber
who
m h
e/sh
e ha
s as
sess
ed fo
r car
e du
ring
the
patie
nt e
piso
de.
e. C
omm
unic
ates
with
prim
ary
and
seco
ndar
y ca
re te
ams
abou
t ini
tiatio
n or
cha
nges
in
med
icat
ions
.
f. En
sure
s pa
tient
s/ca
rer a
war
e of
how
m
edic
atio
ns w
ork,
pos
sibl
e si
de-e
ffec
ts a
nd
dura
tion
of tr
eatm
ent.
g. K
eeps
up
to d
ate
with
loca
l tru
st u
pdat
es fo
r ow
n pr
escr
ibin
g pr
actic
e.
h. P
resc
ribes
for p
eopl
e w
ith li
ver d
isea
se
with
in d
edic
ated
clin
ical
man
agem
ent p
lans
in
con
junc
tion
with
con
sulta
nt le
ads
as a
n in
depe
nden
t and
sup
plem
enta
ry n
on-m
edic
al
pres
crib
er.
i. W
orks
with
trus
t clin
ical
lead
for N
on M
edic
al
Pres
crib
ing
and
phar
mac
ist t
o de
velo
p re
leva
nt
path
way
s fo
r pre
scrib
ing
for p
atie
nts
with
live
r di
seas
e.
j. Au
dits
pre
scrib
ing
deci
sion
s an
d pr
esen
ts
year
ly d
ata
to c
linic
al fo
rum
s.
k. P
resc
ribes
for p
atie
nts
with
live
r dis
ease
w
ithin
loca
l, na
tiona
l and
inte
rnat
iona
l gu
idel
ines
.
• in
depe
nden
t/su
pple
men
tary
pre
scrib
ing
and
rela
ted
role
s an
d re
spon
sibi
litie
s
• im
prov
ing
patie
nt c
are
with
out c
ompr
omis
ing
patie
nt s
afet
y
• m
akin
g it
easi
er fo
r pat
ient
s to
get
the
med
icat
ion
they
nee
d
• in
crea
se p
atie
nt c
hoic
e in
acc
essi
ng m
edic
ines
• m
akin
g be
tter
use
of t
he s
kills
of h
ealth
pro
fess
iona
ls
• c
ontr
ibut
e to
the
intr
oduc
tion
of m
ore
flexi
ble
team
w
orki
ng a
cros
s th
e N
HS
• c
onse
quen
ces
of n
on c
ompl
ianc
e w
ith m
edic
atio
n fo
r pat
ient
s w
ith H
epat
itis
C e.
g. p
ossi
ble
futu
re
resi
stan
ce to
dru
gs
• lo
cal a
nd n
atio
nal p
resc
ribin
g gu
idel
ines
rele
vant
to
role
• ro
les
and
resp
onsi
bilit
ies
of th
e N
MP
in re
latio
n to
th
eir o
wn
pres
crib
ing
prac
tice
with
in th
eir r
ole
e.g.
a
non-
med
ical
pre
scrib
er c
an o
nly
orde
r a d
rug
for
a pa
tient
who
m h
e/sh
e ha
s as
sess
ed fo
r car
e du
ring
the
patie
nt e
piso
de.
• th
at in
depe
nden
t pre
scrib
ers
mus
t not
pre
scrib
e an
y m
edic
ine
for t
hem
selv
es. N
eith
er s
houl
d th
ey
pres
crib
e a
med
icin
e fo
r any
one
with
who
m th
ey
have
a c
lose
per
sona
l or e
mot
iona
l rel
atio
nshi
p,
othe
r tha
n in
an
exce
ptio
nal c
ircum
stan
ce.
• le
gal a
nd e
thic
al a
spec
ts o
f pre
scrib
ing.
Kno
ws
how
to:
• o
btai
n up
to d
ate
know
ledg
e ab
out s
afet
y of
m
edic
ines
• p
resc
ribe
safe
ly a
nd w
ithin
the
boun
ds o
f ind
ivid
ual
NM
P ro
le
• re
cogn
ise
his
or h
er o
wn
limita
tions
/com
pete
nces
an
d to
refe
r to
the
appr
opria
te m
edic
al d
octo
r for
as
sess
men
t or p
resc
ribin
g ou
tsid
e hi
s/he
r lev
el o
f pr
actic
e or
exp
ertis
e
• b
e re
view
ed fo
r com
pete
nce
thro
ugh
Know
ledg
e an
d Sk
ills
Fram
ewor
k (K
SF) a
nd a
nnua
l app
rais
al
proc
ess
• n
otify
the
Med
icin
es a
nd H
ealth
Car
e Pr
oduc
ts
Regu
lato
ry A
genc
y vi
a th
e AD
R Re
port
ing
Sche
me
in
the
even
t of a
ny a
dver
se re
actio
n to
med
icat
ion.
• A
tten
tion
to d
etai
l.
• R
ole
mod
el.
• C
halle
nges
oth
ers.
• L
earn
ing
from
ow
n pr
acti
ce.
• A
ctiv
e le
arne
r.
• D
evel
ops
trus
t.
• A
ctiv
ely
prom
otes
be
tter
hea
lth
for
pati
ents
.
• C
halle
nges
as
sum
ptio
ns a
nd ta
ken
for g
rant
ed w
ays
of
wor
king
.
• V
igila
nce.
Gen
eric
(con
tinu
ed)
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er D
isea
se:
Ris
k fa
ctor
s an
d tr
eatm
ent (
free
acc
ess)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fir
st 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
cha
riti
es
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
G
roup
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy o
f the
Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy o
f Li
ver D
isea
ses
(AA
SLD
)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral a
nd
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
(cur
rent
ly u
nder
revi
ew).
– Gen
eral
Pha
rmac
euti
cal C
ounc
il (2
012)
The
st
anda
rds,
eth
ics
and
perf
orm
ance
49
R O Y A L C O L L E G E O F N U R S I N G
7P
rovi
des
spec
ific
diag
nost
ic/t
reat
men
t opt
ions
saf
ely:
(con
tinu
ed)
7.3.
Pha
rmac
olog
ical
trea
tmen
t and
sid
e-ef
fect
s (c
onti
nued
)
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
8Pr
ovid
es s
peci
fic
inte
rven
tions
sa
fely
with
re
gard
s to
:
phar
mac
olog
ical
tr
eatm
ent a
nd
side
-effe
cts
Core
1
HW
B7
Core
3
a. Is
an
inde
pend
ent/
supp
lem
enta
ry n
on-
med
ical
pre
scrib
er.
b. P
resc
ribes
for p
atie
nts
with
live
r dis
ease
and
a
rang
e of
clin
ical
pro
blem
s, s
uch
as, d
iabe
tes
and
hype
rten
sion
.
c. P
rovi
des
clin
ical
sup
ervi
sion
to n
ew N
MP.
d. Id
entifi
es g
aps
in th
e se
rvic
e w
here
NM
P w
ill
impr
ove
patie
nt q
ualit
y.
e. W
orks
acr
oss
sect
ors
and
deve
lop
outr
each
se
rvic
es.
f. D
evel
ops
and
lead
s im
plem
enta
tion
of N
MP
to
impr
ove
patie
nt a
cces
s to
a q
ualit
y se
rvic
e.
• th
e im
pact
of a
rang
e of
clin
ical
pro
blem
s, s
uch
as,
diab
etes
and
hyp
erte
nsio
n on
pre
scrib
ing
prac
tice
• m
anag
ing
the
patie
nt w
ith c
ompl
ex c
o-m
orbi
ditie
s.
Kno
ws
how
to:
• p
resc
ribe
safe
ly fo
r peo
ple
with
live
r dis
ease
and
as
soci
ated
clin
ical
pro
blem
s.
• S
tron
g cl
inic
al le
ader
ship
.
• C
olla
bora
tive
wor
king
acr
oss
serv
ices
.
• C
ham
pion
s pe
rson
-cen
tred
ap
proa
ch.
• P
assi
onat
e ab
out p
atie
nt s
afet
y.
Spec
ific
• N
MC
(201
5) T
he C
ode.
• N
MC
(201
0) S
tand
ards
for
Med
icin
es M
anag
emen
t.
• N
ICE
Gui
danc
e fo
r Hep
atit
is B
and
C
Trea
tmen
t.
• L
ocal
gui
delin
es a
nd p
roto
cols
.
• N
on-M
edic
al p
resc
ribi
ng.
• U
nive
rsit
y of
Liv
erpo
ol C
entr
e fo
r D
rug
Safe
ty a
nd S
cien
ce
– MH
RA
web
site
ale
rtin
g se
rvic
e
– NM
C (2
006)
Sta
ndar
ds o
f P
rofic
ienc
y fo
r Nur
se a
nd
Mid
wiv
es P
resc
ribe
rs
(c
urre
ntly
und
er re
view
).
– G
ener
al P
harm
aceu
tica
l Cou
ncil
(201
2) T
he s
tand
ards
, eth
ics
and
perf
orm
ance
– NIC
E m
edic
ines
and
pre
scri
bing
– Dep
artm
ent o
f Hea
lth
(Apr
il 20
06) I
mpr
ovin
g P
atie
nts’
A
cces
s to
Med
icin
es: A
Gui
de
to Im
plem
enti
ng N
urse
and
P
harm
acis
t Ind
epen
dent
P
resc
ribi
ng w
ithi
n th
e N
HS
In
Engl
and
(arc
hive
d bu
t ava
ilabl
e).
50
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
5Pr
ovid
es
spec
ific
inte
rven
tions
sa
fely
with
re
gard
s to
:
non-
inva
sive
di
agno
stic
s an
d tr
eatm
ent
optio
ns
Core
1
HW
B7
Core
3
a. C
omm
unic
ates
eff
ectiv
ely
with
the
indi
vidu
al
rega
rdin
g th
e ne
ed fo
r non
inva
sive
live
r scr
een
(NIL
S) te
stin
g.
b. E
xpla
ins
to p
atie
nts
othe
r non
-inva
sive
ap
proa
ches
that
may
be
used
.
c. P
repa
res
patie
nts
and
thei
r fam
ilies
for n
on-
inva
sive
dia
gnos
tics
and
wha
t to
expe
ct.
d. E
nsur
es fo
llow
-up
in p
lace
with
lead
clin
icia
n or
GP
for d
iscu
ssio
n of
resu
lts.
e. D
ocum
ents
cle
ar a
nd a
ccur
ate
info
rmat
ion
rela
ting
to in
vest
igat
ions
requ
este
d in
line
with
lo
cal p
olic
y.
• no
n-in
vasi
ve li
ver s
cree
ning
suc
h as
blo
od
anal
ysis
, ult
raso
und
scan
ning
and
Fib
rosc
an
• un
ders
tand
s th
e ra
nge
of b
lood
test
s w
ithi
n a
non-
inva
sive
live
r scr
een
• de
mon
stra
tes
know
ledg
e of
bas
ic li
ver c
ondi
tion
s an
d ke
y sp
ecia
list i
nter
vent
ions
• no
rmal
par
amet
ers
of a
non
-inva
sive
live
r scr
een.
Kno
ws
how
to:
• ac
cess
furt
her s
uppo
rt a
nd e
xper
tise
to a
llay
pati
ents
fear
s an
d an
xiet
ies.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• S
uppo
rtiv
e.
• E
ncou
ragi
ng.
• P
rovi
des
choi
ces.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• F
lexi
ble.
• N
on-ju
dgm
enta
l.
• P
assi
onat
e ab
out p
atie
nt c
are.
• P
atie
nt c
entr
ed a
nd
com
pass
iona
te.
• L
iste
ns.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• C
onfid
enti
al.
Gen
eric
•
NM
C do
cum
ents
and
gui
danc
e.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
an
d gu
idan
ce.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver N
urse
s Fo
rum
(BA
SLN
F).
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd
of li
fe c
are.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fr
om L
iver
D
isea
se. I
mpl
icat
ions
for e
nd o
f lif
e ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
N
HS
.
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as,
CQU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al
, 201
4)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a
revi
ew o
f pat
ient
s w
ho d
ied
wit
h al
coho
l-rel
ated
live
r dis
ease
, Lon
don,
N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
6Pr
ovid
es
spec
ific
inte
rven
tions
sa
fely
with
re
gard
s to
:
non-
inva
sive
di
agno
stic
s an
d tr
eatm
ent
optio
ns
HW
B7
Core
2
Core
3
a. E
xpla
ins
the
outc
omes
of n
on-in
vasi
ve
diag
nost
ics
to p
atie
nts
and
fam
ilies
.
b. A
cts
upon
resu
lts a
nd in
itiat
es, i
mpl
emen
ts
and
eval
uate
s se
lect
ed in
terv
entio
ns, e
.g. h
ealth
ad
vice
rega
rdin
g N
AFLD
.
c. R
efer
s to
app
ropr
iate
hea
lth c
are
pers
onne
l.
d. E
stab
lishe
s ra
ppor
t and
is a
ble
to s
uppo
rt th
e pa
tient
with
com
plex
and
pot
entia
lly s
tres
sful
di
agno
sis
and
trea
tmen
ts in
a ra
nge
of s
ituat
ions
.
e. D
iscu
sses
pot
entia
l diff
eren
tial d
iagn
oses
.
• lim
itat
ions
of N
ILS
and
advi
ses
on th
e po
ssib
ility
of
futu
re te
sts
• liv
er c
ondi
tion
s, k
ey s
peci
alis
t int
erve
ntio
ns a
nd
ther
apie
s ap
prop
riat
e to
the
liver
pat
ient
• no
rmal
and
abn
orm
al re
sult
s
• di
ffer
enti
al d
iagn
oses
• lo
cal c
are
path
way
s.
Kno
ws
how
to:
• re
fer t
o re
leva
nt h
ealt
h ca
re p
rofe
ssio
nals
suc
h as
liv
er s
peci
alis
t tea
ms,
die
titi
an, a
lcoh
ol s
ervi
ces
• ac
cess
oth
er in
terf
acin
g se
rvic
es s
uch
as d
iabe
tes,
ca
rdio
logy
.
• M
odel
s be
st p
ract
ice.
• E
mpo
wer
ing.
• W
orks
in p
artn
ersh
ip w
ith
othe
rs.
• O
pen
to re
ceiv
ing
feed
back
.
• C
halle
nges
oth
ers
to m
aint
ain
pati
ent s
afet
y.
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.4.
Non
-inv
asiv
e di
agno
stic
s an
d tr
eatm
ent o
ptio
ns
7
51
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd
beha
viou
rs
Cont
extu
al fa
ctor
s
7Pr
ovid
es
spec
ific
diag
nost
ic/
trea
tmen
t op
tions
saf
ely
with
rega
rds
to:
non-
inva
sive
di
agno
stic
s an
d tr
eatm
ent
optio
ns.
HW
B7
Core
2
Core
3
G1
a. P
rovi
des
and
rece
ives
hig
hly
com
plex
, se
nsiti
ve o
r con
tent
ious
info
rmat
ion.
b. C
omm
unic
ates
ver
y se
nsiti
ve, c
ompl
ex
cond
ition
rela
ted
info
rmat
ion
to p
atie
nts,
re
lativ
es w
ith e
mpa
thy
and
reas
sura
nce.
c. R
efer
s ap
prop
riate
ly fo
llow
ing
diag
nosi
s,
for f
urth
er h
aem
atol
ogic
al, b
ioch
emic
al,
viro
logy
and
gen
etic
test
ing
acro
ss a
rang
e of
liv
er d
isor
ders
suc
h as
abd
omin
al u
ltras
ound
, co
mpu
teris
ed to
mog
raph
y/m
agne
tic re
sona
nce
scan
with
in o
wn
scop
e of
pro
fess
iona
l pra
ctic
e.
d. In
itiat
es ti
mel
y an
d ap
prop
riate
con
sulta
tion,
re
ferr
als
and
colla
bora
tion
with
oth
er h
ealth
ca
re p
rovi
ders
.
e. A
ccep
ts d
irect
refe
rral
s/de
velo
ps c
are
path
way
s ac
ross
prim
ary/
seco
ndar
y ca
re.
• cl
inic
al p
athw
ays
for t
reat
men
t e.g
. hep
atit
is C
, he
pati
tis
B, a
lcoh
ol, o
besi
ty
• in
itia
tion
and
mon
itor
ing
of s
peci
fic tr
eatm
ents
• co
mm
unic
atin
g co
mpl
ex a
nd p
oten
tial
ly s
ensi
tive
in
form
atio
n
• a
rang
e of
live
r dis
ease
s at
a h
ighl
y de
velo
ped
leve
l tha
t inc
orpo
rate
s ev
iden
ce b
ase
and
expe
rien
ce
• th
e ro
le o
f non
med
ical
pre
scri
bing
to d
eliv
er
qual
ity
care
in b
oth
prim
ary
and
seco
ndar
y se
ttin
g.
Kno
ws
how
to:
• in
terp
ret c
ompl
ex re
sult
s an
d in
vest
igat
ions
.
• A
tten
tion
to d
etai
l.
• R
ole
mod
el.
• Ch
alle
nges
oth
ers.
• Le
arni
ng fr
om o
wn
prac
tice
.
• A
ctiv
e le
arne
r.
• D
evel
ops
trus
t.
• A
ctiv
ely
prom
otes
bet
ter
heal
th fo
r pat
ient
s.
• Ch
alle
nges
ass
umpt
ions
an
d ta
ken
for g
rant
ed w
ays
of w
orki
ng.
• V
igila
nce.
Gen
eric
(con
tinu
ed)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er D
isea
se:
Ris
k fa
ctor
s an
d tr
eatm
ent (
free
acc
ess)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fir
st 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
cha
riti
es
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
G
roup
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy o
f the
Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy o
f Li
ver D
isea
ses
(AA
SLD
)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral a
nd
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
Spec
ific
• Lo
cal p
olic
ies.
8Pr
ovid
es
spec
ific
inte
rven
tions
sa
fely
with
re
gard
s to
:
non-
inva
sive
di
agno
stic
s an
d tr
eatm
ent
optio
ns.
HW
B7
Core
2
Core
3
G1
a. C
o-or
dina
tes
and
deliv
ers
seam
less
car
e an
d pr
ovid
ing
appr
opria
te s
hort
and
long
term
fo
llow
up
follo
win
g no
n-in
vasi
ve d
iagn
ostic
s an
d tr
eatm
ents
.
b. A
ble
to w
ork
inde
pend
ently
as
the
clin
ical
le
ad in
eith
er p
rimar
y or
sec
onda
ry c
are.
c. In
itiat
es a
udit
to re
view
pat
ient
and
car
ers
expe
rienc
e of
spe
cific
inve
ntio
ns, p
athw
ays
and
serv
ices
.
d. W
orks
with
com
mis
sion
ers
to id
entif
y lo
cal a
nd s
trat
egic
nee
ds fo
r dev
elop
ing
care
pa
thw
ays
with
in li
ver s
ervi
ces.
• au
dit a
nd re
sear
ch
• co
ntem
pora
ry e
vide
nce
base
• lo
cal c
omm
issi
onin
g ar
rang
emen
ts
• ne
w tr
eatm
ent o
ptio
ns fo
r liv
er d
isea
se
• w
orki
ng in
an
outr
each
role
to d
eliv
er li
ver
serv
ices
.
• S
tron
g cl
inic
al le
ader
ship
.
• C
olla
bora
tive
wor
king
ac
ross
ser
vice
s.
• C
ham
pion
s pe
rson
cen
tred
ap
proa
ch.
• P
assi
onat
e ab
out p
atie
nt
safe
ty.
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.4.
Non
-inv
asiv
e di
agno
stic
s an
d tr
eatm
ent o
ptio
ns
7
52
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
5Pr
ovid
es
spec
ific
inte
rven
tions
sa
fely
with
re
gard
s to
:
inva
sive
di
agno
stic
s an
d tr
eatm
ent
optio
ns
Core
1
HW
B7
Core
3
a. E
xpla
ins
to p
atie
nt th
e di
ffer
ent i
nvas
ive
appr
oach
es, p
ossi
ble
side
eff
ects
and
co
mpl
icat
ions
.
b. A
nsw
ers
patie
nts
ques
tions
or i
f una
ble
to th
en a
cces
s in
form
atio
n fr
om a
ppro
pria
te
othe
rs.
c. P
repa
res
patie
nts
for i
nvas
ive
proc
edur
es.
d. M
onito
rs p
atie
nts
follo
win
g in
vasi
ve
proc
edur
es fo
r sid
e-ef
fect
s or
com
plic
atio
ns.
e. D
ocum
ents
all
obse
rvat
ions
and
act
ions
ac
cura
tely
.
• no
rmal
ana
tom
y an
d ph
ysio
logy
of t
he li
ver a
nd
bilia
ry s
yste
m
• in
vasi
ve a
ppro
ache
s to
live
r inv
esti
gati
ons
and
trea
tmen
ts, i
nclu
ding
:
– end
osco
py
– end
osco
pic
retr
ogra
de
chol
angi
opan
cret
ogra
phy
(ER
CP)
– ext
erna
l bili
ary
drai
n
– end
osco
pic
ultr
asou
nd
– liv
er b
iops
y
– par
acen
tesi
s
– tra
nsju
gula
r int
rahe
pati
c po
rtos
yste
mic
shu
nt
(TIP
S)
– tra
nsar
teri
al c
hem
oem
bolis
atio
n (T
ACE
) rad
io
freq
uenc
y ab
lati
on (R
FA)
– the
gen
eral
sid
e ef
fect
s of
inva
sive
inte
rven
tion
s su
ch a
s; h
ypov
olae
mic
sho
ck, p
ain,
sep
sis,
ac
ute
kidn
ey in
jury
– pl
eure
x dr
ains
.
Kno
ws
how
to:
• re
cogn
ise
and
act o
n co
mpl
icat
ions
follo
win
g th
e ab
ove
proc
edur
es.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• Su
ppor
tive
.
• En
cour
agin
g.
• Pr
ovid
es c
hoic
es.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• Fl
exib
le.
• N
on-ju
dgm
enta
l.
• Pa
ssio
nate
abo
ut p
atie
nt c
are.
• Pa
tien
t cen
tred
and
co
mpa
ssio
nate
.
• Li
sten
s.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• Co
nfide
ntia
l.
• Pa
tien
t saf
ety.
Gen
eric
•
NM
C do
cum
ents
and
gui
danc
e.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
and
gu
idan
ce.
• R
CN G
astr
oint
esti
nal N
ursi
ng F
orum
.
• B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Li
ver N
urse
s Fo
rum
(BA
SLN
F).
• B
riti
sh L
iver
Nur
ses
Foru
m (B
LNF)
.
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth
Engl
and.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd o
f lif
e ca
re.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fr
om L
iver
D
isea
se. I
mpl
icat
ions
for e
nd o
f lif
e ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acit
y A
ct 2
005.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ecti
on A
ct 1
998.
• N
HS
Choi
ces.
• N
HS
Inst
itut
e fo
r Inn
ovat
ion
and
Impr
ovem
ent.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as,
CQU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
)
• N
ECPO
D 2
013
Mea
suri
ng th
e un
its:
a
revi
ew o
f pat
ient
s w
ho d
ied
wit
h al
coho
l-re
late
d liv
er d
isea
se,
Lond
on, N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
alit
y)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Liv
er
Dis
ease
: Ris
k fa
ctor
s an
d tr
eatm
ent (
free
ac
cess
)
(con
tinu
ed)
6Pr
ovid
es
spec
ific
inte
rven
tions
sa
fely
with
re
gard
s to
:
inva
sive
di
agno
stic
s an
d tr
eatm
ent
optio
ns
HW
B7
Core
2
Core
3
a. E
xpla
ins
to p
atie
nt a
nd c
arer
s tr
eatm
ent
crite
ria a
nd p
roto
cols
.
b. D
evel
ops
and
eval
uate
s ap
prop
riate
car
e m
anag
emen
t pla
n fo
llow
ing
ther
apeu
tic
inte
rven
tion.
c. G
ives
pat
ient
and
car
ers
advi
ce o
n fo
llow
up
and
on-g
oing
and
futu
re c
are
requ
irem
ents
.
d. S
ignp
osts
pat
ient
s an
d ca
rers
to o
ther
ca
re o
ptio
ns s
uch
as c
omm
unity
pal
liativ
e ca
re.
e. D
evel
ops,
in c
onju
nctio
n w
ith o
ther
hea
lth
care
pro
fess
iona
ls, a
man
agem
ent p
lan
for
refu
sal o
f tre
atm
ent.
• bi
liary
com
plic
atio
ns a
nd c
hola
ngit
is
• liv
er d
isea
se, c
o-m
orbi
diti
es a
nd th
e im
pact
on
trea
tmen
t out
com
es e
.g. c
irrh
osis
/fibr
osis
• flu
id re
plac
emen
t pro
toco
ls in
par
acen
tesi
s
• ra
tion
ale
for T
IPS
in e
mer
genc
y an
d th
erap
euti
c si
tuat
ions
• po
ssib
le c
ompl
icat
ions
of T
IPS
and
man
agem
ents
op
tion
s
• di
ffer
ent t
hera
peut
ic o
ptio
ns th
eir s
tren
gths
, w
eakn
esse
s an
d si
de-e
ffec
t
• si
de e
ffec
ts o
f tre
atm
ents
suc
h as
tran
sart
eria
l ch
emoe
mbo
lisat
ion
(TA
CE),
radi
o fr
eque
ncy
abla
tion
(RFA
), o
ther
new
trea
tmen
ts b
eing
use
d in
diff
eren
t liv
er c
entr
es.
• M
odel
s be
st p
ract
ice.
• Em
pow
erin
g.
• W
orks
in p
artn
ersh
ip w
ith
othe
rs.
• O
pen
to re
ceiv
ing
feed
back
.
• Ch
alle
nges
oth
ers
to m
aint
ain
pati
ent s
afet
y.
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.5
Inva
sive
dia
gnos
tics
and
trea
tmen
t opt
ions
7
53
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd
beha
viou
rs
Cont
extu
al fa
ctor
s
6K
now
s ho
w to
:•
inte
rpre
t res
ults
in c
onju
ncti
on w
ith
othe
r hea
lth
care
pro
fess
iona
ls
• g
ive
rele
vant
info
rmat
ion
and
advi
ce fo
llow
ing
trea
tmen
t int
erve
ntio
n
• in
volv
e re
leva
nt p
rim
ary
care
hea
lth
prof
essi
onal
s.
Gen
eric
(con
tinu
ed)
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is c
are
Bun
dle:
Fir
st 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
cha
riti
es
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
G
roup
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f the
Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy o
f the
Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy o
f Liv
er
Dis
ease
s (A
ASL
D)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral a
nd
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
7Pr
ovid
es
spec
ific
diag
nost
ic/
trea
tmen
t op
tions
saf
ely
with
rega
rds
to:
inva
sive
di
agno
stic
s an
d tr
eatm
ent
optio
ns.
HW
B7
Core
2
Core
3
G1
a. R
evie
ws
with
the
patie
nt a
nd c
arer
pos
sibl
e th
erap
eutic
opt
ions
.
b. A
sses
ses
effe
ctiv
enes
s of
the
trea
tmen
t op
tions
.
c. P
rovi
des
in-d
epth
info
rmat
ion
to p
atie
nt
and
care
rs a
bout
ther
apeu
tic tr
eatm
ents
and
op
tions
.
d. E
valu
ates
eff
ectiv
enes
s of
the
care
m
anag
emen
t pla
n.
e. W
orks
with
oth
er h
ealth
car
e pr
ofes
sion
al to
pr
ovid
e on
-goi
ng fo
llow
up
and
care
.
f. D
iscu
sses
rele
vant
trea
tmen
t opt
ions
with
pa
tient
and
car
ers
such
as
refe
rral
to p
allia
tive
care
ser
vice
s.
g. W
orks
acr
oss
prim
ary
and
seco
ndar
y ca
re to
co
-ord
inat
e ap
prop
riate
/spe
cific
car
e pa
thw
ay.
• p
urpo
se a
nd c
rite
ria
for e
ach
inte
rven
tion
• s
ide-
effe
cts/
com
plic
atio
ns a
nd h
ow th
ey s
houl
d be
man
aged
of:
– end
osco
py
–ER
CP
– ext
erna
l bili
ary
drai
n
– end
osco
pic
ultr
asou
nd
– liv
er b
iops
y
– par
acen
tesi
s
– tra
nsju
gula
r int
rahe
pati
c po
rtos
yste
mic
shu
nt
(TIP
S)
– TA
CE/R
FA
• cr
iter
ia fo
r inv
asiv
e liv
er ri
sk p
rofil
ing
and
whe
ther
th
e re
sult
s w
ill c
hang
e pa
tien
t man
agem
ent e
.g.
man
agem
ent o
f Non
Alc
ohol
ic F
atty
Liv
er D
isea
se
(NA
FLD
) in
prim
ary
and
seco
ndar
y ca
re
• ro
le o
f inv
asiv
e ri
sk p
rofil
ing
in re
lati
on to
mak
ing
a di
agno
sis
or a
sses
smen
t for
trea
tmen
t suc
h as
liv
er tr
ansp
lant
.
Kno
ws
how
to:
• in
terp
ret c
ompl
ex re
sult
s an
d in
vest
igat
ions
• re
fer t
o re
leva
nt s
peci
alis
t.
• P
atie
nt s
afet
y.
• A
tten
tion
to d
etai
l.
• R
ole
mod
el.
• C
halle
nges
oth
ers.
• L
earn
ing
from
ow
n pr
acti
ce.
• A
ctiv
e le
arne
r.
• D
evel
ops
trus
t.
• A
ctiv
ely
prom
otes
bet
ter
heal
th fo
r pat
ient
s.
• C
halle
nges
ass
umpt
ions
an
d ta
ken
for g
rant
ed
way
s of
wor
king
.
• V
igila
nce.
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.5
Inva
sive
dia
gnos
tics
and
trea
tmen
t opt
ions
7
54
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
8Pr
ovid
es
spec
ific
inte
rven
tions
sa
fely
with
re
gard
s to
:
inva
sive
di
agno
stic
s an
d tr
eatm
ent
optio
ns.
HW
B7
Core
2
Core
3
G1
a. U
nder
take
s a
full
com
preh
ensi
ve a
sses
smen
t an
d hi
stor
y an
d in
itiat
es tr
eatm
ent a
ccor
ding
to
loca
l gui
danc
e or
pro
toco
l.
b. E
nsur
es c
linic
al ju
stifi
catio
n of
the
exam
inat
ion
requ
est a
nd a
ppro
pria
te in
dica
tion
for p
roce
dure
, ass
essi
ng a
ny c
ontr
aind
icat
ions
.
c. U
nder
take
s th
e fo
llow
ing
proc
edur
es
safe
ly w
ithin
agr
eed
com
pete
nce
limits
and
or
gani
satio
nal p
roto
cols
:
– pa
race
ntes
is
– liv
er b
iops
y
– en
dosc
opy.
d. E
valu
ate
the
effe
ctiv
enes
s of
the
inte
rven
tion
and
need
for f
urth
er in
terv
entio
n.
e. T
akes
app
ropr
iate
act
ion
in th
e ev
ent o
f co
mpl
icat
ions
and
liai
ses
with
med
ical
team
as
requ
ired.
f. En
sure
s sa
fe d
isch
arge
of t
he p
atie
nt w
ith
agre
ed fo
llow
up
for d
iscu
ssio
n of
resu
lts.
g. P
rovi
des
advi
ce o
n ne
ed fo
r fut
ure
trea
tmen
t op
tions
.
h. L
iais
es w
ith a
ppro
pria
te m
edic
al te
am o
r ot
her h
ealth
car
e pr
ofes
sion
als.
• in
-dep
th a
nato
my,
phy
siol
ogy
and
path
olog
y in
re
lati
on to
the
ther
apeu
tic
opti
on:
– par
acen
tesi
s
– liv
er b
iops
y
– end
osco
py
• bo
unda
ries
of c
ompe
tenc
e an
d ho
w to
kee
p th
is
up to
dat
e
• in
form
ed c
onse
nt a
nd le
gal i
mpl
icat
ions
• m
orbi
dity
and
mor
talit
y ri
sks
asso
ciat
ed w
ith
the
abov
e pr
oced
ures
and
how
thes
e ca
n be
m
inim
ised
and
reco
gnis
ed.
Kno
ws
how
to:
• ob
tain
info
rmed
con
sent
• en
sure
pat
ient
par
amet
ers
prio
r to
proc
edur
es a
re
wit
hin
agre
ed li
mit
s
• sa
fely
ope
rate
ult
raso
und
mac
hine
in li
ne w
ith
loca
l pol
ices
• re
cogn
ise
abno
rmal
ana
tom
y su
ch a
s bi
liary
ob
stru
ctio
n an
d fo
cal a
bnor
mal
itie
s.
• un
dert
ake
proc
edur
es s
afel
y an
d ac
cord
ing
to
prot
ocol
s
• re
cogn
ises
and
act
on
side
eff
ects
and
co
mpl
icat
ions
• in
terp
ret r
esul
ts a
nd c
omm
unic
ates
to o
ther
s
• do
cum
ent p
roce
dure
s co
rrec
tly
and
com
mun
icat
es to
pat
ient
and
gen
eral
pra
ctit
ione
r
• pa
rtic
ipat
e in
pee
r rev
iew
.
• St
rong
clin
ical
lead
ersh
ip.
• Co
llabo
rati
ve w
orki
ng a
cros
s se
rvic
es.
• Ch
ampi
ons
pers
on-c
entr
ed
appr
oach
.
• Pa
ssio
nate
abo
ut p
atie
nt s
afet
y.
Spec
ific
• L
ocal
pro
toco
ls a
nd p
atie
nt p
athw
ays.
• B
SG G
uida
nce
on L
iver
Bio
psy
(200
4).
• U
pper
GI B
leed
ing
(201
5).
• A
ASL
D g
uide
lines
: asc
ites
due
to
cirr
hosi
s an
d da
te (2
012)
and
live
r bi
opsy
(201
4).
• E
ASL
clin
ical
pra
ctic
e gu
idel
ines
on
the
man
agem
ent o
f asc
ites
, sp
onta
neou
s ba
cter
ial p
erit
onit
is a
nd
hepa
tore
nal s
yndr
ome
in c
irrh
osis
.
• Jo
int A
dvis
ory
Gro
up fo
r GI
Endo
scop
y.
• R
CN (2
012)
Adv
ance
d N
urse
pr
acti
tion
er a
nd R
CN G
uide
to
adva
nced
nur
sing
pra
ctic
e, a
dvan
ced
nurs
e pr
acti
tion
er a
nd p
rogr
amm
e ac
cred
itat
ion.
• N
ICE
guid
ance
on
liver
con
diti
ons
and
trea
tmen
ts.
Pro
vide
s sp
ecifi
c di
agno
stic
/tre
atm
ent o
ptio
ns s
afel
y: (c
onti
nued
)
7.5
Inva
sive
dia
gnos
tics
and
trea
tmen
t opt
ions
7N
urse
s op
erat
ing
at th
is le
vel w
ill n
eed
to h
ave
rece
ived
app
ropr
iate
inte
rven
tion
al tr
aini
ng a
nd a
sses
sed
com
pete
nce
as d
efine
d by
thei
r or
gani
sati
on.
55
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
1-4
Use
s ea
rly
war
ning
tool
s/
appr
oach
es
(suc
h as
re
d al
ert)
to
iden
tify
the
patie
nt’s
ch
angi
ng a
nd
dete
rior
atin
g co
nditi
on,
and
take
s ap
prop
riat
e ac
tion.
HW
B2
HW
B3
Core
3
a. A
sses
ses
patie
nt’s
wel
l-bei
ng.
b. U
nder
take
s cl
inic
al o
bser
vatio
ns a
nd
docu
men
ts in
app
ropr
iate
pla
ce.
c. U
ses
early
war
ning
tool
s to
pic
k up
cha
nges
an
d de
terio
ratio
n.
d. R
epor
ts a
ll fin
ding
s to
qua
lified
nur
sing
sta
ff.
e. R
espo
nds
appr
opria
tely
to c
once
rns
rais
ed.
• th
e si
gnifi
canc
e of
per
form
ing
clin
ical
ob
serv
atio
ns o
n pa
tien
ts w
ith
liver
dis
ease
• ea
rly
war
ning
tool
s (b
asic
kno
wle
dge)
• w
ho to
rais
e co
ncer
ns w
ith
e.g.
whe
n re
ceiv
ing
verb
al c
ompl
aint
s or
any
phy
sica
l cha
nges
in
cond
itio
n or
oth
er in
cide
nts.
Kno
ws
how
to:
• re
port
any
cha
nges
in th
e pa
tien
t tha
t mig
ht le
ad
to d
eter
iora
tion
in th
eir c
ondi
tion
.
• A
war
e of
role
lim
itat
ions
and
w
hen
to o
btai
n he
lp.
• Pe
rson
-cen
tred
and
co
mpa
ssio
nate
.
• Li
sten
s.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• Co
nfide
ntia
l.
• Pr
ide
in w
ork.
• R
espe
ctfu
l.
Gen
eric
•
NM
C do
cum
ents
and
gui
danc
e.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
an
d gu
idan
ce.
• R
CN G
astr
oint
estin
al N
ursi
ng F
orum
.
• B
ritis
h As
soci
atio
n fo
r the
Stu
dy o
f the
Li
ver N
urse
s Fo
rum
(BAS
LNF)
.
• B
ritis
h Li
ver N
urse
s Fo
rum
(BLN
F).
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth E
ngla
nd.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd
of li
fe c
are.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fro
m L
iver
D
isea
se. I
mpl
icat
ions
for e
nd o
f life
ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acity
Act
200
5.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ectio
n Ac
t 199
8.
• N
HS
Choi
ces.
• N
HS
Inst
itute
for I
nnov
atio
n an
d Im
prov
emen
t.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as,
CQU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
)
• N
ECPO
D 2
013
Mea
surin
g th
e un
its:
a re
view
of p
atie
nts
who
die
d w
ith
alco
hol-r
elat
ed li
ver d
isea
se,
Lond
on, N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
ality
)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Live
r D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s)
(con
tinue
d)
5U
ses
earl
y w
arni
ng to
ols/
ap
proa
ches
(s
uch
as
red
aler
t) to
id
entif
y th
e pa
tient
’s
chan
ging
and
de
teri
orat
ing
cond
ition
, an
d ta
kes
appr
opri
ate
actio
n.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
a. U
ses
the
loca
l ear
ly w
arni
ng to
ol to
asc
erta
in
chan
ges
in v
ital s
igns
and
oth
er in
dica
tors
of
det
erio
ratio
n fr
om c
ompl
icat
ions
of l
iver
di
seas
e or
follo
win
g in
vasi
ve p
roce
dure
s an
d/or
tr
ansp
lant
atio
n.
b. A
sses
ses
the
patie
nt fo
r the
abo
ve
com
plic
atio
ns.
c. D
ocum
ents
, mon
itors
and
act
s on
find
ings
, an
d m
akes
app
ropr
iate
refe
rral
.
d. E
duca
tes
unre
gist
ered
nur
sing
team
on
the
sign
ifica
nce
and
impo
rtan
ce o
f tak
ing
regu
lar
clin
ical
obs
erva
tions
.
• th
e lo
cal o
utre
ach
team
• th
e im
port
ance
of i
nter
pret
ing
vita
l sig
ns in
re
lati
on to
live
r dis
ease
and
follo
win
g in
vasi
ve
proc
edur
es
• si
gns
and
sym
ptom
s of
det
erio
rati
on, a
nd e
arly
w
arni
ng to
ols
for c
ompl
icat
ions
, inc
ludi
ng:
– sid
e ef
fect
s of
dru
g tr
eatm
ents
– hyp
oten
sion
due
to d
rug
rela
ted
e.g.
pr
opra
nolo
l, an
d no
n-dr
ug re
late
d re
ason
s e.
g.
deco
mpe
nsat
ed li
ver d
isea
se
– jau
ndic
e as
an
indi
cato
r of d
eter
iora
ting
live
r di
seas
e i.e
. ris
e in
bili
rubi
n
– bili
ary
com
plic
atio
ns, i
.e. c
hole
cyst
itis
and
/or
chol
angi
tis
or b
iliar
y ob
stru
ctio
n
– por
tal h
yper
tens
ion
and
oeso
phag
eal v
aric
es
– asc
ites
– hep
ator
enal
failu
re
– acu
te k
idne
y in
jury
– hep
atic
enc
epha
lopa
thy
– sep
sis
whi
ch o
ften
pre
cipi
tate
s va
rice
al b
leed
ing
or h
epat
ic e
ncep
halo
path
y
– car
diov
ascu
lar a
nd re
spir
ator
y co
mpl
icat
ions
– coa
gulo
path
y
– acu
te li
ver f
ailu
re in
clud
ing
risk
of c
ereb
ral
oede
ma.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• W
orks
in p
artn
ersh
ip.
• Su
ppor
tive
.
• En
cour
agin
g.
• Pr
ovid
es c
hoic
es.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• Fl
exib
le.
• N
on-ju
dgm
enta
l.
• Pa
ssio
nate
abo
ut p
atie
nt c
are.
Use
s ea
rly
war
ning
tool
s/ap
proa
ches
(su
ch a
s re
d al
ert)
to id
enti
fy th
e pa
tien
t’s
chan
ging
and
det
erio
rati
ng c
ondi
tion
and
take
s ap
prop
riat
e ac
tion
8
56
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
5•
Pote
ntia
l com
plic
atio
ns p
ost l
iver
tran
spla
nt e
.g.
blee
ding
via
dra
ins,
type
s of
sho
ck, s
epsi
s, b
iliar
y le
aks
and
reje
ctio
n
• un
reco
gnis
ed a
lcoh
ol w
ithd
raw
al.
Kno
w h
ow to
: •
cont
act a
nd re
fer t
o th
e lo
cal o
utre
ach
team
.
• N
HS
Atl
as o
f Var
iati
on:L
iver
(201
3)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is
care
Bun
dle:
Fir
st 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
ch
arit
ies
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
G
roup
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy
of th
e Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy
of L
iver
Dis
ease
s (A
ASL
D)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral
and
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h.
(con
tinu
ed)
6U
ses
earl
y w
arni
ng to
ols/
ap
proa
ches
(s
uch
as
red
aler
t) to
id
entif
y th
e pa
tient
’s
chan
ging
and
de
teri
orat
ing
cond
ition
, an
d ta
kes
appr
opri
ate
actio
n.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
a. In
vest
igat
es th
e ca
use
of e
arly
sig
ns o
f de
terio
ratio
n an
d ta
kes
appr
opria
te a
ctio
n.
b. D
ocum
ents
all
findi
ngs
and
liais
es w
ith th
e m
edic
al te
ams.
c. R
ole
mod
els
and
emph
asis
e to
oth
ers
the
impo
rtan
ce o
f bei
ng a
lert
to c
hang
es in
vita
l si
gns.
• re
late
d pa
thop
hysi
olog
ical
cha
nges
that
can
oc
cur s
udde
nly
or g
radu
ally
, res
ulti
ng in
rapi
d de
teri
orat
ion
or d
eath
• di
ffer
ent e
arly
war
ning
tool
s an
d th
eir u
se a
nd
cont
radi
ctio
ns in
pat
ient
s w
ith
liver
dis
ease
e.g
. po
or re
liabi
lity
of G
lasg
ow C
oma
Scal
e in
pat
ient
s w
ith
acut
e liv
er fa
ilure
• di
fficu
lty
of u
sing
som
e to
ols
wit
h pa
tien
ts w
ith
chro
nic
liver
dis
ease
bec
ause
of h
ypot
ensi
on a
nd
poor
rena
l fun
ctio
n et
c.
Kno
ws
how
to:
• or
der a
nd u
nder
take
app
ropr
iate
inve
stig
atio
ns
and
inte
rpre
t res
ults
; ide
ntify
acu
te c
ompl
icat
ions
an
d m
ake
appr
opri
ate
plan
of c
are
and
refe
rral
to
spec
ialis
t tea
m
• un
dert
ake,
reco
rd a
nd a
ct o
n nu
rsin
g ob
serv
atio
ns.
• Em
pow
erin
g.
• V
alue
s le
arni
ng.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• W
orks
in p
artn
ersh
ip.
• Em
brac
es d
iffer
ent p
ersp
ecti
ves.
• A
naly
tica
l.
• A
tten
tion
to d
etai
l.
• M
odel
s be
st p
ract
ice.
Use
s ea
rly
war
ning
tool
s/ap
proa
ches
(su
ch a
s re
d al
ert)
to id
enti
fy th
e pa
tien
t’s
chan
ging
and
det
erio
rati
ng c
ondi
tion
and
take
s ap
prop
riat
e ac
tion
(con
tinu
ed)
8
57
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
7U
ses
earl
y w
arni
ng to
ols/
ap
proa
ches
(s
uch
as
red
aler
t) to
id
entif
y th
e pa
tient
’s
chan
ging
and
de
teri
orat
ing
cond
ition
, an
d ta
kes
appr
opri
ate
actio
n.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
G1
a. U
nder
take
s a
full
com
preh
ensi
ve a
sses
smen
t an
d hi
stor
y an
d in
itiat
es tr
eatm
ent a
ccor
ding
to
loca
l gui
danc
e or
pro
toco
l.
b. D
ocum
ents
in th
e nu
rsin
g an
d m
edic
al n
otes
, an
d re
port
s to
spe
cial
ist t
eam
or m
edic
s.
c. E
duca
tes
othe
r nur
ses
and
med
ical
team
s on
the
sudd
en o
r gra
dual
cha
nges
in p
atie
nt
cond
ition
.
d. E
duca
tes
othe
r hea
lth c
are
prof
essi
onal
s on
th
e m
ajor
com
plic
atio
ns o
f liv
er d
isea
se a
nd
sign
s an
d sy
mpt
oms.
• th
e pa
thop
hysi
olog
y an
d th
e co
ntex
t of s
udde
n on
set o
f det
erio
ratio
n pr
ecip
itate
d by
the
dise
ase
proc
ess
and
othe
r pre
cipi
tatin
g fa
ctor
s.
Kno
ws
how
to:
• as
sess
and
iden
tify
sign
ifica
nt s
igns
and
sym
ptom
s,
incl
udin
g th
e fo
llow
ing:
– sid
e ef
fect
s of
dru
g tr
eatm
ents
– hyp
oten
sion
due
to d
rug
rela
ted
e.g.
pr
opra
nolo
l, an
d no
n-dr
ug re
late
d re
ason
s e.
g.
deco
mpe
nsat
ed li
ver d
isea
se
– jau
ndic
e as
an
indi
cato
r of d
eter
iora
ting
liver
di
seas
e i.e
. ris
e in
bili
rubi
n
– bili
ary
com
plic
atio
ns, i
.e.c
hole
cyst
itis
and/
or
chol
angi
tis o
r bili
ary
obst
ruct
ion
– por
tal h
yper
tens
ion
and
oeso
phag
eal v
aric
es
– hep
ato-
rena
l fai
lure
– acu
te k
idne
y in
jury
– hep
atic
enc
epha
lopa
thy
– sep
sis
whi
ch o
ften
pre
cipi
tate
s va
ricea
l ble
edin
g or
hep
atic
enc
epha
lopa
thy
– car
diov
ascu
lar a
nd re
spira
tory
com
plic
atio
ns
– coa
gulo
path
y
– acu
te li
ver f
ailu
re in
clud
ing
risk
of c
ereb
ral
oede
ma
– unr
ecog
nise
d al
coho
l wit
hdra
wal
.
• w
ork
with
in th
e lo
cal g
uide
lines
or p
roto
col,
and
the
scop
e of
pra
ctic
e w
hen
initi
atin
g tr
eatm
ent
• R
ole
mod
el.
• In
ter-
prof
essi
onal
wor
king
.
• Co
llabo
rati
ve.
• In
clus
ive.
• St
rong
clin
ical
lead
ersh
ip.
• Ch
ampi
ons
pers
on-c
entr
ed
appr
oach
es.
• Ch
alle
nges
ass
umpt
ions
and
ta
ken
for g
rant
ed w
ays
of w
orki
ng.
• A
ctiv
ely
prom
otes
bet
ter h
ealt
h fo
r pat
ient
s.
Spec
ific
• N
atio
nal E
arly
War
ning
Sco
re.
• Lo
cal g
uide
lines
and
pro
toco
ls.
• Th
e R
esus
cita
tion
Cou
ncil.
• N
PSA
(200
7) S
afer
car
e fo
r the
ac
utel
y ill
pat
ient
: lea
rnin
g fr
om
seri
ous
inci
dent
s.
• St
anda
rds
for c
linic
al p
ract
ice
and
trai
ning
( jo
int s
tate
men
ts) f
rom
:
– Roy
al C
olle
ge o
f Ana
esth
etis
ts
– Roy
al C
olle
ge o
f Phy
sici
ans
• Th
e In
tens
ive
Care
Soc
iety
.
• R
CN (2
012)
Adv
ance
d N
urse
pr
acti
tion
er a
nd R
CN G
uide
to
adva
nced
nur
sing
pra
ctic
e, a
dvan
ced
nurs
e pr
acti
tion
er a
nd p
rogr
amm
e ac
cred
itat
ion.
Use
s ea
rly
war
ning
tool
s/ap
proa
ches
(su
ch a
s re
d al
ert)
to id
enti
fy th
e pa
tien
t’s
chan
ging
and
det
erio
rati
ng c
ondi
tion
and
take
s ap
prop
riat
e ac
tion
(con
tinu
ed)
8
58
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d
unde
rsta
ndin
g of
:A
ttit
udes
and
beh
avio
urs
Cont
extu
al fa
ctor
s
8U
ses
earl
y w
arni
ng to
ols/
ap
proa
ches
(s
uch
as
red
aler
t) to
id
entif
y th
e pa
tient
’s
chan
ging
and
de
teri
orat
ing
cond
ition
, an
d ta
kes
appr
opri
ate
actio
n.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
G1
a. C
ontr
ibut
es to
org
anis
atio
n’s
stra
tegy
and
po
licie
s fo
r man
agin
g de
terio
ratin
g pa
tient
s.
b. P
rovi
des
expe
rt re
view
of p
atie
nts
who
hav
e de
terio
rate
d du
e to
live
r con
ditio
ns a
cros
s ow
n or
gani
satio
n an
d ot
her o
rgan
isat
ions
.
c. C
olla
bora
tes
in re
sear
ch p
rogr
amm
es th
at
addr
ess
dete
riora
ting
patie
nts
with
live
r co
nditi
ons
and
thei
r man
agem
ent.
• th
e de
teri
orat
ing
liver
pat
ient
and
opt
imis
ing
trea
tmen
t opt
ions
to p
reve
nt fu
rthe
r de
teri
orat
ion
• re
ferr
al to
oth
er h
ealt
h ca
re p
rofe
ssio
nals
or f
rom
ot
her o
rgan
isat
ions
• st
rate
gic
aim
s in
rela
tion
to li
ver p
atie
nts
and
outr
each
ser
vice
• cl
inic
al tr
ials
and
recr
uitm
ent t
o tr
ials
whe
re
appr
opri
ate.
Kno
ws
how
to:
• re
cogn
ise
in a
tim
ely
man
ner t
he a
cute
live
r fa
ilure
pat
ient
• re
cogn
ise
the
pati
ent w
ith
on-g
oing
var
icea
l bl
eedi
ng a
nd c
onsi
der s
uita
ble
trea
tmen
t opt
ions
w
ith
colle
ague
s
• su
ppor
t sta
ff to
iden
tify
the
dete
rior
atin
g liv
er
pati
ent.
• St
rong
asp
irat
iona
l lea
ders
hip.
• Co
llabo
rati
ve w
orki
ng a
cros
s se
rvic
es.
• Pa
ssio
nate
abo
ut p
atie
nt s
afet
y.
See
abov
e.
Use
s ea
rly
war
ning
tool
s/ap
proa
ches
(su
ch a
s re
d al
ert)
to id
enti
fy th
e pa
tien
t’s
chan
ging
and
det
erio
rati
ng c
ondi
tion
and
take
s ap
prop
riat
e ac
tion
(con
tinu
ed)
8
59
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
7Ac
tivel
y im
prov
es a
nd
prom
otes
se
rvic
es a
cros
s th
e ca
re
path
way
.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
Core
4
Core
5
G1
a. P
rovi
des
clin
ical
lead
ersh
ip fo
r nur
ses
and
heal
th c
are
prof
essi
onal
s in
volv
ed w
ith c
are
of
thos
e w
ith a
cute
and
chr
onic
live
r dis
ease
.
b. W
rites
and
upd
ates
pro
toco
ls fo
r car
e pa
thw
ays.
c. E
nsur
es s
moo
th tr
ansf
er a
nd d
ocum
enta
tion
of
patie
nts
ente
ring
into
and
leav
ing
loca
l ser
vice
s.
d. U
nder
take
s re
gula
r ser
vice
revi
ews/
audi
ts a
nd
take
s ap
prop
riate
act
ion
to im
prov
e se
rvic
e.
e. O
rgan
ises
feed
back
from
pat
ient
s, th
eir
fam
ilies
/car
ers
and
mak
es a
ppro
pria
te c
hang
es
to e
nsur
e se
rvic
es m
eet p
atie
nts’
nee
ds.
f. Co
mm
unic
ates
eff
ectiv
ely
and
in a
tim
ely
way
w
ith o
ther
hea
lth c
are
prac
titio
ners
to e
nabl
e co
nsis
tent
sta
ndar
ds o
f car
e to
be
impl
emen
ted.
g. P
rovi
des
staf
f tra
inin
g an
d as
sess
men
t fo
r nur
ses
wor
king
with
pat
ient
s w
ith li
ver
dise
ase,
e.g
. tra
inin
g of
A &
E s
taff
to re
cogn
ise
sym
ptom
s.
h. K
eeps
up
to d
ate
with
med
ical
/nur
sing
re
sear
ch s
o th
at n
ew d
evel
opm
ents
are
ado
pted
.
i. En
sure
s th
at c
are
path
way
s ar
e se
amle
ss fo
r pa
tient
s by
eng
agin
g w
ith o
wn
inst
itutio
n (e
.g.
A&E)
and
oth
er s
ervi
ce p
rovi
ders
, inc
ludi
ng:
– ou
tpat
ient
s
– ot
her s
peci
alis
t ser
vice
s (e
.g. d
rug
and
alco
hol,
card
iac,
psy
chol
ogic
al)
– pr
imar
y ca
re (i
nclu
ding
com
mun
ity a
nd
prac
tice
nurs
es)
– ot
her h
ospi
tals
– ed
ucat
ion,
incl
udin
g sc
hool
nur
ses
and
univ
ersi
ty s
taff
– so
cial
ser
vice
s, h
ousi
ng a
nd b
enefi
ts a
dvis
ers
– vo
lunt
ary
sect
or a
nd lo
cal s
uppo
rt n
etw
orks
.
j. W
orks
in c
onju
nctio
n w
ith li
ver c
harit
ies
and
supp
ort g
roup
s.
k. W
orks
with
oth
er h
ealth
car
e pr
ofes
sion
als
to
run
nurs
e-le
d cl
inic
s an
d se
rvic
es.
(con
tinu
ed)
• re
leva
nt N
ICE
guid
elin
es
• he
alth
and
wel
l bei
ng s
trat
egie
s fo
r hea
lthy
live
rs
and
lifes
tyle
s
• cl
inic
al g
over
nanc
e
• ap
prai
sal a
nd s
taff
dev
elop
men
t (KS
F)
• as
sess
ing
com
pete
nce
• cl
inic
al s
uper
visi
on a
nd m
ento
ring
• et
hics
• ba
rrie
rs to
con
tinu
ity
and
the
stra
tegi
es to
ov
erco
me
thes
e ba
rrie
rs
• re
sour
ce im
plic
atio
ns in
rela
tion
to fu
ndin
g of
th
erap
ies
• PR
OM
s an
d PR
EMs.
Kno
ws
how
to:
• su
bmit
pro
toco
ls fo
r app
rova
l acc
ordi
ng to
loca
l gu
idan
ce
• co
nduc
t res
earc
h ac
cord
ing
to lo
cal e
thic
s an
d go
vern
ance
gui
danc
e
• un
dert
ake
audi
t and
und
erta
ke q
ualit
y re
view
s
• en
able
all
grad
es o
f sta
ff w
ith
thei
r lea
rnin
g an
d de
velo
pmen
t aro
und
prom
otin
g he
alth
y liv
ers
and
lifes
tyle
s.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• Su
ppor
tive
.
• En
cour
agin
g.
• Em
pow
erin
g.
• Pr
ovid
es c
hoic
es.
• G
ives
and
rece
ives
feed
back
.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• Fl
exib
le.
• N
on-ju
dgm
enta
l.
• Pa
ssio
nate
abo
ut p
atie
nt c
are.
• Pa
tien
t cen
tred
and
co
mpa
ssio
nate
.
• Li
sten
s.
• U
nder
stan
ding
.
• W
elco
min
g.
• O
pen
to re
ceiv
ing
feed
back
.
• R
espe
cts
confi
dent
ialit
y.
• W
orks
in p
artn
ersh
ip w
ith
othe
rs.
• R
ole
mod
els
heal
thy
livin
g.
• In
terp
rofe
ssio
nal w
orki
ng.
• Em
brac
es d
iffer
ent p
ersp
ecti
ves.
• A
tten
tion
to d
etai
l.
• M
odel
s be
st p
ract
ice.
Gen
eric
•
NM
C do
cum
ents
and
gui
danc
e.
• R
oyal
Col
lege
of N
ursi
ng d
ocum
ents
an
d gu
idan
ce.
• R
CN G
astr
oint
estin
al N
ursi
ng F
orum
.
• B
ritis
h As
soci
atio
n fo
r the
Stu
dy o
f the
Li
ver N
urse
s Fo
rum
(BAS
LNF)
.
• B
ritis
h Li
ver N
urse
s Fo
rum
(BLN
F).
• N
HS
Engl
and.
• D
H (2
009)
Mak
ing
a D
iffer
ence
.
• P
ublic
Hea
lth E
ngla
nd.
• N
HS
Empl
oyer
s an
d Sk
ills
Fram
ewor
k.
• G
old
Stan
dard
s Fr
amew
ork
for p
eopl
e ne
arin
g th
e en
d of
life
.
• N
HS
(200
9) c
ore
com
pete
nces
for e
nd
of li
fe c
are.
• N
atio
nal E
nd o
f liv
e Ca
re In
telli
genc
e N
etw
ork
(201
2) D
eath
s fro
m L
iver
D
isea
se. I
mpl
icat
ions
for e
nd o
f lif
e ca
re.
• N
ICE
liver
gui
danc
e.
• M
enta
l Cap
acity
Act
200
5.
• N
HS
Com
mis
sion
Boa
rd S
afeg
uard
ing
vuln
erab
le p
eopl
e in
the
refo
rmed
NH
S .
• D
H C
onse
nt 2
009.
• D
ata
Prot
ectio
n Ac
t 199
8.
• N
HS
Choi
ces.
• N
HS
Inst
itute
for I
nnov
atio
n an
d Im
prov
emen
t.
• Q
ualit
y O
utco
me
Mea
sure
s, s
uch
as,
CQU
INS,
PRO
MS
etc.
• Th
e La
ncet
Com
mis
sion
(Will
iam
s et
al,
2014
)
• N
ECPO
D 2
013
Mea
surin
g th
e un
its:
a re
view
of p
atie
nts
who
die
d w
ith
alco
hol-r
elat
ed li
ver d
isea
se,
Lond
on, N
CEPO
D.
• N
HS
IQ (I
mpr
ovin
g qu
ality
)
• N
ursi
ng T
imes
Lea
rnin
g U
nit.
Live
r D
isea
se: R
isk
fact
ors
and
trea
tmen
t (fr
ee a
cces
s)
Act
ivel
y im
prov
es a
nd p
rom
otes
live
r se
rvic
es a
cros
s th
e ap
prop
riat
e ca
re p
athw
ay9
60
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
7Se
e ab
ove
See
abov
el.
Co-o
rdin
ates
tran
sitio
n so
that
you
ng p
eopl
e ca
n m
ove
confi
dent
ly a
nd s
eam
less
ly fr
om
paed
iatr
ic to
adu
lt se
rvic
es.
m. D
evel
ops
and
eval
uate
s ou
trea
ch s
ervi
ces.
n. L
eads
, man
ages
and
app
rais
es s
taff
acr
oss
the
serv
ice.
o. D
evel
ops
loca
l and
regi
onal
net
wor
ks to
su
ppor
t exc
elle
nce
in n
ursi
ng fo
r peo
ple
with
liv
er d
isea
se.
p. P
rom
otes
, rol
e m
odel
s an
d co
ache
s ot
hers
in
heal
th a
nd w
ell b
eing
aro
und
min
imis
ing
liver
di
seas
e.
q. U
nder
take
s te
achi
ng in
rele
vant
pos
t-re
gist
ratio
n co
urse
s.
See
abov
eSe
e ab
ove
Gen
eric
•
NH
S A
tlas
of V
aria
tion
:Liv
er (2
013)
• N
atio
nal C
linic
al G
uide
lines
Cen
tre.
• B
ASL
/B
SG: D
ecom
pens
ated
Cir
rhos
is
care
Bun
dle:
Fir
st 2
4 ho
urs
• N
HS
Engl
and
(201
3) T
he 6
Cs
• Ke
y qu
alit
y as
sure
d pa
tien
t and
car
er
info
rmat
ion
and
supp
ort f
rom
key
ch
arit
ies
and
orga
nisa
tion
s, s
uch
as:
– B
riti
sh L
iver
Tru
st–
Child
ren’
s Li
ver D
isea
se F
ound
atio
n–
Alc
ohol
Con
cern
– Th
e H
epat
itis
C T
rust
– H
epat
itis
B F
ound
atio
n U
K–
Hae
moc
hrom
atos
is S
ocie
ty–
Wils
on’s
Dis
ease
Sup
port
G
roup
(UK)
– PB
C Fo
unda
tion
– R
are
Dis
ease
s U
K–
PSC
Supp
ort
– R
oyal
col
lege
s, s
uch
as, P
hysi
cian
s,
Gen
eral
Pra
ctit
ione
rs, S
urge
ons,
A
naes
thet
ists
– B
riti
sh S
ocie
ty o
f Gas
troe
nter
olog
y (B
SG)
– B
riti
sh A
ssoc
iati
on fo
r the
Stu
dy o
f th
e Li
ver (
BA
SL)
– Eu
rope
an A
ssoc
iati
on fo
r the
Stu
dy
of th
e Li
ver (
EASL
)–
Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy
of L
iver
Dis
ease
s (A
ASL
D)
– B
riti
sh A
ssoc
iati
on o
f Par
ente
ral
and
Ente
ral N
utri
tion
(BA
PEN
)
• N
HS
Engl
and
The
In
form
atio
n St
anda
rd
• B
riti
sh N
atio
nal F
orm
ular
y (B
NF)
• Sk
ills
for H
ealt
h
Spec
ific
• R
CN (2
010)
Mea
suri
ng th
e qu
alit
y of
H
ealt
h Ca
re: a
pos
itio
n st
atem
ent.
• R
CN (2
014)
The
eig
ht p
rinc
iple
s.
• D
H E
lect
roni
c in
form
atio
n sy
stem
s.
8Ac
tivel
y pr
omot
es
and
impr
oves
se
rvic
es a
cros
s th
e ca
re
path
way
Core
1
HW
B1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
Core
4
Core
5
G1
G2
G6
G7
Ik3
a. C
ontr
ibut
es to
qua
lity
acco
unts
, CQ
UIN
and
Q
IPP
activ
ity a
nd d
irect
ion.
b. E
ngag
es w
ith o
ther
par
ts o
f the
org
anis
atio
n co
ncer
ning
the
who
le c
are
path
way
so
that
car
e is
sea
mle
ss fo
r pat
ient
s.
c. E
nsur
es s
moo
th a
nd s
afe
wor
king
acr
oss
the
serv
ice
and
orga
nisa
tion.
d. A
dvoc
ates
for p
atie
nts
and
influ
ence
s co
mm
issi
onin
g.
e. E
nsur
es re
leva
nt c
linic
al d
ata
are
confi
dent
ially
col
lect
ed, a
udite
d an
d ev
alua
ted
to s
uppo
rt a
nd im
prov
e pa
tient
car
e ac
ross
or
gani
satio
nal b
ound
arie
s.
f. D
eliv
ers
wor
ksho
ps/c
onfe
renc
es.
g. Im
plem
ents
nur
se-le
d cl
inic
s an
d se
rvic
es
that
add
ress
the
heal
th n
eeds
of p
atie
nts
with
liv
er d
isea
se.
h. C
ontin
uous
ly id
entifi
es g
aps
in s
ervi
ce,
deve
lops
inno
vativ
e so
lutio
ns a
nd m
onito
rs
outc
omes
.
i. Le
ads,
man
ages
and
app
rais
es s
taff
acr
oss
the
orga
nisa
tion,
dev
elop
ing
the
lead
ersh
ip
pote
ntia
l of a
ll.
(con
tinu
ed)
• w
orki
ng a
t a s
trat
egic
leve
l wit
hin
own
orga
nisa
tion
• lo
cal n
etw
orks
• pr
imar
y ca
re s
ervi
ces
• th
e se
rvic
es o
ffer
ed b
y th
e vo
lunt
ary
sect
or
• th
e se
rvic
es o
ffer
ed b
y th
e st
atut
ory
sect
or
(inc
ludi
ng lo
cal s
choo
ls, l
ocal
hou
sing
de
part
men
ts a
nd lo
cal s
ocia
l ser
vice
s de
part
men
ts)
• st
anda
rds
and
polic
ies
• qu
alit
y ac
coun
ts, C
omm
issi
onin
g fo
r Qua
lity
and
Inno
vati
on (C
QU
IN) a
nd Q
ualit
y, In
nova
tion
, Pr
even
tion
and
Pro
duct
ivit
y Q
IPP
• de
velo
pmen
ts a
nd in
nova
tion
s
• th
e co
nseq
uenc
es o
f poo
r pra
ctic
e
• be
st in
dica
tors
• le
ader
ship
‘cha
mpi
on’ s
kills
• ch
ange
/dev
elop
men
t ski
lls
• th
e sk
ills
need
ed to
bui
ld g
ood
rela
tion
ship
s w
ith
prof
essi
onal
col
leag
ues
in o
ther
dep
artm
ents
and
se
rvic
es
• th
e pr
eval
ence
rate
of l
iver
dis
ease
s in
loca
l po
pula
tion
s.
(con
tinu
ed)
• St
rong
clin
ical
lead
ersh
ip.
• Co
llabo
rati
ve w
orki
ng a
cros
s se
rvic
es.
• Ch
ampi
ons
pers
on c
entr
ed
appr
oach
.
• In
clus
ive.
• Ch
alle
nges
ass
umpt
ions
and
ta
ken
for g
rant
ed w
ays
of
wor
king
.
• A
naly
tica
l.
• Ch
ampi
ons
pati
ent s
afet
y.
Act
ivel
y im
prov
es a
nd p
rom
otes
live
r se
rvic
es a
cros
s th
e ap
prop
riat
e ca
re p
athw
ay (c
onti
nued
)
9
61
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Co
ntex
tual
fact
ors
8Se
e ab
ove.
See
abov
e.j.
Neg
otia
tes
and
influ
ence
s ke
y st
akeh
olde
rs
tow
ards
exc
elle
nce
in n
ursi
ng o
f pat
ient
s w
ith
liver
dis
ease
.
k. E
nsur
es g
ood
clin
ical
gov
erna
nce
and
acco
unta
bilit
y ac
ross
the
serv
ice
and
orga
nisa
tion.
l. U
nder
take
s re
sear
ch a
nd p
ublis
hes.
• in
form
atio
n sy
stem
s fo
r sha
ring
info
rmat
ion
acro
ss b
ound
arie
s
• ev
alua
tion
, pro
fess
iona
l sta
ndar
ds a
nd
mea
sure
men
t and
the
rela
tion
ship
bet
wee
n th
em
• di
ffer
ent r
esea
rch
appr
oach
es to
dev
elop
ing
know
ledg
e of
saf
e, e
ffec
tive
and
per
son-
cent
red
care
.
Kno
ws
how
to:
• ut
ilise
pat
ient
info
rmat
ion
syst
ems
• m
aint
ain
pati
ent r
ecor
ds in
com
plia
nce
wit
h st
anda
rds
at lo
cal l
evel
and
acr
oss
the
NH
S qu
alit
y im
prov
emen
t and
pra
ctic
e de
velo
pmen
t st
rate
gies
• sh
are
good
pra
ctic
e
• ev
alua
te c
are,
ass
ess
effe
ctiv
enes
s an
d us
e au
dit
tool
s
• ta
ke fo
rwar
d Q
IPP
in e
very
day
prac
tice
• de
velo
p a
cult
ure
of e
ffec
tive
ness
in th
e w
orkp
lace
.
See
abov
e.Se
e ab
ove.
Act
ivel
y im
prov
es a
nd p
rom
otes
live
r se
rvic
es a
cros
s th
e ap
prop
riat
e ca
re p
athw
ay (c
onti
nued
)
9
62
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Appendix 1:nurse census of roles
(Department of Health, 2012) This information was collected as a quick “snap shot” of liver nursing roles and is not
a complete reflection of the full liver nurse workforce.
63
R O Y A L C O L L E G E O F N U R S I N G
Sen
ior
staf
f nur
se/j
unio
r si
ster
rol
eCo
mpe
tenc
e N
umbe
r 1
– P
rovi
des
empa
thy
and
unde
rsta
ndin
g an
d w
orks
wit
h th
e pa
tien
t (an
d th
eir
fam
ily/
care
rs) a
nd p
arti
cula
rly
thos
e w
ith
chro
nic
live
r di
seas
e as
exp
erts
in th
eir
own
cond
itio
n
App
endi
x 2:
Exa
mpl
es o
f evi
denc
e to
mee
t Car
ing
for p
eopl
e w
ith
liver
di
seas
e: a
com
pete
nce
fram
ewor
k fo
r nur
sing
*
* Th
ese
are
inte
nded
onl
y as
a g
uide
in o
rder
to a
chie
ve a
n in
divi
dual
com
pete
nce.
The
re m
ay b
e ot
her e
xam
ples
of l
iver
nur
sing
car
e th
at c
ould
be
used
as
evid
ence
to a
chie
ve th
e co
mpe
tenc
e.
Exam
ples
of
evid
ence
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Ev
iden
ce t
o ac
hiev
e co
mpe
tenc
e
6Pr
ovid
es
empa
thy
and
unde
rsta
ndin
g an
d w
orks
w
ith th
e pa
tient
(and
th
eir f
amily
/ ca
rers
) and
pa
rtic
ular
ly
thos
e w
ith
chro
nic
liver
di
seas
e as
ex
pert
s in
thei
r ow
n co
nditi
on.
Core
1
Core
6
HW
B1
HW
B3
HW
B4
HW
B5
HW
B6
a. S
uppo
rts
team
mem
bers
to c
o-de
velo
p,
impl
emen
t and
eva
luat
e pe
rson
al c
are
plan
s.
b. A
cts
as a
role
mod
els
to e
nsur
e th
at te
am
mem
bers
ena
ble
the
pati
ent’
s vo
ice
to b
e he
ard
and
acte
d on
.
• ad
voca
cy n
eeds
for t
hose
who
are
less
abl
e to
ac
t for
them
selv
es d
ue to
thei
r liv
er c
ondi
tion
le
adin
g to
cha
lleng
ing
beha
viou
r, d
epre
ssio
n or
in
abili
ty to
art
icul
ate
thei
r nee
ds d
ue to
hep
atic
en
ceph
alop
athy
or o
ther
cog
niti
ve im
pair
men
t
• ac
ute
and
long
-ter
m c
ompl
icat
ions
rela
ted
to li
ver
dise
ase
• st
rate
gies
pat
ient
s ca
n us
e fo
r man
agin
g co
-mor
bidi
ties
• of
loca
l and
nat
iona
l str
ateg
y fo
r pat
ient
s w
ith
liver
dis
ease
and
how
to c
ontr
ibut
e
• Pa
tien
t Rep
orte
d O
utco
me
Mea
sure
s (P
RO
MS)
an
d Pa
tien
t Rep
orte
d Ex
peri
ence
Mea
sure
s (P
REM
S).
Kno
ws
how
to:
• bu
ild a
nd fo
ster
an
equi
tabl
e nu
rse-
pati
ent
rela
tion
ship
• w
ork
wit
h pa
tien
ts w
ith
chal
leng
ing
beha
viou
r an
d co
llabo
rati
vely
dev
elop
car
e pl
ans
• di
ffus
e an
ger a
nd c
halle
ngin
g be
havi
our
• de
velo
p ca
re p
lans
in c
onju
ncti
on w
ith
loca
l gu
idel
ines
.
• M
odel
s be
st p
ract
ice.
• A
ctiv
ely
prom
otes
bet
ter h
ealt
h fo
r pat
ient
s.
• Ch
alle
nges
oth
ers.
• Pl
ans,
impl
emen
ts a
nd e
valu
ates
an
agre
ed c
are
plan
wit
h th
e pa
tien
t and
/o
r the
ir c
arer
s.
• Ca
n de
mon
stra
te u
nder
stan
ding
of
pati
ent’
s ca
re n
eeds
and
adv
ocat
es
for t
he p
atie
nt o
n th
e w
ard
roun
d or
at
rele
vant
MD
T m
eeti
ngs.
• G
ives
app
ropr
iate
info
rmat
ion
to
pati
ents
or t
heir
car
ers
and
sign
pos
ts
them
to o
ther
sou
rces
of i
nfor
mat
ion
such
as
the
Bri
tish
Liv
er T
rust
.
• A
ble
to w
rite
a re
flect
ive
acco
unt
of a
n ep
isod
e of
car
e th
at m
ay b
e ch
alle
ngin
g fo
r the
ir o
wn
pers
onal
an
d pr
ofes
sion
al d
evel
opm
ent.
• Is
abl
e to
sup
port
juni
or n
urse
s in
as
sess
ing
and
impl
emen
ting
a c
are
plan
that
focu
ses
on a
n as
pect
of
care
suc
h as
hep
atic
enc
epha
lopa
thy,
co
ntin
ued
alco
hol d
epen
denc
e an
d /
or d
epre
ssio
n.
• Is
abl
e to
und
erta
ke o
r con
trib
ute
to re
leva
nt li
ver n
ursi
ng a
udit
s,
diss
emin
ate
outc
omes
and
cha
nge
prac
tice
whe
re re
leva
nt.
• Id
enti
fy o
wn
lear
ning
nee
ds to
su
ppor
t the
se p
atie
nts
such
as
a fo
rmal
live
r edu
cati
on a
t a h
ighe
r ed
ucat
ion
inst
itut
e; lo
cal a
nd n
atio
nal
liver
rela
ted
stud
y da
ys o
r loc
al c
ours
e su
ch a
s co
nflic
t res
olut
ion
or s
peci
fic
man
agem
ent a
nd le
ader
ship
cou
rses
.
64
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Exam
ples
of
evid
ence
Pra
ctic
e nu
rse
role
Com
pete
nce
Num
ber
2 –
Sig
npos
ts a
nd s
uppo
rts
pati
ents
(an
d fa
mil
ies/
care
rs) i
n th
eir
unde
rsta
ndin
g of
thei
r co
ndit
ion
thro
ugh
pati
ent e
duca
tion
and
hea
lth
prom
otio
n
* Th
ese
are
inte
nded
onl
y as
a g
uide
in o
rder
to a
chie
ve a
n in
divi
dual
com
pete
nce.
The
re m
ay b
e ot
her e
xam
ples
of l
iver
nur
sing
car
e th
at c
ould
be
used
as
evid
ence
to a
chie
ve th
e co
mpe
tenc
e.
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Ev
iden
ce t
o ac
hiev
e co
mpe
tenc
e
5Si
gnpo
sts
and
supp
orts
pa
tient
s (a
nd
fam
ilies
/ ca
rers
) in
thei
r un
ders
tand
ing
of th
eir
cond
ition
th
roug
h pa
tient
ed
ucat
ion
and
heal
th
prom
otio
n.
HW
B1
HW
B2
HW
B3
HW
B5
HW
B6
Core
1
Core
3
a. A
sses
ses
know
ledg
e an
d un
ders
tand
ing
of
pati
ent’
s an
d ca
rer’
s ow
n co
ndit
ion,
cau
ses,
risk
fa
ctor
s an
d co
nseq
uenc
es.
b. P
rovi
des
tailo
red
educ
atio
n to
pat
ient
and
fa
mily
/car
ers
on c
ondi
tion
, tre
atm
ents
and
si
de-e
ffec
ts.
c. P
rovi
des
info
rmat
ion
abou
t life
styl
e fa
ctor
s,
cons
eque
nces
and
ser
vice
s av
aila
ble
to s
uppo
rt
lifes
tyle
cha
nges
.
d. R
efer
s to
oth
er a
ppro
pria
te h
ealt
h ca
re
prof
essi
onal
s if
requ
ired
.
• ri
sk fa
ctor
s e.
g. d
rugs
, obe
sity
, alc
ohol
• in
form
atio
n e.
g. D
H D
rink
wis
e, e
duca
tion
and
su
ppor
t res
ourc
es, s
ervi
ces
and
spec
ialis
t sta
ff
avai
labl
e
• di
ffer
ent c
omm
unic
atio
n an
d en
gage
men
t ap
proa
ches
to p
rovi
ding
edu
cati
on a
nd
info
rmat
ion
• he
alth
pro
mot
ion,
sex
ual h
ealt
h st
rate
gies
and
e-
lear
ning
reso
urce
s av
aila
ble
e.g.
from
PH
E A
lcoh
ol L
earn
ing
Res
ourc
es
• po
siti
ve li
fest
yle
appr
oach
es a
nd a
dvic
e
• ho
w to
giv
e br
ief a
dvic
e an
d in
terv
enti
ons.
Kno
ws
how
to:
• ta
ilor i
nfor
mat
ion
and
educ
atio
n to
the
pers
on
• ob
tain
edu
cati
onal
info
rmat
ion
or d
irec
t pat
ient
s/fa
mili
es/c
arer
s to
ava
ilabl
e re
sour
ces,
ser
vice
s an
d st
aff,
incl
udin
g th
e vo
lunt
ary
sect
or
• w
ork
wit
hin
thei
r lev
el o
f com
pete
nce.
• A
war
e of
role
lim
itat
ions
.
• R
ecog
nise
s ow
n le
vel o
f co
mpe
tenc
e, a
ble
to id
enti
fy
lear
ning
nee
ds.
• A
ccou
ntab
le.
• Em
path
etic
.
• En
cour
agin
g.
• Su
ppor
tive
.
• N
on-ju
dgm
enta
l.
• W
orks
in p
artn
ersh
ip w
ith
othe
rs.
• W
illin
g to
refle
ct o
n an
d le
arn
from
ow
n pr
acti
ce.
• Fl
exib
le.
• Pa
ssio
nate
abo
ut p
atie
nt c
are.
• A
tten
ds a
ccre
dite
d lo
cal u
pdat
es o
n liv
er d
isea
se.
• Lo
cal e
duca
tion
thro
ugh
e-le
arni
ng.
• D
evel
ops
wit
h th
e pr
acti
ce le
ad a
sc
reen
ing
and
heal
th e
duca
tion
pr
ogra
mm
e th
at in
corp
orat
es is
sues
ar
ound
live
r hea
lth
such
as
alco
hol,
risk
fact
ors
for v
iral
hep
atit
is, f
amily
hi
stor
y of
live
r dis
ease
, obe
sity
, pr
evio
us b
lood
tran
sfus
ions
, tat
toos
or
pie
rcin
gs, r
ecen
t ove
rsea
s tr
avel
an
d se
xual
hea
lth.
• D
evel
ops
awar
enes
s of
link
s to
oth
er
chro
nic
dise
ase
grou
ps s
uch
as
diab
etes
, met
abol
ic s
yndr
ome,
hea
rt
dise
ase.
• H
as a
tten
ded
rele
vant
cou
rse
or
upda
tes
in s
uch
as, m
otiv
atio
nal
inte
rvie
win
g, b
rief
adv
ice
or
inte
rven
tion
rela
ted
to a
lcoh
ol.
• U
nder
stan
ds a
nd d
evel
ops
a pa
thw
ay
for r
efer
ral o
f pat
ient
s w
ith
poss
ible
liv
er d
isea
se to
rele
vant
ser
vice
suc
h as
dru
gs a
nd a
lcoh
ol o
r loc
al v
iral
he
pati
tis
serv
ices
.
• D
emon
stra
tes
awar
enes
s of
ava
ilabl
e liv
er re
sour
ces
such
as
web
site
s an
d ch
arit
ies.
65
R O Y A L C O L L E G E O F N U R S I N G
Clin
ical
Nur
se S
peci
alis
t rol
e Co
mpe
tenc
e N
umbe
r 3
– U
nder
take
s a
com
preh
ensi
ve c
lini
cal a
sses
smen
t inc
ludi
ng r
isk
profi
ling
and
foll
ows
up w
ith
appr
opri
ate
acti
on, i
nclu
ding
ref
erra
l to
spec
iali
sts,
for
rele
vant
ac
ute
and
chro
nic
heal
th c
are
cond
itio
ns
Exam
ples
of
evid
ence
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Ev
iden
ce t
o ac
hiev
e co
mpe
tenc
e
7U
nder
take
s a
com
preh
ensi
ve
phys
ical
as
sess
men
t an
d fo
llow
s up
with
ap
prop
riat
e ac
tion,
in
clud
ing
refe
rral
to
med
ical
sp
ecia
lists
fo
r rel
evan
t ch
roni
c an
d ac
ute
heal
th c
are
cond
ition
s.
Core
1
HW
B3
HW
B5
HW
B6
HW
B7
Core
3
a. A
sses
ses,
dia
gnos
es a
nd tr
eats
peo
ple
wit
h on
-goi
ng li
ving
dis
ease
and
its
com
plic
atio
ns.
b. U
nder
take
s a
med
ical
his
tory
, com
plet
es a
de
taile
d ph
ysic
al a
nd n
ursi
ng e
xam
inat
ion,
fo
rmul
ates
a d
iagn
osis
, ini
tiat
es in
vest
igat
ions
an
d/or
trea
tmen
ts a
nd re
fers
to s
peci
alis
t tea
ms
as a
ppro
pria
te.
c. D
iagn
oses
new
or w
orse
ning
com
plic
atio
ns
of a
cute
and
chr
onic
live
r dis
ease
.
d. Id
enti
fies
earl
y si
gns
of o
ther
dis
ease
s.
e. P
rovi
des
the
pati
ent w
ith
info
rmat
ion
on h
ow
to m
anag
e an
d m
onit
or s
peci
fic s
ympt
oms.
f. Im
plem
ents
end
of l
ife c
are
for t
he p
atie
nt
and
thei
r fam
ily, p
rovi
des
supp
ort a
nd re
fers
to
the
appr
opri
ate
heal
th p
rofe
ssio
nals
.
• al
l cau
ses
of li
ver d
isea
se in
clud
ing
thos
e re
late
d to
occ
upat
ion
and
trav
el
• co
mpl
icat
ions
of a
cute
and
chr
onic
live
r dis
ease
• de
sign
ing,
impl
emen
ting
and
eva
luat
ing
a m
anag
emen
t pla
n th
at in
clud
es s
peci
fic s
igns
an
d sy
mpt
oms
or s
ide
effe
cts
such
as:
– pru
ritu
s
– ski
n ra
shes
as
side
eff
ects
of d
rug
trea
tmen
ts
espe
cial
ly in
rela
tion
to v
iral
hep
atit
is
– hyp
oten
sion
due
to d
rug
rela
ted
reas
ons
e.g.
Pr
opra
nolo
l, an
d no
n-dr
ug re
late
d re
ason
s e.
g.
deco
mpe
nsat
ed li
ver d
isea
se
– jau
ndic
e
– bili
ary
com
plic
atio
ns, i
.e. c
hole
cyst
itis
and
/or
chol
angi
tis
– por
tal h
yper
tens
ion
and
oeso
phag
eal v
aric
es
– asc
ites
/spo
ntan
eous
bac
teri
al p
erit
onit
is
– hep
ator
enal
failu
re
– hep
atic
enc
epha
lopa
thy
– ris
k of
cer
ebra
l oed
ema
in a
cute
live
r fai
lure
– sep
sis
whi
ch o
ften
pre
cipi
tate
s va
rice
al b
leed
ing
or h
epat
ic e
ncep
halo
path
y
– car
diov
ascu
lar a
nd re
spir
ator
y co
mpl
icat
ions
– coa
gulo
path
y
• tr
eatm
ent r
egim
es, i
nclu
ding
elig
ibili
ty a
nd
suit
abili
ty c
rite
ria
for d
iffer
ent l
iver
dis
ease
s
• op
tion
s fo
llow
ing
failu
re o
f tre
atm
ent e
.g. e
arly
re
ferr
al fo
r liv
er tr
ansp
lant
atio
n as
sess
men
t in
chro
nic
liver
dis
ease
• pa
lliat
ion
of s
ympt
oms
e.g.
che
mo-
embo
lisat
ion
or p
arac
ente
sis
and
plan
ning
for e
nd o
f life
car
e.
• R
ole
mod
el.
• In
ter-
prof
essi
onal
wor
king
.
• Co
llabo
rati
ve.
• In
clus
ive.
• St
rong
clin
ical
lead
ersh
ip.
• Ch
ampi
ons
pers
on-c
entr
ed
appr
oach
es.
• Ch
alle
nges
ass
umpt
ions
and
ac
cept
ed w
ays
of w
orki
ng.
• A
ctiv
ely
prom
otes
bet
ter h
ealt
h fo
r pat
ient
s.
• D
emon
stra
tes
a w
ide
rang
e of
kn
owle
dge
and
expe
rien
ce o
f m
anag
ing
pati
ents
wit
h ac
ute
and
chro
nic
liver
dis
ease
.
• A
dvan
ced
asse
ssm
ent s
kill
cour
se a
t de
gree
or m
aste
rs le
vel.
• Fo
rmal
live
r edu
cati
on a
t deg
ree
or
mas
ters
leve
l.
• In
depe
nden
t pre
scri
bing
cou
rse
at
degr
ee o
r mas
ters
leve
l.
• Pr
esen
ts p
atie
nts
and
care
pla
ns to
m
ulti
dis
cipl
inar
y te
am.
• Ke
eps
up-t
o-da
te w
ith
new
and
ch
angi
ng tr
eatm
ents
thro
ugh
stud
y da
ys s
uch
as:
– RCN
Gas
troi
ntes
tina
l Nur
sing
For
um
– Bri
tish
Ass
ocia
tion
for t
he S
tudy
of
the
Live
r Nur
ses
Foru
m (B
ASL
NF)
– Bri
tish
Liv
er N
urse
s Fo
rum
(BLN
F).
• O
r rel
evan
t med
ical
con
fere
nces
suc
h as
:
– Bri
tish
Soc
iety
of G
astr
oent
erol
ogy
(BSG
)
– Bri
tish
Ass
ocia
tion
for t
he S
tudy
of
the
Live
r (B
ASL
)
– Eur
opea
n A
ssoc
iati
on fo
r the
Stu
dy
of th
e Li
ver (
EASL
)
– Am
eric
an A
ssoc
iati
on fo
r the
Stu
dy
of L
iver
Dis
ease
s (A
ASL
D).
• R
elev
ant a
dvan
ced
clin
ical
pra
ctic
e do
cum
ents
to s
uppo
rt c
linic
al ro
le.
• Pr
esen
ting
wor
k at
con
fere
nces
.
• W
riti
ng lo
cal a
nd n
atio
nal g
uide
lines
.
66
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Exam
ples
of
evid
ence
Leve
lCo
mpe
tenc
eK
SF
Per
form
ance
cri
teri
aK
now
ledg
e an
d un
ders
tand
ing
of:
Att
itud
es a
nd b
ehav
iour
s Ev
iden
ce t
o ac
hiev
e co
mpe
tenc
e
7K
now
s ho
w to
:•
unde
rtak
e a
deta
iled
clin
ical
and
nur
sing
as
sess
men
t
• un
dert
ake
an a
bdom
inal
ass
essm
ent a
nd o
ther
sy
stem
s as
app
ropr
iate
• ex
plai
n si
gnifi
canc
e of
any
inve
stig
atio
ns to
pa
tien
ts
• in
itia
te in
vest
igat
ions
app
ropr
iate
ly
• ac
t on
inve
stig
atio
ns a
nd in
terp
ret r
esul
ts
incl
udin
g liv
er s
cree
n
• fo
rmul
ate
an a
ppro
pria
te m
anag
emen
t pla
n in
clud
ing,
whe
re a
ppro
pria
te, e
nd o
f life
car
e
• id
enti
fy a
cute
alc
ohol
wit
hdra
wal
and
saf
ely
prov
ide
phar
mac
olog
ical
man
agem
ent o
f sy
mpt
oms
duri
ng a
n ep
isod
e ac
ute
alco
hol
wit
hdra
wal
• ad
min
iste
r tre
atm
ent w
ithi
n th
eir s
peci
alis
t rol
e as
a
non-
med
ical
pre
scri
ber
• re
cogn
ise,
man
age
and
refe
r pat
ient
s in
rela
tion
to
thei
r co-
mor
bidi
ties
• as
sess
com
pete
nce
of n
urse
s un
dert
akin
g cl
inic
al
asse
ssm
ents
• ac
t as
a ro
le m
odel
.
• Pu
blis
hing
art
icle
s in
nur
sing
and
/or
m
edic
al jo
urna
ls.
• D
emon
stra
ting
lead
ersh
ip a
nd
init
iati
ng c
hang
e.
• Fo
cuse
d on
pat
ient
out
com
es,
wor
king
wit
h th
e pa
tien
t or s
peci
fic
grou
ps e
.g. v
iral
hep
atit
is, a
lcoh
ol
rela
ted
liver
dis
ease
and
NA
FLD
.
Clin
ical
nur
se s
peci
alis
t rol
e (c
onti
nued
)
Com
pete
nce
Num
ber
3 –
Und
erta
kes
a co
mpr
ehen
sive
cli
nica
l ass
essm
ent i
nclu
ding
ris
k pr
ofili
ng a
nd fo
llow
s up
wit
h ap
prop
riat
e ac
tion
, inc
ludi
ng r
efer
ral t
o sp
ecia
list
s, fo
r re
leva
nt a
cute
and
chr
onic
hea
lth
care
con
diti
ons
67
R O Y A L C O L L E G E O F N U R S I N G
Leve
lCo
mpe
tenc
eEv
iden
ce t
o ac
hiev
e co
mpe
tenc
e
App
endi
x 3:
Bla
nk c
ompe
tenc
e sh
eet t
o pr
oduc
e ow
n ev
iden
ce fo
r Ca
ring
for p
eopl
e w
ith
liver
dis
ease
: a c
ompe
tenc
e fr
amew
ork
for
nurs
ing
Nam
eR
ole
Hos
pita
l
Nur
se s
igna
ture
Asse
ssor
sig
natu
reD
ate
Has
the
com
pete
nce
been
ach
ieve
d? Y
ES
NO
Plea
se m
ake
com
men
ts a
nd if
any
furt
her p
lann
ing
requ
ired
:
68
R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Bla
nk c
ompe
tenc
e sh
eet t
o pr
oduc
e ow
n ev
iden
ce fo
r Car
ing
for
peop
le w
ith
liver
dis
ease
: a c
ompe
tenc
e fr
amew
ork
for n
ursi
ng
Nur
se s
igna
ture
Asse
ssor
sig
natu
reD
ate
Leve
lCo
mpe
tenc
eEv
iden
ce t
o ac
hiev
e co
mpe
tenc
e
Nam
eR
ole
Hos
pita
l
Has
the
com
pete
nce
been
ach
ieve
d? Y
ES
NO
Plea
se m
ake
com
men
ts a
nd if
any
furt
her p
lann
ing
requ
ired
:
69
R O Y A L C O L L E G E O F N U R S I N G
Appendix 4: References
Babor T, Higgins-Biddle J, Saunders j, Monteiro M (2011) AUDIT The Alcohol Use Disorders Identification Test Guidelines for use in primary care 2nd edition, WHO
Benner P (1982) From novice to expert. American Journal of Nursing, 82(3), pp.402-407.
Department of Health (2010) National Liver Disease Strategy (unpublished) Nurse census via SHA
Department of Health (2012) Compassion in Practice. Nursing, Midwifery and Care Staff. Our vision and strategy. Department of Health, Leeds.
National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2013) Alcohol-related liver disease: measuring the units. Available at: http://www.ncepod.org.uk/2013arld.htm [accessed 29 June 2015]
National End of Life Care Intelligence Network (2012) Deaths from liver disease implications for end of life care
NHS Employers (2011) Agenda for change pay. Available at: http://www.nhsemployers.org/your-workforce/pay-and-reward/pay/agenda-for-change-pay [accessed 4 August 2015]
NHS Knowledge and Skills Framework. Available at: www.nhsemployers.org/PayAndContracts/AgendaForChange/KSF/Simplified-KSF/Pages/SimplifiedKSF.aspx.[accessed 4 August 2015]
NICE (2012) Hepatitis B & C - ways to promote and offer testing PH43 NICE: London.
NICE (2014) Obesity identification, assessment and mangement of overweight and obesity in children, young people and adults CG 189 NICE: London. Available at: https://www.nice.org.uk/guidance/cg189 [accessed 29 June 2015]
NICE guidelines. Available at: www.nice.org.uk/guidancemenu/conditions-and-diseases/liver-conditions [accessed 4 August 2015]
NMC (2015) Revalidation. Available at: http://www.nmc.org.uk/standards/revalidation/ [accessed 4 August 2015]
NMC: London.
Nursing Times Learning Unit. Liver Disease: risk factors and treatment. Available at: http://www.nursingtimes.net/online-nurse-training-courses/ [accessed 4 August 2015]
(Please note this resource is free to access but registration is required)
RCN (2009) Integrated core career and competence framework for registered nurses, RCN London. Available at: www.rcn.org.uk/__data/assets/pdf_file/0005/276449/003053.pdf [accessed 4 August 2015]
RCN (2010) Principles of Nursing Practice, RCN: London Available at: www.rcn.org.uk/development/practice/principles [accessed 4 August 2015]
Roach M S (1992) The human act of caring. Ottawa Canadian Hospitals Association
Skills for Health Career Framework. Available at: www.skillsforhealth.org.uk/workforce-transformation/customised-career-frameworks-services [accessed 4 August 2015]
Willians R., Aspinall R., Bellis M., et al Addressing Liver Disease in the UK: a blueprint for attaining excellence in healthcare and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity and viral hepatitis, Lancet 2014, 38:1953-97. Available at: http://www.thelancet.com/commissions/crisis-of-liver-disease-in-the-UK [accessed 4 August 2015]
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R C N C O M P E T E N C E S – C A R I N G F O R P E O P L E W I T H L I V E R D I S E A S E
Appendix 5: Useful contacts
American Association for the Study of Liver Disease (AASLD)
www.aasld.org/Pages/Default.aspx
Autoimmune patient support group
www.autoimmunehepatitis.org.uk
British Liver Nurses Forum (BLNF)
http://www.britishlivertrust.org.uk/health-professionals/british-liver-nurses-forum/
British Society of Gastroenterology (BSG)
www.bsg.org.uk
British Association of the Study of the Liver (BASL)
www.basl.org.uk
British Association of the Study of the Liver Nurse Forum (BASLNF)
www.basl.org.uk
British Liver Trust (BLT)
www.britishlivertrust.org.uk
Children’s Liver Disease Foundation (CLDF)
www.childliverdisease.org
European Association for the Study of Liver Disease (EASL)
http://www.easl.eu/discover
Liver4life
www.liver4life.org.uk
PBC Foundation
http://www.pbcfoundation.org.uk/
Royal College of Nursing Gastrointestinal Nursing Forum
www.rcn.org.uk/development/communities/rcn_forum_communities/gastro_and_stoma_care
The Hepatitis C Trust
www.hepctrust.org.uk
71
R O Y A L C O L L E G E O F N U R S I N G
Appendix 6: The six Cs and how they fit into Caring for people with liver disease: a competence framework for nursing
Getting staffing right Enabling knowledge, skills and attitudes that are required to develop person centred liver care
Positive staff experience Improving knowledge and skills to develop quality care, teaching other members of the MDT on the liver / gastroenterology ward, day care, outpatients, A & Es, medical admission units, urgent care centres, primary care and as a professional standard to which to aspire.
Strengthening leadership Working to support liver nurse leadership to integrate better pathways between primary and secondary care
Improving patient experience The expert liver nurse / team has knowledge and understanding of liver care and is able to offer more information to help people to understand their choices.
Measuring levels of patient care by improving nursing knowledge this should have a positive impact on patient care. For example day case paracentesis needs continuity of care, patient focus groups and patient experience at the heart of delivering world class care
Helping people to stay independent
better working partnerships between primary and secondary care enabling working towards earlier identification and end of life care planning
(Department of Health, 2013)
The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies
Revised edition
September 2015
Review date September 2017
RCN Online www.rcn.org.uk
RCN Direct www.rcn.org.uk/direct 0345 772 6100
Published by the Royal College of Nursing 20 Cavendish Square London W1G 0RN
020 7409 3333
Publication code: 004 983
Norgine Pharmaceuticals Ltd have provided financial support by way of sponsorship for the production and distribution of this framework. Norgine Pharmaceuticals Ltd had no editorial input into the content of this framework other than a review for medical accuracy.
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