Adult Audiology —
Training activity: 3

Details

Assess and manage patients with conductive or mixed hearing loss

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Local and national guidelines and international best practice
• Principles of patient-centred care
• Use of interpreters
• Impressions for anatomically abnormal ears
• Modifications to hearing aid and earmould fitting
• Counselling and setting of expectations
• Referral for implantable devices assessment
• Medical referral and awareness of medical or surgical management options

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like?
  • What are the expected outcomes for safely assessing and managing adults with conductive or mixed hearing loss?
  • What does successful application of knowledge about the medical aetiology and assessment/management options for these types of hearing loss look like in practice?
• What is your prior experience of this activity?
  • What is your existing knowledge and prior experience with assessing and managing conductive or mixed hearing loss?
  • What specific challenges might you anticipate when working with patients who have conductive or mixed hearing loss (e.g., identifying aetiology, selecting appropriate tests, or managing complex presentations)? How will you prepare to handle these challenges?
  • Do you recognise the scope of your own practice for managing these specific types of hearing loss? Do you know when you might need to seek advice, refer, or escalate, and from whom?

• What do you anticipate you will learn from the experience?
  • What specific skills related to the assessment or management of conductive or mixed hearing loss do you aim to develop during this activity?
  • What specific insights do you hope to gain about the characteristics or management approaches for conductive and mixed hearing loss?
• What additional considerations do you need to make?
  • Have you reviewed any feedback or identified actions for development from previous experiences with conductive or mixed hearing loss?
  • What important information do you need to consider about the patient or their presentation before the appointment (e.g., potential related healthcare needs, disabilities, or mental health conditions that might impact assessment or management)?

In action

• During the activity is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate during the assessment and management of a patient with conductive or mixed hearing loss? Are you encountering situations such as:
    • Otoscopy findings that suggest an urgent or complex medical pathology (e.g., signs of active infection, unexpected perforation, clear evidence of cholesteatoma) not anticipated by the referral?
    • Audiometric findings (e.g., unusually large air-bone gaps, non-healing patterns, steep slopes) that conflict significantly with the patient’s medical history or presentation?
    • Difficulty performing the required objective tests (like tympanometry or acoustic reflexes) due to technical issues or patient discomfort that you did not foresee?
    • The patient strongly resisting the necessary onward referral to an ENT specialist or physician, or rejecting management options like bone conduction hearing aids or surgery?
  • How does this experience compare with previous experiences of similar activities?
• How are you reacting to the unexpected development?
  • How is the unexpected development being resolved as you progress during the activity? Are you successfully managing the situation yourself (e.g., troubleshooting equipment, explaining complex findings), or do you need support because the necessary action (e.g., immediate medical escalation) is beyond your current scope?
  • What are you learning in this moment as a result of the unexpected development? For example, are you learning a more efficient troubleshooting technique for bone conduction testing, or a clearer way to explain complex middle ear findings and the need for medical intervention?
  • How is this impacting your actions?
    • Are you responding to the situation appropriately (e.g., prioritising safety and medical clearance over immediate hearing aid fitting)? Are you adapting or changing your assessment or management approach immediately (e.g., adjusting masking levels, or focusing the discussion on medical referral)?
    • Is this unexpected event affecting your ability to undertake the activity independently?
    • Specifically, are you immediately consulting internal protocols for managing medical red flags, or are you changing the sequencing of your tests to verify the unexpected audiometric result?
  • How are you feeling in this moment? For example, are you finding it difficult to adapt? Is it affecting your confidence in interpreting conflicting data? Are you feeling positive you can reach a successful conclusion?
• What is the conclusion or outcome?
  • How do you work within your scope of practice? E.g. Are you practising within your scope by immediately consulting internal protocols for managing medical red flags identified during otoscopy, prioritising medical clearance and onward referral before proceeding with management? Are you successfully assessing the patient, ensuring that the extended understanding of medical aetiology of hearing-related disorders is informing your interpretation and synthesis of the test battery results, especially when audiometric data conflicts with the patient’s history?
  • What do you learn as a result of the unexpected development? E.g. Are you gaining proficiency in troubleshooting technical issues efficiently during objective test procedures or when performing bone conduction testing? Did you learn a clearer way to explain complex middle ear findings and the necessity of medical intervention (such as ENT referral or surgery), improving your patient-centred care approaches?

On action

• Begin by summarising the key points of how you assess and manage a patient presenting with conductive or mixed hearing loss.
  • Consider specific events, actions, or interactions that feel important, such as confirming the diagnosis, interpreting air-bone gaps, deciding on the necessity of medical referral, or discussing management options (e.g., hearing devices, surgery). How do you feel during this experience?
  • Include any ‘reflect-in-action’ moments where you adapt your assessment strategy, such as adjusting masking levels, or prioritise urgent medical referral based on immediate findings.
• Identify what learning you take from this experience regarding conductive or mixed hearing loss.
  • What strengths do you demonstrate (e.g., accurate interpretation of audiometric results, clear risk communication, adherence to referral protocols)?
  • What skills and/or knowledge gaps are evident (e.g., advanced knowledge of specific middle ear pathologies, efficient medical referral processes, or technical selection of appropriate hearing devices)?
  • Compare this experience against previous similar engagements. Have any previously identified actions for development been achieved? Has your practice in assessing and managing these losses improved?
  • Identify any challenges you experience (e.g., patient resistance to specialist referral, conflicting test results, or managing a sudden change in pathology) and how you react to these. Does this affect your ability to deal with the situation? Are you able to overcome the challenges?
  • Identify anything significant about this activity, such as needing to seek advice or clarification on a complex medical pathology or an urgent referral protocol.
  • Acknowledge any changes in your own feelings now that you are looking back on the experience.
• Identify the actions or ‘next steps’ you now take to support the assimilation of what you learn, including from any feedback you receive.
  • What will you do differently next time you assess or manage conductive or mixed hearing loss?
  • Has anything changed in terms of what you would do if you are faced with a similar situation again?
  • Do you need to practise any specific aspect of assessment (e.g., masking) or management (e.g., explaining risks/benefits of surgery/devices) further?

Beyond action

• Have you revisited your previous reflections (reflect-before-action, reflect-in-action, and reflect-on-action) for this specific activity – assessing and managing conductive or mixed hearing loss?
  • When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to accurate interpretation of complex audiometric configurations, prompt identification of medical red flags, or discussing management options like bone conduction devices or surgical intervention?
  • Have you completed these previously identified actions? If not, what are the barriers? If so, how did completing them impact your subsequent performance of this activity? Are you ready to demonstrate this new learning confidently and consistently when performing this task?
  • Have you engaged in professional storytelling or discussed your experiences of managing conductive/mixed losses with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of the pathophysiology of middle ear disorders, safe referral protocols, or the criteria for selection and verification of hearing devices for these complex losses?
• Considering your cumulative experiences and reflections on this activity, how does the learning you have gained support you in preparing for relevant observed ‘in-person’ assessments for the module?
• How has your practice related to assessing and managing conductive or mixed hearing loss developed and evolved over time across multiple instances of undertaking this ETA?
  • Can you identify specific examples of improvement or increased confidence in diagnosing the site of lesion, integrating test results, or discussing the necessity and timing of medical or surgical intervention versus amplification?
• Based on your experiences, how has your ability to recognise when something related to this management is beyond your scope of practice improved?
  • Do you have a clearer understanding of when and from whom (e.g., supervisor, ENT consultant, advanced device specialist) you need to seek advice or clarification regarding unusual or conflicting test results, management of complex pathologies (e.g., cholesteatoma), or patients who are resistant to necessary onward referral?

Relevant learning outcomes

#	Outcome
# 1	Outcome Use a range of tests to safely assess the extent and nature of auditory problems in adults, including those with complex aetiologies, complex audiological configurations and comorbidities.
# 2	Outcome Apply shared decision-making to develop an individualised management plan and counselling for adults with hearing loss and other auditory difficulties, taking into account differing cultural and social attitudes to hearing care.
# 3	Outcome Evaluate individual patient outcomes and safely manage a range of routine and complex hearing losses.
# 4	Outcome Practice within their own personal and professional scope, identifying where onward referral is appropriate.