Vestibular —
Training activity: 3

Details

Select and safely perform the following standard diagnostic tests:

• Videonystagmography, including static body positional testing and headshake test
• Caloric testing (with the aid of an assistant)
• Video head impulse test
• Vestibular-evoked myogenic potential testing (either cervical or ocular)

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

• Principles of patient-centred care
• Contraindications and cautions to testing
• Screening tests
• Selection of appropriate tests
• Methods to minimise artifacts
• Local and national recommended procedures and protocols, and international best practice

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 indicators of successfully selecting and safely performing this wide range of diagnostic vestibular tests?
  • What are the criteria for valid results for each test (VNG, Calorics, vHIT, VEMP)?
  • Have you discussed expectations for performance and result validity with your training officer?
• What is your prior experience of this activity?
  • Have you performed these specific tests before?
  • What do you already know about the procedures and technical requirements for each of these tests, including the use of an assistant for caloric testing?
  • What specific challenges related to equipment setup, patient cooperation (especially for VEMP or calorics), or obtaining artefact-free results might you face. How might you plan to handle them?
  • What is the scope of your own practice for performing this test battery. When will you need to seek advice or help, and from whom?
  • How do you feel about performing this extensive battery of objective tests?
• What do you anticipate you will learn from the experience?
  • What specific skills in safe adaptation of tests to suit patient needs, or technical mastery (e.g., vHIT or VEMP setup), do you want to develop, drawing upon previous experiences?
  • What specific insights into the clinical use and limitations of each test procedure do you hope to gain?
• What additional considerations do you need to make?
  • Have you reviewed any actions identified from your previous reflections on performing objective tests?
  • Do you need to check that all required equipment (e.g., water/air irrigators, electrodes, goggles) is calibrated and ready?
  • Do you need to review the specific protocols for performing static positional tests or caloric testing before starting?

In action

• During the activity is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate during the performance of these standard diagnostic tests? Are you encountering situations such as:
    • Technical difficulties (e.g., VEMPs electrode setup failure, vHIT calibration errors, VNG software freezing) that delay or compromise the data collection?
    • Unexpected patient intolerance (e.g., severe discomfort during caloric testing, inability to maintain fixation during oculomotor testing) that forces an early stop?
    • Unexpected findings on the monitoring screen (e.g., highly asymmetrical caloric responses or VEMPs waveforms) that suggest complex pathology?
  • 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, adapting the test approach), or do you need support (e.g., from an assistant during caloric testing, or a senior clinician)?
  • What are you learning in this moment as a result of the unexpected development? For example, are you gaining increased proficiency in efficient troubleshooting of recording software, or learning techniques to minimize patient discomfort during tests like caloric testing?
  • How is this impacting your actions? E.g.
    • Are you responding to the situation appropriately (e.g., prioritising safety protocols)? Are you adapting or changing your approach to the test procedure (e.g., switching the order of tests, modifying parameters)?
    • Is this unexpected event affecting your ability to undertake the activity independently?
    • Specifically, are you immediately checking if the equipment is calibrated and working correctly before continuing?
  • How are you feeling in this moment? For example, are you finding it difficult to adapt? Is it affecting your confidence in relying on the recorded data? Are you feeling positive you can reach a successful conclusion?
• What is the conclusion or outcome?
  • How are you working within your scope of practice? E.g. Are you successfully concluding the testing series, confirming that all safety protocols (especially during caloric testing with an assistant) are followed? Are you practising within your scope by safely executing the test procedures, ensuring all equipment is calibrated and working correctly?
  • What do you learn as a result of the unexpected development? E.g. Are you gaining increased proficiency in efficient troubleshooting of recording software or equipment (e.g., vHIT setup)? Are you learning techniques to minimise patient discomfort during tests like caloric testing, thereby improving the clinical utility of the results?

On action

• What happened?
  • Begin by summarising the key steps you took to select and safely perform the standard diagnostic tests.
  • Consider specific events, actions, or interactions that felt important, such as technical setup, working with an assistant during caloric testing, or managing patient tolerance. How did you feel during the testing?
  • Include any ‘reflect-in-action’ moments, where you had to adapt your protocol or approach due to equipment issues or patient response in the moment.
• How has this experience contributed to your developing practice?
  • What learning can you take from performing these specific tests?
  • What strengths did you demonstrate in selecting and safely performing the activities? What skills or knowledge gaps were evident (e.g., related to protocol adherence, technical execution, patient management, working with an assistant)?
  • How did this experience compare against previous engagements with similar activities? Were any previous identified actions for development achieved? Has your practice improved?
  • Identify any challenges you experienced (e.g., technical issues, patient cooperation, time management, standardisation of procedure) and how you reacted to these. Did these challenges affect your ability to deal with the situation? Were you able to overcome them?
  • Was there anything significant about this activity, such as needing to seek advice or clarification on procedure or technical aspects, or considering if you were working within your scope of practice?
• What will you take from this experience moving forward?
  • Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you received.
  • What will you do differently next time you perform these standard diagnostic tests?
  • Has anything changed in terms of what you would do if you were faced with a similar situation again?
  • Do you need to practise any aspect of selecting or performing these standard diagnostic tests further? E.g.
    • Develop a troubleshooting checklist for technical issues related to VEMP and vHIT equipment to minimise delays during testing.
    • Practise standardising patient setup and calibration procedures for caloric testing to ensure reliable results, particularly when working with an assistant.
    • Refining patient communication strategies to better prepare patients for tests that may induce discomfort, such as caloric stimulation, to improve cooperation.
    • Seek opportunities to practise protocol selection rationale for deciding which VEMP (cervical or ocular) is most appropriate based on the history.

Beyond action

• Have you revisited the experiences?
  • Have you revisited your previous reflections (reflect-before-action, reflect-in-action, and reflect-on-action) for this specific activity (selecting and safely performing standard diagnostic tests)?
  • When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to efficient equipment setup, safe caloric testing with an assistant, accurate vHIT setup, reliable VEMP acquisition, or managing patient tolerance across the test battery?
  • 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 performing these standard tests with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of optimising test protocols, managing technical artefacts, or ensuring maximum patient comfort?
• How have these experiences impacted upon current practice?
  • Considering your cumulative experiences and reflections on this activity, how will the learning you have gained support you in preparing for relevant observed ‘in-person’ assessments for the module?
  • How has your practice related to selecting and safely performing standard diagnostic tests developed and evolved over time across multiple instances of undertaking this training activity? Can you identify specific examples of improvement or increased confidence in working efficiently with an assistant, troubleshooting equipment in the moment, or adapting test duration/sequence based on patient factors?
  • Based on your experiences, how has your ability to recognise when something related to performing these standard tests is beyond your scope of practice improved? Do you have a clearer understanding of when and from whom (e.g., supervisor, biomedical engineer, vestibular specialist) you need to seek advice or clarification regarding unusual technical failures, contraindications to specific tests, or complex adaptations for patients with mobility issues?

Relevant learning outcomes

#	Outcome
# 2	Outcome Perform vestibular assessments making safe and appropriate adaptions to the test approach to suit the needs of the patient.
# 3	Outcome Perform and interpret a wide range of diagnostic vestibular tests.