Vestibular —
Training activity: 9

Details

Evaluate and modify vestibular rehabilitation programmes for routine patients

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
• Objective outcome measures
• Patient-reported outcome measures
• Methods of review
• Level and grading of exercises
• Adjustment of short-term goals
• National guidance 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 constitutes successfully evaluating and modifying an established vestibular rehabilitation programme for a routine patient?
  • Have you discussed expectations for using objective and subjective data to inform modifications with your training officer?
• What is your prior experience of this activity?
  • Have you previously evaluated and modified rehabilitation programmes?
  • What do you already know about reviewing patient progress, identifying barriers to recovery, and determining when a modification is necessary?
  • What specific challenges related to identifying why a rehabilitation programme may have failed, or knowing when to transition to different exercises or seek psychological intervention might you face. How might you plan to handle them?
  • What is the scope of your own practice for evaluating and modifying programmes? When will you need to seek advice and from whom?
  • How do you feel about evaluating the effectiveness of a management plan?
• What do you anticipate you will learn from the experience?
  • What specific skills in using outcome measures or critical evaluation of management plan effectiveness do you want to develop, drawing upon previous experiences?
  • What specific insights into how external factors (physical or psychological) influence rehabilitation success do you hope to gain?
• What additional considerations do you need to make?
  • Have you reviewed any actions identified from your previous reflections on evaluating patient outcomes?
  • Do you need to review the specific outcome measures used for this patient and the criteria for modifying or escalating the rehabilitation plan?

In action

• During the activity is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate during the evaluation session? Are you encountering situations such as:
    • The patient reporting unexpected worsening or severe setbacks despite compliant exercise adherence?
    • The patient demonstrating a functional limitation or compensatory strategy that you did not foresee during the initial assessment?
    • The patient reporting that poor functional outcomes are linked to significant social or psychological barriers rather than just physical issues?
  • 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., incrementally increasing complexity), or do you need support because the patient requires additional input outside of standard rehabilitation (e.g., psychological support)?
  • What are you learning in this moment as a result of the unexpected development? For example, are you learning a more rigorous approach to assessing patient progress using appropriate outcome measures, or gaining confidence in incrementally increasing the complexity of exercises?
  • How is this impacting your actions?
    • Are you responding to the situation appropriately? Are you adapting or changing your approach to modifying the programme (e.g., changing the frequency or type of exercises)?
    • Is this unexpected event affecting your ability to undertake the activity independently?
    • Specifically, are you immediately recognising when the patient requires onward referral due to non-standard progression?
  • How are you feeling in this moment? For example, are you finding it difficult to adapt? Is it affecting your confidence in ensuring continued progression? 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 evaluating and modifying the programme, ensuring that changes are evidence-based and align with the patient’s documented progress and functional goals? Are you recognising when the patient requires additional input outside of standard rehabilitation (e.g., psychological support) and identify the necessity for onward referral?
  • What do you learn as a result of the unexpected development? E.g. Are you learning a more rigorous approach to assessing patient progress using appropriate outcome measures and subjective reports? Are you gaining You confidence in incrementally increasing the complexity or difficulty of the exercises to maintain challenge and progression?

On action

• What happened?
  • Begin by summarising the key steps you took to evaluate and modify the vestibular rehabilitation programme for a routine patient.
  • Consider specific events, patient interactions, or decisions that felt important, such as assessing patient adherence, measuring progress, or deciding on a modification strategy. How did you feel during the evaluation and modification session?
  • Include any ‘reflect-in-action’ moments, where you adapted your modification strategy based on the patient’s immediate feedback or unexpected progress reports.
• How has this experience contributed to your developing practice?
  • What learning can you take from evaluating and modifying this specific programme?
  • What strengths did you demonstrate in assessing patient progress and making appropriate modifications? What skills or knowledge gaps were evident (e.g., related to assessing outcomes, identifying barriers, adapting exercises)?
  • 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., patient non-adherence, unclear progress, difficulty identifying reasons for lack of progress) 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 how to proceed or modify, 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 evaluate and modify a rehabilitation programme?
  • 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 evaluating or modifying rehabilitation programmes further? E.g.
    • Refining your use of standardised outcome measures to objectively quantify patient progress before and after modifications are made to the programme.
    • Structuring the evaluation session to effectively identify barriers to adherence, distinguishing between physical limitations and lack of motivation.
    • Documenting the rationale for why specific exercises were modified or progressed more comprehensively in the patient notes
    • Seeking opportunities to observe experienced clinicians evaluate programmes where progress has plateaued to enhance your troubleshooting skills.

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 (evaluating and modifying vestibular rehabilitation programmes)?
  • When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to selecting appropriate outcome measures, accurately assessing patient adherence/progress, justifying programme modifications based on evidence, or discussing necessary changes clearly with the patient?
  • 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 programme review (e.g., when modification was unexpectedly required) with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of the reliability of outcome measures, strategies for motivating non-adherent patients, or the timing of plan changes?

• 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? Your proficiency in evaluation is crucial for any Case-Based Discussions (CBDs) where you are required to demonstrate and justify ongoing patient management.
  • How has your practice related to evaluating and modifying vestibular rehabilitation programmes developed and evolved over time across multiple instances of undertaking this training activity? Can you identify specific examples of improvement or increased confidence in diagnosing the source of lack of progress, making fine-tuned exercise adjustments, or ensuring patient engagement with the modified plan?
  • Based on your experiences, how has your ability to recognise when something related to rehabilitation evaluation is beyond your scope of practice improved? Do you have a clearer understanding of when and from whom (e.g., supervisor, physiotherapist, geriatrician) you need to seek advice or clarification regarding unresponsive cases, complex progression issues requiring a multi-disciplinary input, or suspected new medical issues impacting recovery?

Relevant learning outcomes

#	Outcome
# 5	Outcome Provide safe and effective vestibular rehabilitation for commonly occurring disorders in patients without significant comorbidities.
# 6	Outcome Evaluate vestibular rehabilitation options for complex cases with comorbidities.