Management of Complex Sleep —
Training activity: 4

Details

Review referrals for patients referred for complex sleep investigations and identify the most appropriate investigation to answer the clinical question

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.

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?

• Identify what is expected of you in relation to reviewing patient referrals for complex sleep investigations and selecting the most appropriate investigation that accurately answers the clinical question.
• Consider how the relevant learning outcomes apply, specifically in relation to selecting appropriate investigations based on referral criteria and demonstrating a patient-centred approach to practice, including effective communication.
• What does the accurate identification of the appropriate exercise protocol to answer the clinical question look like for this activity?
• Discuss with your training officer or assessor to gain clarity on expectations for the specific criteria used for protocol selection, common clinical questions associated with complex sleep disorders, and the expected format for documenting your rationale for investigation choice.

What is your prior experience of this activity?

• Think about what you already know regarding reviewing patient referrals and identifying appropriate investigations for complex sleep disorders. This might include your knowledge of various investigations such as Polysomnography (PSG), Multiple Sleep Latency Tests (MSLT), Actigraphy, sleep logs, or sleep questionnaires.
• Consider possible challenges you might face during the activity, such as ambiguous clinical questions, incomplete referral information, or referrals concerning very rare conditions e.g., certain parasomnias or neurodegenerative disorders, and think about how you might plan to handle them.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom, for instance, if a referral suggests a condition or investigation that is entirely outside your current expertise or the department’s standard procedures.
• Acknowledge how you feel about reviewing patient referrals where complex sleep investigations are needed. How confident do you feel about identifying appropriate investigations?

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop related to refining your ability to critically analyse referral information, deepening your understanding of the indications and limitations of different sleep tests e.g., understanding why MSLT vs MWT is chosen, or enhancing your clinical decision-making in selecting investigations.
• Identify specific insights you hope to gain from engaging with the activity. For example, a better understanding of the clinical pathways for specific complex sleep disorders (e.g., hypersomnias, insomnias) or how to align investigation choices with the underlying pathophysiology of non-respiratory sleep disorders.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of reviewing similar referrals or undertaking related tasks.
• Identify important information you need to consider before embarking on the activity. This might involve familiarising yourself with local protocols for referral management, reviewing the common tools and techniques used in sleep assessment (e.g., vigilance testing, electrode placement, EEG signal processing), or understanding the different types of complex sleep disorders.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst reviewing the referrals for complex sleep investigations?
• Are you encountering situations such as:
  • An ambiguous or incomplete clinical question within the referral.
  • Missing or contradictory patient information.
  • Identifying a rare or unusually complex sleep disorder e.g., certain parasomnias or neurodegenerative disorders that you were not familiar with.
  • A referral where the initially indicated investigation seemed inappropriate after deeper review.
  • The need to consider alternative investigations not immediately obvious from the referral e.g., Actigraphy, sleep log, or sleep questionnaire alongside PSG or MSLT.
• Consider how this specific experience compared with previous experiences of similar activities e.g., reviewing simpler referrals, or referrals for other specialties.

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to reviewing the referral or selecting the investigation? Did it affect your ability to undertake the activity independently in that moment?
• Consider the steps you are taking in the moment, such as:
  • Needing to pause and consult additional resources e.g., local protocols, textbooks, or specific guidelines on complex sleep disorders or investigation limitations.
  • Seeking clarification from the referrer or accessing further patient history to effectively select the appropriate investigation based on referral criteria.
  • Adapting or changing your initial approach to reviewing the referral or selecting the investigation.
• How are you feeling in that moment? For instance, are you finding it difficult to adapt to the unexpected information or challenge? Is it affecting your confidence in selecting the most appropriate investigation? Are you feeing positive you can reach a successful conclusion despite the unexpected elements?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully resolving the query and justifying the protocol choice? Or are you needing support because the complexity of the finding requires escalation or advice from a senior colleague or Training Officer if a referral is genuinely outside your current expertise or the department’s standard procedures?
• Identify what you are learning as a result of the unexpected development during the referral review process. For example, are you gaining new insights into specific complex sleep disorders, the nuances of referral information, or the application of various diagnostic tests and their limitations e.g., MSLT versus MWT?

On action

What happened?

• Begin by summarising the key points of the experience of reviewing the referrals and identifying the most appropriate investigation.
• Consider specific events, actions, or interactions which felt important, such as how you approached interpreting the clinical question or selecting the investigation, including your own feelings during the experience.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded. For example, describe instances where you encountered ambiguous clinical questions, incomplete referral information, or unusually complex sleep disorders, and how you responded in the moment.
• Reflect on how you applied your knowledge of various investigations such as Polysomnography (PSG), Multiple Sleep Latency Tests (MSLT), Actigraphy, sleep logs, or questionnaires to select the most appropriate investigation.

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding interpreting complex referrals or selecting the most appropriate sleep investigation. What strengths did you demonstrate, e.g., critically analysing referral information or selecting investigations based on referral criteria? What skills and/or knowledge gaps were evident, e.g., understanding the indications/contraindications or limitations of specific sleep tests (like MSLT vs MWT) or knowledge of particular non-respiratory sleep disorders (e.g., hypersomnias, parasomnias)?
• Compare this experience against previous engagement with similar activities (e.g., simpler referral reviews). Were any previously identified actions for development achieved? Has your practice improved?
• Identify any challenges you experienced, such as conflicting clinical information, rare conditions, or difficulty justifying your chosen protocol, and how you reacted to these. Did this affect your ability to deal with the situation?
• Identify anything significant about the activity, such as needing to seek advice or clarification from your Training Officer or a senior colleague regarding an ambiguous clinical question, or if you needed to escalate to ensure you were working within your scope of practice.
• Acknowledge any changes in your own feelings now that you are looking back on the experience.

What will you take from the 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 have received in relation to your ability to review referrals for patients who require complex sleep investigations. What feedback have you received in relation to you accurately identifying appropriate investigations?
• What will you do differently next time you review complex sleep referrals? Has anything changed in terms of what you would do if you were faced with a similar situation again, such as an ambiguous referral or a rare sleep disorder?
• Do you need to practise any aspect of this activity further, such as understanding specific diagnostic testing limitations (e.g., in MSLT) or the implications of drugs on test results?
• Consider how this experience will support you in preparing for observed ‘in-person’ assessments for the module, such as where you might communicate why a referral may not be appropriate.

Beyond action

Have you revisited the experiences?

• Have you reviewed the actions you identified from your prior reflections for this training activity? What specific actions did you identify you would need to take to improve your practice regarding the selection of appropriate investigations based on referral criteria?
• Have you completed these previously identified actions? For example, if you planned to review the indications and limitations of various diagnostic tests for sleep disorders (e.g., PSG, MSLT, Actigraphy), how did completing this review impact your subsequent ability to review ambiguous referrals and justify protocol choice? Are you ready to demonstrate this new learning in practice?
• Engage in professional storytelling with peers, near peers, or colleagues about your experiences reviewing complex sleep referrals. Consider if your view of certain referral complexities, appropriate investigation choices (e.g., PSG, MSLT, Actigraphy/sleep log/sleep questionnaire), or challenges (e.g., ambiguous clinical questions, rare conditions) has changed because of analysing this with others.

How have these experiences impacted upon current practice?

• Consider how the accumulated learning from performing or reflecting on referral review and protocol selection will support you in preparing for observed ‘in-person’ assessments for the module.
• Specifically, how does your enhanced ability to review referrals for complex sleep investigations relate to a Case-Based Discussion or an Observed Communication Event? For example, how has your understanding developed regarding communicating to other healthcare professionals why a referral may not be appropriate to answer the clinical question?
• How has your practice in reviewing complex sleep referrals and identifying appropriate investigations has developed and evolved over time?
  • How has your ability to critically evaluate referral information improved?
  • How has your understanding of the indications and limitations of various diagnostic tests for sleep disorders (e.g., PSG, MSLT, Actigraphy) deepened?
  • Can you now more consistently and effectively identify when a referral is beyond your current scope of practice and when to seek advice or escalate?
  • Reflect on how these experiences have helped you to demonstrate a patient-centred approach to practice and to practice effectively as part of a multidisciplinary team.
• What transferable skills e.g., diagnostic reasoning or pattern recognition did you develop through this activity, and how will this understanding help you evaluate and adopt new monitoring or diagnostic technologies in the future?

Relevant learning outcomes

#	Outcome
# 2	Outcome Select appropriate investigations based on referral criteria.
# 7	Outcome Demonstrate a patient centered approach to practice, considering communication with patients and relatives and the patient experience.