Advanced Competency in Vestibular Assessment and Management: British Columbia’s Perspective
Striking the Right Balance
Michael Vekasi, MClSc, RAud, Aud(C) and Erica Zaia, AuD will be coordinating the “Striking the Right Balance,” column which will cover the latest information on “all things vestibular.”
In this edition of “Striking the Right Balance,” Erica Zaia, audiologist with St. Paul's Hospital in Vancouver, talks about her involvement with the College of Speech and Hearing Health Professions of British Columbia and the development of the Advanced Competency Certificate in vestibular assessment and management which requires audiologists undergo advanced education and training in order to provide services in this restricted area of practice.
If you would like to be more involved in all things vestibular, please sign up for the Vestibular Special Interest Group. Sign up by simply emailing JanineAllison.Verge@nshealth.ca to let us know you want to be a part. Also, check out our FaceBook page for a free list of on-line vestibular resources at the CAA National Vestibular Special Interest Group page.
In the issue 4/2014, guest editors Maxine Armstrong and Janine Verge reported on the results of a survey investigating the state of vestibular testing in Canada and posed the question, “Are we ready to successfully brace the storm of vestibular testing heading our way?”
One of the topics analyzed by the survey was certification. Results indicated that 74% of respondents were not required advanced certification by their provincial colleges to perform vestibular testing. However, this is not the case in British Columbia. Since January, 1, 2010 when the College of Speech and Hearing Health Professions of British Columbia came into effect, audiologists performing vestibular testing in the province are required to hold an advanced competency in vestibular assessment and management. The advanced competency requires that audiologists undergo advanced education and training in order to provide services in a restricted area of practice.
The development of the advanced competency in vestibular testing began in January of 2001, when the former Health Professions Council recommended that audiology and speech-language pathology be designated under the Health Professions Act. In May, 2007, the Ministry of Health published the Speech and Hearing Health Professionals regulation which outlined a proposed scope of practice of audiology, SLP, and hearing instrument practitioners in BC under the Health Professions Act. On December 15, 2008, the provincial government announced the formation of the new College of Speech and Hearing Health Professionals of British Columbia (CSHHPBC). The first board of the new college was promptly appointed and began to draft the college bylaws.
As determined by the Health Professions Act in its 2008 regulation, audiologists may perform restricted activities required to perform specific vestibular tests such as “put[ting] into the external ear canal, up to the eardrum and for the purposes of cerumen management or assessment of vestibular system dysfunction, water that is under pressure.” The act goes further and establishes that, however, an audiologist may provide assessment of vestibular system dysfunction that includes the performance of such restricted activity only if the audiologist has successfully completed a certification program established, required or approved under the bylaws. This is to ensure registrants are qualified and competent to provide assessment of vestibular system dysfunction and to perform the restricted activity.
It was with this regulation in mind that a working group was formed in 2009 to draft the bylaws for the Advanced Competency in Vestibular Assessment and Management. I took part in the development of the bylaw as a consulting audiologist. I had been working in the field for many years, in a variety of clinical and educational settings and in a few different countries, and was currently practicing in a major tertiary public hospital. My fellow working group members were all experienced vestibular audiologists; a highly experienced hearing aid dispensing audiologist and college board member coordinated the group.
The working group had a basic outline of how the bylaws were to be worded and organized, working in tandem with other audiology and speech-language working groups also drafting bylaws for other Advanced Competencies as designated by the act.
After a series of very productive conference calls and several revisions of the draft, the first set of bylaws for the Advanced Certificate A - Vestibular Assessment and Management was completed. The advanced competency came into effect in January, 1, 2010.
Health Professions Council recommends Audiology and Speech-Language Pathology to be designated under the Health Professions Act (HPA)
Following HPA recommendation, Ministry of Health gives notice of Speech and Hearing Health Professionals Regulation
Government announces Audiology, Speech-Language Pathology and Hearing Instrument Practitioners are designated under HPA;
HPA defines restricted activities and determines advanced certification;
College of Speech and Hearing Health Professionals of British Columbia (CSHHPBC) is established and first board appointed
working groups created to draft bylaws for Advanced Competencies
CSHHPBC becomes effective
One of the intentions of our working group was to provide direction to aspiring vestibular audiologists on their studies and training, alluding to our own experience with gaining the competencies required to practice. The objectives listed under the Program of Study intend to provide the applicant with a general guide for their studies, enabling them to make informed decisions in the search for a suitable training course.
All of the vestibular audiologists in the working group had either graduated or completed intensive training courses abroad (or both) prior to practicing in British Columbia, a trend also observed in the Interest Group survey. At the time the advanced competency was developed, the majority of the audiology degree programs in Canada, including the University of British Columbia, did not offer full graduate-level courses in vestibular assessment and management. The working group discussed and revised the bylaws a number of times around the requirement for advanced training in vestibular testing, focusing on what might be considered “equivalent to” the required graduate level courses. For 4 years the equivalent courses accepted by the college were the American Institute of Balance and the Micromedical Didactic Courses in Vestibular Assessment and Management.
By 2015, it was decided by the Quality Assurance Committee that audiology graduates of 2014 or later from the University of British Columbia would be considered to have an equivalent 3 credit-hour course with the completion of a course in advanced diagnostics, Audiology 553. In spite of the perceived benefit to new graduates, this change raises concerns given that this 26 hour lecture – 39 hour lab course includes vestibular assessment as well as high frequency audiometry, central auditory processing disorders, cochlear dead regions, the TEN test and advanced middle ear analysis techniques.
The working group also recognized the importance of practicum experience in vestibular assessment and management. All of us in the working group had ourselves relied on experienced teachers, clinical supervisors and colleagues to build our own competencies and gain confidence in the field. In recognition of the need for mentorship in developing clinical competency, the bylaws now stipulate the need for the constant and indirect supervision by a qualified practitioner. The applicant must complete 10 patient assessments under constant (direct) supervision and 10 additional patient assessments under general (indirect) supervision.
By the end of 2009, in preparation for the establishment of the College, audiologists practicing in British Columbia received information on how to become registrants of the College and to obtain Advanced Competencies. Full members in good standing with BCASLPA or CASLPA were grandfathered into the College until the end of September, 2010. Similarly, audiologists who had successfully completed a course in vestibular assessment and management and who declared they had been practicing in the field for at least a year prior to April 1, 2010, were granted the Advanced Competency certificate. Current requirements to obtain the certificate can be found at http://cshhpbc.org/docs/acceptable_program_of_study_certificate_a.pdf?LanguageID=EN-US
The certificate expires after 3 years and the registrant must complete at least 4 hours of continuing competencies in the area in order to renew their certificate.
Out of the 262 audiologists currently holding an Active registrant status with the College of Speech and Hearing Health Professionals of British Columbia, only 18 (fewer than 7%) are certified in vestibular assessment and management. The vast majority of the audiologists providing these services were grandfathered into the College and are employed in the public sector within the Lower Mainland. Very few practice in private clinics. It is known to the college that a significant number of formal vestibular assessments is performed in a large tertiary care centre by professionals other than vestibular audiologists, who obviously are not regulated under the same bylaws.
Currently, as highlighted in the Interest Group survey and mentioned above, there are no national requirements for audiologists to practice in the field of vestibular assessment and management. There is also little consistency across provinces for Canadian graduates seeking for job opportunities in a province other than where they graduated. The issue becomes even more significant when the audiologist is an internationally educated professional.
Audiologists and speech-language pathologists have made the list of professionals in demand in Canada for several years in a row; however, there are no national standards to assess these individuals’ knowledge and skills prior to entry in the Canadian work force. Since its launch in 2012, the Canadian Alliance of Audiology and Speech-Language Pathology Regulators (CAASPR) has worked to develop a national, competency-based entry-to-practice assessment framework for those wishing to practice the two professions in Canada. The project’s impact will be greatest for those individuals from outside Canada who are seeking to practice; however, there are also changes ahead for Canadian graduates. CAASPR plans to establish an academic equivalency framework that will identify a candidate’s course and clinical requirements and to develop an online portfolio tool, allowing candidates to submit evidence of their knowledge and skills. CAASPR is also working to develop and set an entry-to-practice examination by 2018 and to set as a language proficiency standard. The regulators will require are seeking further funding in order to proceed with the project and working with professional associations and university programs to ensure changes are well-understood.
Presently there is no mention of Advanced Competencies in the CAASPR documents and it is unclear how British Columbia’s bylaws pertaining to these competencies will translate into a national standard for Canadian and internationally-educated professionals.
The process of becoming a regulated profession is lengthy and laborious, as evidenced by our experience with vestibular assessment and management qualification in BC. Nevertheless, it seems clear that as audiology and particularly the vestibular field evolves and grows the need for regulation becomes increasingly important if not essential.
In the past few years we have witnessed the discovery of several new vestibular assessment techniques, making our approach to diagnosis and treatment much broader and deeper. It has also been a common observation amongst vestibular audiologists that the complexity of our client’s concerns and the extent of their handicap seem to be on the rise. As health care providers gain more knowledge about dizziness, vertigo, and balance disorders, the number of referrals for vestibular assessment has been consistently growing in all of hospitals providing these services. This only adds to the anticipated increase of referrals for vestibular testing as the baby boomers enter their senior years.
In order to effectively and efficiently attend to these demands it is fundamental that audiologists are well prepared and fully qualified. The requirements established by the advanced competencies are originally intended to protect the public; however, they also represent a benchmark for vestibular audiologists practicing in British Columbia. The Advanced Competency requirements can serve as a powerful tool for audiologists in advocating for better quality education and more comprehensive curriculum in vestibular assessment and management in the Audiology degree programs across the country. These same requirements also potentially protect both the beginner vestibular audiologist, who cannot simply receive on-the-job training and be expected to attain adequate competencies to perform, and the qualified one, who can demonstrate the need to obtain continued education in the field.
So far the British Columbia experience, albeit limited and with apparent room for improvement, seems promising and can hopefully be one other provincial and national regulating bodies and associations can learn from.
Advanced Competency in Vestibular Assessment and Management - CSHHPBC. Available at: http://cshhpbc.org/docs/acceptable_program_of_study_certificate_a.pdf?LanguageID=EN-US
The Canadian Alliance of Audiology and Speech-Language Pathology Regulators
College of Speech and Hearing Health Professionals of British Columbia http://www.cshhpbc.org/
The Health Professions Act. Available at:
Ministry of Health - Speech and Hearing Health Professions. Available at:
School of Audiology and Speech Sciences - University of British Columbia. http://www.courses.audiospeech.ubc.ca/courselisting.asp
Speech and Hearing Health Professions Regulation. Available at: http://www.bclaws.ca/civix/document/id/complete/statreg/413_2008