Developing and Implementing Driving Rehabilitation Programs: A Phenomenological Approach

Research Design

This study had a phenomenological qualitative design and used semistructured interviews to obtain information regarding the experiences of occupational therapy practitioners when developing driving rehabilitation programs (Creswell, 2006). This approach not only illuminated practitioner experiences but allowed for rich descriptions of the barriers encountered and strategies used to overcome those barriers. The information gleaned from these interviews was used to supplement quantitative results from a previous study (Stav et al., 2011) that identified the barriers to developing and sustaining driving and community mobility programs. The rich descriptions of practitioner experiences yielded from this study were used to clarify identified barriers and guide decisions about content during the development of a resource tool kit for practitioners and administrators to develop driving or community mobility rehabilitation programs. This study received institutional review board approval from Towson University, and all participants provided consent.

Participant Selection

Potential participants were drawn from the sample of a previously conducted quantitative study examining the barriers to developing driving rehabilitation and community mobility programs (Stav et al., 2011). Participants were selected from those who had previously indicated a willingness to be contacted for future research and responded positively to the presence of a driving rehabilitation or community mobility program in their facility. Inclusion criteria included having developed and sustained a driving rehabilitation or community mobility program. Additionally, the participant’s program must have been in operation for ≥5 yr. The researchers (four graduate-level occupational therapy students under the supervision of a faculty advisor) decided that requiring at least 5 years of clinical experience in driving rehabilitation or community mobility would yield informants who were sufficiently seasoned to have experienced successes and barriers with lessons learned and strategy outcomes.

Twenty-three people were identified as meeting the inclusion criteria, and their participation was solicited by e-mail. After participants expressed interest in the study, they were e-mailed consent forms and asked to return them through a secure fax machine. The first 4 respondents were initially selected for the study with plans for further selection until data saturation occurred. The researchers determined that data saturation was reached after the first 4 participants had been interviewed and that no further interviewing was required.

Procedures

After receiving an e-mail invitation to enroll in the study, participants were given 1 wk to respond indicating a willingness to participate. After receipt of the signed consent form, participants were sent an electronic version of the interview protocol to stimulate thought before the interview. The researchers generated the interview protocol after review of the previously conducted quantitative study (Stav et al., 2011). They developed the semistructured interview protocol to specifically capture the practitioners’ experiences with developing and implementing a driving rehabilitation program. The development process included several phases of reviews and revisions for organization, clarity, and thoroughness to gather information that could answer the research questions.

The interview protocol consisted of open-ended questions inquiring about the participants’ experiences in the development and sustainment of their respective driving rehabilitation programs, their roles and responsibilities, and the facilitators of and barriers to success. Each interview included core questions on the interview protocol as well as individualized follow-up questions based on responses provided during the interviews. Researchers contacted the participants via telephone to schedule a semistructured interview on the basis of participants’ availability. All interviews were conducted via telephone.

Data Collection

Data were collected by four graduate-level occupational therapy students under the supervision of a faculty advisor. The graduate student researchers had completed foundational coursework in research methods and data analysis before study implementation. Further training specific to this study was provided before recruitment, with continued supervision and guidance throughout data collection and analysis.

Telephone interviews lasted 45 min to 1 hr. The researchers were able to obtain sufficient information from each participant during a single interview because detailed quantitative information had already been gathered from each participant during the previously conducted quantitative study (Stav et al., 2011). At the time of the interview, participants were reminded that the interview was being audiorecorded and later transcribed to ensure accurate documentation of participant responses. Researchers used tape recorders and telephone recording devices to ensure that they accurately captured the study participants’ experiences as described in their responses. The researchers asked follow-up questions for clarification and elaboration to make sure the researcher and participant both had a clear understanding of the other’s meaning. After the semistructured interviews, recordings were transcribed verbatim using a transcription machine.

Data Analysis

Before data analysis, the team of researchers engaged in an open discussion about possible results. This important process provided them with an opportunity to eliminate bias in the data analysis process by overtly identifying expectations and consciously avoiding seeking those patterns in the data. The first transcript was then read by each individual member of the research team and coded. Reciprocal data analysis was performed between teams of two researchers to move toward preliminary consensus. The entire research team then convened to present the codes identified by individual teams so that consensus could be achieved by all team members. Once consensus of themes from the first transcript was reached, the process was repeated with subsequent transcripts from the second, third, and fourth interviews. With each subsequent transcript, the text was coded in isolation from other analyses and searched for the presence of, support for, or contradiction of themes identified from previous transcripts.

After analyzing the fourth interview and identifying no new codes, the researchers determined that data saturation had occurred and that additional participant interviews were not necessary. All transcripts were then reviewed again to ensure that ideas, perspectives, or additional themes were not missed. Extensive discussions ensued to ensure that themes were mutually exclusive and that further collapsing of ideas was not possible.

After all team members defined and agreed on identified themes, member checking was completed with 2 participants. The themes were presented to the participants, who confirmed that results accurately depicted their experiences. The results were further triangulated against existing literature and the results of the previously conducted quantitative study (Stav et al., 2011) identifying barriers to developing and sustaining driving rehabilitation and community mobility programs.

Funding and Equipment

The participants described funding as a major barrier, particularly affording program vehicles. They reported that funding for driving rehabilitation programs consisted of financial assistance for further program development and donations or financial assistance for acquiring program equipment. The participants defined funding as money for equipment, additional staff, and services that clients might not be able to afford. Within facilities, funding was provided through donations, fundraising, and grants. The hospital where Angela worked held many fundraisers over a year, with all proceeds used for payment for a vehicle. Jessica’s program was provided with a vehicle obtained from a vendor’s private donation. Another issue concerned the lack of affordable services for many clients. As Casey stated, “I do have some patients that can’t afford the equipment. . . . That’s our biggest barrier, the affordability of equipment for people that need it.” In Casey’s situation, the state in which she worked provided “a grant [that] covers the cost of the evaluation and training for people that don’t have insurance coverage” and a “United Way grant” that provided facility funding for specified numbers of evaluations and training. To emphasize the need for funding, Jessica stated that “it’s not a cheap program, as far as vehicles, as far as getting the equipment. . . . We need specific things, specific things with the car, specific things with the van.” Monetary assistance was a recurring theme throughout all interviews, reinforcing the idea that a successful program requires some source of funding.

Institutional Support

The participants defined institutional support as assistance from within the department, support from coworkers, and the willingness of managers to stand behind a program to make it successful. Most of the participants expressed that their institutions were supportive but had limited knowledge of the services the program provided. Tara explained this situation:

Jessica also suggested that knowledge was a factor in sustaining a program, as well as full support from staff members, especially new employees. Jessica stated that “there was definitely an education curve. . . . We were at a point at our facility, there was a lot of changeover in the management above us, which meant we were doing a lot of educating and reeducating.” Angela found that support from the initial stages of program development made sustaining the program a successful experience:

Thus, institutional support, both financial and administrative, was found to be a major factor needed throughout the development, implementation, and sustainment of driving rehabilitation programs.

Interdisciplinary Conflict

Struggles and conflict arose when members of the treatment team were unaware of the roles that occupational therapists play in driving rehabilitation. Participants indicated that appropriate referrals may not be written or clients’ needs to participate fully in desired daily activities may not be considered, thus negatively affecting their recovery process. Tara found it difficult to work with other professionals who did not share the definition of recovery as encompassing full participation in desired activities:

At Angela’s facility, available services were multidisciplinary—occupational therapists, physical therapists, speech therapists, and driver educators. Angela found the multidisciplinary approach to be too segmented: “If the client passed all three sections [of the evaluation], then . . . they would do a behind-the-wheel evaluation. . . . We weren’t being very consistent.” Angela felt that other service professionals did not attend fully to all sections of the driving evaluation. Consistency was also an issue across the disciplines with regard to scoring and identification of items considered most important. Angela observed conflict among the occupational therapists and driver educators:

Jessica also found working with driver educators difficult, stating that it “just seems we did better with [occupational therapists] than we did with driver educators. . . . I’m not trying to [be disrespectful to] them. . . . The ones we happened to get just seemed to have a different approach.” Although Jessica was aware that a range in skill level existed among professionals, she felt that many driver educators did not possess sufficient knowledge regarding cognition, visual perception, and neuromuscular skills to make accurate decisions about client driving ability. Tara, Angela, and Jessica expressed that interdisciplinary conflict served as a barrier to implementing a team approach and ultimately making the safest decision for the client.

Role Expectations

Role expectations are the duties that an occupational therapist is expected to execute as part of his or her position in the facility and as a member of the profession. In the area of driving rehabilitation, an occupational therapist is expected to be able to provide clinic-based driving assessments, understand and use adaptive equipment, and use driver education principles during behind-the-wheel assessments and training.

At Casey’s facility, the program was required to be “licensed through the state as a driving school [and] therapists . . . have to be licensed as driving instructors.” Instructors must “keep abreast of changes with state regulations.” Recent changes in state regulations had forced Casey’s facility to reconsider and update policies and procedures regarding driving rehabilitation services. Having knowledge of driver education regulations and policies in addition to clinical evaluation and intervention skills is a requirement.

In addition, participants indicated that driving rehabilitation specialists are expected to fulfill other nonbillable, ancillary duties such as marketing and networking. These marketing duties involved advertising occupational therapy and driving rehabilitation programs, advocating for occupational therapy services, and working with state and local organizations to promote awareness. Participants identified marketing and promotion as critical to program success because they allow people to become aware of available services.

One way to market and promote driving rehabilitation programs is through the provision of demonstrations and in-services. Tara used her marketing and promotion skills by talking to various “community groups, support groups, . . . lots of physicians’ groups” and by writing targeted newsletter articles for these groups. Tara also educated employees working in the state driver’s licensing agency as to the importance of occupational therapy in driving rehabilitation. Tara also extended her marketing efforts to other health care providers:

Jessica believed that being involved in the community was an effective way to market and promote driving rehabilitation programs: “We did a lot of . . . community education, but we also did things like the CarFit. . . . We became AARP instructors. . . . Educating seniors and not so much promoting our program but promoting safe driving.” Both Tara and Jessica expressed that people need to be educated on available driving rehabilitation resources and promoted driver and community mobility within their communities.

Networking duties were also found to be critical to program success and involved working with vendors, state and local organizations, vehicle manufacturers, schools, and any organization useful in sustaining driving rehabilitation programs. Networking was viewed as a way of gaining and facilitating resources. Participants stated that it is useful to have a variety of networking resources that can assist with referrals, promotion, and funding.

To network, Casey worked with the Area Agency on Aging to “get information about transportation services” and facilitate use of city Web sites for information on “senior programs for transportation.” Angela networked with driver evaluators and would ride with a driver education instructor and a passenger, serving as “the hospital representative.” Jessica mentioned that typical resources include the Association of Driver Rehabilitation Specialists, the National Mobility Equipment Dealers Association, AOTA, and occupational therapy state organizations. Her facility also “developed good relationships with voc[ational] rehab.”

In general, participants felt that the expectations for their roles exceeded those for the generalist occupational therapists working in the same facility. In addition to traditional occupational therapy expectations, participants were required to schedule appointments, call and communicate with physicians outside the facility, build alternate funding sources, accept and manage payments from clients, develop and disseminate marketing materials, train new therapists, advocate for resources and policies at the state level, oversee the mechanics of the program automobile, and establish and maintain relationships with agencies outside of the facility. This vast array of additional, nonclinical duties were identified as necessary for program success but often were not described by employers as job duties.

Professional Development

Professional development is defined as “a program of continuing competence but also includes a focus on one’s career development in terms of achieving excellence; achieving independent-practitioner and expert-role status; and assuming new, more complex roles and responsibilities” (AOTA, 2009, p. 30). Participants indicated that therapists who work in the area of driving rehabilitation commonly engage in professional development beyond typical attendance at continuing education courses. Driver rehabilitation practitioners commonly develop and present educational courses, acquire certifications, participate in mentoring relationships, advocate for clients, guest lecture, collaborate with colleagues, and contribute to research. Participants felt that professional development was an important aspect of practice and should be understood by practitioners entering this specialty area.

Both Casey and Angela emphasized the need for continuing education and urged therapists interested in driving rehabilitation to attend courses and observe programs before becoming involved. Angela advised therapists interested in driving rehabilitation to “find a mentor, go out and visit other programs, see if they would allow you to sit and observe driver evaluations being done. . . . It is important to see more than one program.”

Casey suggested that therapists initially work with familiar clinical populations and

Jessica pursued professional development through educating occupational therapy students. She had groups of students “come out and [we] give kind of an overview . . . and we take them out driving with hand controls.” Jessica hopes that educating students while they are in school will lead to interest in and pursuit of further education in driving rehabilitation.

There was full agreement among participants about the importance of and commitment to professional development because of the complexity of the practice area. This level of complexity and need for additional training in the specialty area of driving rehabilitation serve as the impetus behind a hesitancy to hire new graduates. The participants consistently agreed that clinical experience beyond the new graduate level is important before consideration for hire. A catch-22 exists, however, with participants stating that new graduates without experience are not typically hired, yet they are then unable to acquire the experience needed to obtain employment in driving rehabilitation. This situation results in inadequate staffing with qualified therapists.

Staffing

Staffing involves finding qualified occupational therapy and administrative staff to operate a program. Because many facilities will not hire new graduates, the first challenge is finding someone with experience. Casey explained the difficulties inherent in employing new graduates:

The issue of limited knowledge does not exist only among new graduates. Many occupational therapists, as Jessica put it, are “thrown in it” despite their lack of comfort working with the population and with driving rehabilitation.

Casey’s difficulty with staffing was in part because of her state’s requirement that all occupational therapists specializing in driving be licensed as driving instructors. Casey also shared that difficulties with staff availability were the result of other practice demands:

The 4 participants identified that limited staffing is a serious barrier to sustaining driving rehabilitation programs. This issue is further compounded by the fact that existing trained staff are often involved in the time-consuming process of training new staff in addition to meeting caseload needs. These challenges are difficult to neglect because training duties are embedded within the role expectations of driving rehabilitation specialists.

Limitations

Limitations of this study include using telephone interviews rather than face-to-face interactions with participants, which may have limited the information collected because researchers were unable to observe participants’ body language. Another limitation may have been the participants’ comfort level with expressing specific challenges and barriers because of fear of recognition, which could have reduced full disclosure. Although we ensured participant confidentiality, the field of driving rehabilitation is small, and practitioners are likely to know one another. Another concern was the accuracy and credibility of participants’ memories. The participants were asked to recall experiences that occurred up to 19 yr previously, and this time lapse may have had a detrimental effect on the accuracy of their recollections.

Additionally, the researchers noted that their own biases may have influenced data collection and analysis. Extensive background research and literature reviews were conducted before administering the research study, and during this process the researchers formed their own beliefs and opinions.

Implications for Occupational Therapy Practice

Because of the complexities in the driving rehabilitation practice area beyond a clinical skill set, this study has several implications for occupational therapy practice. Specifically, the findings indicate the need for

Future Research

On the basis of this study’s findings and the literature reviewed, further research on the development of driving rehabilitation programs is indicated. This study focused on the experiences of occupational therapists who developed successful programs but neglected the perspective of practitioners involved in the development and implementation of driving programs that were not successful and ultimately ceased operation. Moreover, the participants in this study worked exclusively in hospital-based rehabilitation programs, and thus the results do not capture the experiences of practitioners in alternate settings, such as community-based settings and private practices. Finally, all of the driving programs discussed in this study were staffed exclusively by occupational therapists. It would be useful for additional studies to include programs that incorporate professionals from other disciplines, such as driver educators, physical and speech therapists, and physicians, into their service delivery process.