Abstract
Keywords
Increasingly, health professionals, especially occupational therapists, participate in the screening, comprehensive assessment, and retraining of older adults who are potentially unsafe drivers (Korner-Bitensky, Bitensky, Sofer, Man-Son-Hing, & Gelinas, 2006; McGwin, Sims, Pulley, & Roseman, 2000). Internationally, it is expected that the number of older drivers will continue to grow substantially in coming years. In Canada, 71% of people ages 65–69 hold a driver’s license, as do 23% of people age ≥85 (Transport Canada, 2003). In the United States, as in most developed countries, by age 70, the accident rate per miles driven rises, and the rate increases even more rapidly at age 80 (National Highway Traffic Safety Administration, 2004). Age alone does not influence driver safety; the increased prevalence of age-related health conditions such as stroke (Akinwuntan et al., 2002), Parkinson’s disease (Meindorfner et al., 2005), Alzheimer’s disease (Dubinsky, Stein, & Lyons, 2000), and common chronic conditions such as diabetes (Begg, Yale, Houlden, Rowe, & McSherry, 2003) take their toll on drivers.
The growing number of older drivers, along with mounting concern regarding their safety, has placed an onus on health professionals to implement rigorous and valid screening and assessment processes. Generally speaking, screening is the identification of an unrecognized disease or defect using tests, examinations, or other procedures that can be applied quickly. With respect to driving, the screening process attempts to distinguish people who require further evaluation regarding their driving safety from those who are most likely safe drivers, on the basis of a quick examination of their driving-specific skills (Korner-Bitensky, Gelinas, Man-Son-Hing, & Marshall, 2005).
Assessment in health care is typically considered to be a much more extensive and comprehensive process than screening. With respect to driving, assessment entails a more detailed evaluation of the client’s driving-specific skills and safety in domains that were flagged as potential concerns during the screening process. Part of this assessment process may take place within the context of a generalized occupational therapy practice. However, when this process is undertaken by an occupational therapist who is specifically trained in driving assessment, the content and structure of this detailed evaluation is interchangeably termed a comprehensive driving evaluation, driving assessment, or functional driving evaluation (American Medical Association, 2003). When the client is referred to a driving evaluation service where a specially trained occupational therapist performs an in-depth functional assessment, the purpose is “to plan, develop, coordinate and implement driving services for individuals with disabilities” (American Medical Association, 2003, p. 53). It is common for this evaluation to include both an on-road and off-road (also referred to as in-depth or in-clinic) assessment.
Although driver assessment is an important domain of practice, professional attention should also be focused on developing and providing driver refresher and retraining programs. Three recent systematic reviews (Hunt & Arbesman, 2008; Korner-Bitensky, Kua, von Zweck, & Van Benthem, 2009; Kua, Korner-Bitensky, Desrosiers, Man-Song-Hing, & Marshall, 2007) revealed mounting evidence supporting the effectiveness of driver retraining programs for older adults. Specific recommendations include physical training targeted to axial and extremity flexibility, coordination, and speed of movement and, when deemed appropriate, an educational intervention combined with an on-road component. A cost–benefit analysis (Viamonte, Ball, & Kilgore, 2006) using simulator-based performance as the criterion measure, suggested that an intervention focused on processing speed for drivers ≥ age 75 could reduce collision risk and costs compared with screening with perceptual–cognitive measures and intervening only where indicated or relicensing with the usual “do-nothing” approach.
Given the public safety issues associated with older drivers and the importance of a health promotion and prevention focus, adequately trained health professionals must be available to provide driving-specific services for this population across the continuum of care. We do have some knowledge regarding the driving evaluation practices of rehabilitation specialists who work in driver assessment (Korner-Bitensky et al., 2006); however, little is known about the skill set and readiness of occupational therapists working across the continuum of health care to offer driving-related services to a prevalent older clientele. Exploration of capacity readiness among occupational therapists is of particular importance, given that occupational therapy is recognized internationally as having a key role in the management of driver safety (Korner-Bitensky et al., 2006).
Thus, we undertook this study to understand current capacity-building needs of occupational therapists related to older driver screening, assessment, and intervention. The primary objective was to conduct a nationwide survey to elicit information from occupational therapists working with an older clientele across the continuum of care regarding
Actual practices related to older driver screening, assessment, and intervention;
Importance of continuing education in various knowledge areas, including screening, assessment, interventions, and advanced practice specific to older drivers;
Perceived competence in various knowledge areas (i.e., screening, assessment, interventions, and advanced practice) specific to older drivers; and
Likelihood of undertaking driving-related continuing education according to course content and mode of delivery.
A secondary objective was to compare the perceived importance, competence, and continuing education needs of occupational therapists who currently screen older clients for driving safety with that of therapists who do not screen for driving safety.
Method
Research Design
A Canadawide survey was used to investigate the capacity-building needs of occupational therapists related to older driver screening, assessment, and intervention. Occupational therapists were interviewed by telephone in either English or French using a standardized questionnaire. Research ethics approval for the study was attained from the Faculty of Medicine, McGill University, Montreal, Quebec.
Study Population
The goal was to accrue a representative sample of occupational therapists who treat older adults across the continuum of care. Occupational therapists were eligible if they were registered with the professional regulatory body; worked in an acute care, inpatient rehabilitation, or community setting; worked with clients ≥ age 55; and were able to respond in either English or French to an English questionnaire. Those who agreed to participate provided verbal consent.
Sample Size Considerations
A comprehensive review of the literature revealed no studies on which to accurately estimate the prevalence of occupational therapy practices related to older driver screening, assessment, and intervention in Canada. Given an estimated range of prevalence of older driver screening, assessment, and intervention from 10% to 30% by occupational therapists working in stroke rehabilitation, a sample of 133 occupational therapists is sufficient to provide stable estimates with 95% confidence and precision ranging from ±5.0% to ±7.8%.
Survey Questionnaire
The telephone-administered questionnaire was developed using the Tailored Design Method (Dillman, 2000). Use of a telephone mode for surveys is considered more efficient and less expensive than face-to-face interviewing (Fowler, 1988) and typically results in a high response rate.
The questionnaire included five sections of closed-ended questions. Section A elicited demographic information on gender, professional education, work setting, and province. Section B included 27 Likert-type questions to rate importance of continuing education in various knowledge areas: screening and assessment (e.g., physical function, vision, visual perception, behavior, cognition, and endurance), intervention (e.g., refresher or retraining programs, driving cessation), and advanced practice (e.g., evidence-based practice, effects of medications and medical conditions on driving skills). Table 1 describes these items. Section C (Table 2) included 11 Likert-type questions to elicit information on occupational therapists’ perceived competence in various knowledge areas specific to older drivers (i.e., screening, assessment, interventions, and advanced practice). Section D requested information from occupational therapists regarding their actual practices related to older driver screening, assessment, and intervention. Finally, Section E (Table 3) included 8 Likert-type questions regarding the occupational therapist’s likelihood of undertaking driving-related continuing education according to course content and mode of delivery (online vs. in person).
Occupational Therapists’ Rating of Importance of Continuing Education in Knowledge Areas Specific to Older Drivers
Note. N = 133 unless otherwise indicated. Percentages may not total 100 because of rounding.
Occupational Therapists’ Perceived Competence in Various Knowledge Areas Specific to Older Drivers
Note. N = 133 unless otherwise indicated. Percentages may not total 100 because of rounding.
Occupational Therapists’ Likelihood of Undertaking Driving-Related Continuing Education According to Course Content and Mode of Delivery - 316
Note. Percentages may not total 100 because of rounding.
For preliminary validation of the survey content before its use, five experts, including researchers, occupational therapists, and driver rehabilitation specialists, reviewed the questions and suggested modifications, additions, and clarifications. Next, the final version was pilot tested using a convenience sample of four occupational therapists who did not participate in this study to ensure that the questions were clear and easy to understand and that there was no redundancy or important omissions in content area.
Recruitment Process
Contact lists from the Canadian Association of Occupational Therapists (CAOT) were used to identify occupational therapists working with older adult populations across the 10 provinces. Given that CAOT is the primary source of occupational therapy professional liability insurance in Canada (with the exception of the province of Quebec), these contact lists include the majority of registered occupational therapists across Canada. To ensure sufficient sampling of therapists from Quebec specifically, a separate contact list of occupational therapists working with older adults was sought from their provincial regulatory body, the Ordre des ergothérapeutes du Quebec.
Disproportional random sampling was used to identify a representative sample of occupational therapists from the 10 Canadian provinces and to ensure sufficient numbers per province were included given that some provinces have very few occupational therapists (CAOT, 2009). To achieve maximal participation, a specific recruitment and interview guide based on guidelines of the Tailored Design Method (Dillman, 2000) was designed. Trained research assistants applied rigorous tracing procedures when contacting occupational therapists at their workplace, which included calling at different times of the day and on different days of the week. When a voicemail was available, a message was left either on the voicemail or with a contact person. For occupational therapists who no longer worked at a site, attempts were made to ascertain their current place of employment. When necessary, the telephone directory (online Web search) from the region was consulted.
Once an occupational therapist was contacted, eligibility was ascertained. Those who were eligible and agreed to participate were scheduled for a 35-min telephone interview to respond to the survey questionnaire.
Data Collection, Management, and Analysis
During each interview, a trained research assistant used a standard script to administer the questionnaire and respond to occupational therapists’ queries. Afterward, the research assistant reviewed the questionnaire for completeness. Data were then entered into an online computerized database by one research assistant and verified for accuracy by a second. Data analyses were performed using SPSS 14.0 (SPSS, Inc., Chicago).
Descriptive statistics were used to summarize the demographics of the sample. Next, for the group as a whole, frequency distributions were used to describe actual driving-related practices, rated importance of driving-related continuing education, perceived competence in knowledge areas specific to older drivers, and likelihood of undertaking driving-related continuing education according to mode and content.
To explore differences in capacity-building needs among occupational therapists, respondents were dichotomized into two groups on the basis of whether they screened or did not screen older clients for driving safety. Using χ2 tests or independent t tests, the two groups were compared according to their rated importance of driving-related continuing education, perceived competence in knowledge areas specific to older drivers, hours spent on continuing education, and likelihood of undertaking driving-related continuing education. Given the multiple correlations (see Tables 1, 2, and 3 for list of variables), the level of significance was set at .01 using a Bonferroni correction (Kleinbaum, Kupper, & Muller, 1987).
Results
Respondent Characteristics
Two hundred forty occupational therapists were contacted. Of those, 93 were ineligible to participate primarily because they did not treat older adults. A total of 147 occupational therapists met the inclusion criteria; of those, 138 (93.8%) agreed to participate. Those who refused (n = 9) indicated being too busy or not interested. Further review of the questionnaires indicated that 133 interviews were sufficiently complete to allow data analyses to be performed.
Respondents came from all 10 provinces and two territories and worked in a wide range of environments, including community service, driving assessment centers, outpatient programs, rehabilitation centers, home care, and acute care hospitals. Most were women (92.5%; n = 123) and held a bachelor’s degree (85.7%; n = 114). Acute care hospitals and rehabilitation centers were equally represented (n = 34 each); 65 participants practiced in community-based environments. Only 6 respondents indicated working in a driving assessment center. Nine respondents had completed courses on topics related to the management of older driver safety; of those, only 2 worked in specialized driver assessment centers, and the remainder worked at sites providing general care (i.e., acute care, rehabilitation, or community-based settings).
Actual Driving-Related Practices
When respondents were asked about their actual driving-related practices, they were twice as likely to use screening tools as in-depth assessments (n = 79 vs. n = 37; see Figure 1) when evaluating older drivers. Only 18.8% (n = 25) ever performed on-road assessments. In terms of interventions, although few offered driver retraining or refresher courses aimed at older drivers, 42.9% (n = 57) recommended vehicle modifications to their clients. Of all respondents, 19.6% (n = 26) indicated that they screened and assessed older drivers and offered driving-specific interventions. In particular, of the 79 respondents who used driving-specific screening tools, 36 used in-depth or on-road assessments as necessary; of those, 27 offered a driving-specific intervention to their older clients (i.e., driver retraining, driver refresher program, vehicle modification). By contrast, of the 79 respondents who used screening tools, only 18 offered a driving-specific intervention. Of the 6 respondents who worked at a driving assessment center, 5 indicated that they performed a thorough evaluation of driving safety (i.e., screening, in-depth preroad assessment, on-road assessment).
Actual practices of occupational therapists related to older driver screening, assessment, and intervention.
Importance of Continuing Education in Driving-Related Areas
Table 1 shows the occupational therapists’ rating of the importance of continuing education in various knowledge areas specific to older drivers. A higher percentage considered continuing education related to screening of older drivers as very or somewhat important (ranging from 34.6% to 61.7%) as opposed to education related to assessment (ranging from 17.6% to 59.5%). In terms of interventions, continuing education on driving cessation was perceived as very or somewhat important by almost half of respondents. When questioned about advanced practice topics, 39.9% (n = 53) of respondents felt that it was not important to receive training to critically appraise the driving literature.
When comparing occupational therapists who screen (n = 79) to those who do not screen (n = 54) for older driver safety, we found no differences between the groups regarding the importance they placed on driver-related continuing knowledge areas related to screening (χ2[3] = 1.745–5.600, n = 133, p = 0.133–0.627 for knowledge areas listed in Table 1) and in-depth assessment (χ2[3] = 0.52–5.22, n = 131, p = 0.187–0.915 for knowledge areas listed in Table 1). In terms of interventions, occupational therapists who screen were more likely to feel that continuing education related to refresher programs was very important than were those who do not screen (χ2[3] = 9.911, n = 132, p = 0.019), this finding approached significance.
Perceived Competence in Driving-Related Areas
When occupational therapists were asked about their perceived competence in various knowledge areas specific to older drivers (see Table 2), a higher percentage felt very competent screening than felt very competent performing in-depth assessments. Only 14.3% felt very competent assessing on-road fitness to drive. When respondents were asked about advanced practice topics, 60.2% felt not very or not at all competent about legal issues and liability related to older driver screening, assessment, and retraining.
We examined whether competence in driving-related knowledge areas would differ among respondents who currently screen versus those who do not. Respondents who screen were more likely to feel competent in many domains, including choosing valid screening tools (χ2[3] = 25.366, p = .000), screening for impairments (χ2[3] = 28.199, p = .000), performing in-depth assessments (χ2[3] = 22.408, p = .000), and evaluating on-road fitness to drive (χ2[3] = 19.420, p = .000); for each χ2, df = 3 and N = 133. By contrast, we found no difference in perceived competence for research skills (i.e., analysis, critical appraisal of driving literature) between occupational therapists who screen and those who do not screen (χ2[3] = 3.431, N = 133, p = .330).
Likelihood of Undertaking Driving-Related Continuing Education
Table 3 describes the likelihood of undertaking driving-related continuing education courses according to course content and mode of delivery. Occupational therapists were most likely to consider taking courses where the content was related to older driver screening. When asked about the mode of course delivery, they were twice as likely to consider participating if courses were offered through Web-based distance learning than through in-person classes.
We examined whether continuing education needs would differ among therapists who screen versus those who do not. Occupational therapists who screen were more likely to undertake training related to screening (χ2[3] = 11.197, n = 132, p = 0.011), in-depth assessment (χ2[3] = 10.380, n = 130, p = 0.016), and interventions (χ2[3] = 14.289, n = 132, p = 0.003). Moreover, occupational therapists who screen had participated in significantly more hours of driver-related continuing education during the past year (11.8 hr ± 25.5 vs. 1.5 hr ± 4.2; t = 2.939, p = .004).
Discussion
We set out to identify the capacity-building needs of occupational therapists working with an older clientele across the continuum of care, including perceived importance, competence, and willingness to learn about older driver screening, assessment, and intervention. Not surprisingly, screening of prerequisite skills required for safe driving was the domain in which respondents felt most competent: A substantial proportion of respondents were willing to invest time for continuing education to improve their screening abilities. Few respondents conducted on-road driving assessments; this finding is not surprising, given that this component of driving assessment in most parts of Canada is usually performed by a specialized occupational therapist working with a driving instructor. What was especially surprising and disconcerting was that there was little perceived competence or professional focus related to providing older driver retraining or refresher programs. This finding is important and warrants immediate attention, especially given the mounting evidence supporting the effectiveness of older driver retraining programs for improving driving-related skills (Hunt & Arbesman, 2008; Korner-Bitensky et al., 2009; Kua et al., 2007). An additional perplexing finding is that a substantial proportion of those surveyed were providing vehicle modification or aids and adaptations, but few were performing on-road driving assessments. This finding raises concern that some older people may be inadequately prepared to use vehicle modifications or aids and adaptations being provided.
Occupational therapists are well suited to enhance their professional role in the area of driver safety (American Occupational Therapy Association [AOTA], 2008). A strong background in activity analysis enables occupational therapists to analyze how functional limitations (e.g., physical, visual–perceptual, attention, cognition) and environmental factors affect a client’s ability to lead an independent, productive, and satisfying life (AOTA, 2008; Stav, 2008). Nowhere is this background more evident than in the domain of driving safety, where an occupational therapist must have an understanding of the driving task, the requisite skills needed to perform the task, interventions to improve these skills, knowledge about the aids and adaptations that can enhance performance even in the face of impairments, and ways to adapt the driving environment to prolong the driving lifespan (Hunt & Arbesman, 2008; Stav, 2008). Occupational therapists are also ideally suited to prepare older adults to eventually retire from driving with dignity and with opportunities for mobility outside of driving. Yet, many survey respondents did not feel competent in the area of driving cessation and wanted to become better educated in assisting older drivers to prepare for alternative mobility solutions.
To respond to gaps in the competence of occupational therapists regarding the management of older driver safety, capacity building is likely necessary at three levels (Korner-Bitensky et al., 2005): (1) generalist training of occupational therapists to screen to detect driving-related safety issues that require referral for in-depth assessment or that can potentially be addressed by a refresher program; (2) advanced training of occupational therapists to evaluate various skills related to safe driving using in-depth and on-road assessments, as well as the provision of targeted interventions aimed at driver retraining; and (3) advanced specialization, consisting of expertise in assessment, training and retraining of driving skills, vehicle modifications, and use of assistive technology for those with health conditions beyond the effects of normal aging. Although more than half of the surveyed occupational therapists seemed to have generalist training, few in this random sample had advanced training. Fortunately, a growing number of resources are in place to address knowledge gaps and meet the capacity-building needs of occupational therapists (Pellerito, 2006), both in terms of practice guidelines specific to older driver assessment (Korner-Bitensky et al., 2005; Korner-Bitensky, Toal-Sullivan, & von Zweck, 2007a, 2007b; Stav, Hunt, & Arbesman, 2006) and of driving-related specialty courses (see McGill University, www.autoeduc.ca; Association of Driver Rehabilitation Specialists, www.driver-ed.org; among others).
In summary, management of older driver safety is a growing domain of practice for occupational therapists. It is an opportunity for therapists to delve into a health promotion and injury prevention arena that is well suited to their professional training and expertise. Our findings suggest that many occupational therapists would benefit from capacity-building strategies aimed at developing the skills needed to work within this area of practice, and survey respondents gave a clear message of willingness to invest the time and energy. As a next step, it would be important to gain a better understanding of the processes in place—including the prevalence of referrals to driving assessment centers, follow-up of clients, and specialized training of health professionals along with the governmental and community structures in place to meet the demand—and costs associated with providing comprehensive older driver screening, assessment, and rehabilitation.
Limitations
The primary limitation is that this study is based on a sample of occupational therapists from one country. Given that random sampling was used, however, it is likely that the findings can be generalized to occupational therapists across Canada and, possibly, to those from other countries with similar professional training and a prevalent older driver age group. Even in Canada, however, factors at the provincial level, such as differences in jurisdictional requirements for older driver assessment, may have influenced occupational therapists’ assessment practices or capacity-building needs. This study was not sufficiently powered to explore this line of questioning.
Conclusion
We identified the current capacity-building needs of occupational therapists as related to older driver screening, assessment, and intervention. Not only are occupational therapists using screening tools and feeling, for the most part, competent in these abilities, they also think that driving-related professional training is important. An excellent window of opportunity exists for occupational therapists to expand their capacity to work in a health promotion venue that recognizes community mobility—specifically, driving—as a critically important component of healthy aging.
Footnotes
Acknowledgments
We acknowledge the financial support of the Public Health Agency of Canada grant, which provided support for this initiative within the context of a National Blueprint for Injury Prevention in Older Drivers. Nicol Korner-Bitensky is supported through a senior career award from the Fond de la recherche en santé du Québec. Anita Menon is supported by a doctoral fellowship from a Canadian Institute of Health Research knowledge translation program award. We acknowledge the time and effort provided by the study participants. We also acknowledge the support of Julie Lamoureux for statistical analysis, Patrick Paul for creating the computerized database, and the interviewers involved in the study.