In the next 10 years, the number of North American older adults (aged 65+ years) who hold a valid driver's license is expected to increase exponentially.1,2 As individuals age, they are more likely to experience changes in cognitive and physical health, which can negatively affect driving.3–5 Unfortunately, older drivers are not always aware of the impact such changes can have on their driving performance, thereby putting themselves, as well as other road users, at risk. Concerns for public safety and efforts to restrict older drivers must be weighed against the personal impact of license forfeiture on mobility and social participation. Loss of licensure, whether voluntary or otherwise, is associated with reduced out-of-home activity levels,6 decreased health status,7,8 higher depression rates,9 and institutionalization.10 Given these implications, it is critical that health care professionals responsible for reporting medically at-risk drivers understand how driver licensing legislation applies in their clinical interactions with older clients, caregivers, and members of the health care team.
Collaboration between health and transportation authorities is essential to ensure fitness-to-drive decisions are based on functional assessment, rather than age or medical condition alone.4,11 In Canada, as well as the United States, licensing and fitness-to-drive legislation, alongside medical-reporting policies, can vary across provincial and state jurisdictions. Provincial or state transportation authorities are responsible for determining the parameters and medical reporting requirements for health care professionals. For example, in the Canadian province of Ontario, physicians have a legal and professional obligation to identify individuals who may have a medical condition that can impact their driving ability. Such clinical screening for driving has been described as an “attempt 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.”12(p3) While most physicians (72.4%; n = 448) agree with legislation that mandates their role in reporting drivers who are medically unfit to drive, many do not feel confident or qualified to evaluate driving (30.4%; n = 448).13 Friedland and colleagues14 described “gray areas” in clinical practice, where adhering to guidelines developed to support physicians can instead result in ethical dilemmas when raising the issue of driving with older patients and their caregivers.
Occupational therapists (OTs) are optimally positioned to not only screen medical fitness to drive but also address continued mobility when transitions to alternative transportation may be necessary.15–17 Levels of knowledge and training for OTs who address medical fitness to drive have been reflected as a 3-tiered framework of expertise (Table 1).12 In Canada, OTs graduate as generalist practitioners with tier 1 training. OTs in this first tier are expected to perform basic screening for potential problems that can impact driving ability and intervene where appropriate.18,19 However, a national survey of OTs in Canada found that only 19.1% (n = 131) of respondents reported feeling competent when it came to their understanding of licensing legislation.20 In addition, 60.2% (n = 133) identified limited competence with addressing legal and liability issues associated with screening and evaluating older drivers.20 Having to report medically at-risk drivers presents an ethical conundrum for most health care professionals such that medical reporting policies in many North American jurisdictions include clauses that protect physicians from legal action when fulfilling their professional obligation.21–23 Even when legal protections are in place, the number of appropriate reports submitted by physicians remains low.21,24 These low rates may be due, in part, to the gap in clinically validated assessment tools,25 as well as limited understanding of the laws and regulations specific to medical fitness to drive.26 Aschkenasy and colleagues27 suggest that medical practitioners have a reciprocal responsibility to not only inform patients about the potential impact of a health condition on driving but also provide education on relevant policies and procedures in place.
There has been a concerted effort to engage physicians in continuing education initiatives to improve their knowledge of medical risk and driving, including awareness of relevant legal regulations.28–31 Despite these initiatives, an understanding of legal and professional responsibilities among clinicians when addressing medical fitness to drive remains a major knowledge-to-practice gap. As the North American population ages, issues of medical fitness to drive will increase, prompting the need for collaboration between health and transportation authorities to promote more effective driver screening and medical reporting. As such, practice guidelines and administrative procedures specific to addressing medical fitness to drive must be developed and disseminated in a way that is both understandable and applicable for the intended audience (ie, health care professionals). This project describes the practice context within which frontline OTs in one Canadian province, Ontario, address medical fitness to drive. The objective of the current investigation was to examine OTs' legal and professional responsibilities of fitness to drive and determine what educational resources might improve understanding of reporting requirements. Specific aims of this study were 3-fold: (1) to explore OTs' and other informants' perceptions of legislation, policies, and clinical practice that inform OTs' current roles and responsibilities when addressing medical fitness to drive; (2) to collate resources that support OTs' understanding of current legislation and associated clinical responsibilities; and (3) to propose how existing resources can be adapted to ensure OTs consider the needs of clients and other stakeholders when medical fitness to drive is addressed. This project was prompted by changes in the professional obligation of OTs to report medically at-risk drivers in Ontario (changes occurred in July 2018). Forewarning of these changes by the provincial transportation authority presented a window of time that provided a unique opportunity to explore perspectives of frontline clinicians alongside other key informants (eg, policy makers, professional regulatory organizations) to understand the potential impact of these changes on clinical practice before they were implemented. In addition, our study methods demonstrate a process that can be considered by other jurisdictions that might experience similar changes in legislation and corresponding policies.
Using qualitative description,32 OTs' level of knowledge and awareness of relevant legislation and its influence on their clinical practice with medically at-risk drivers were explored. Participants' perspectives were elicited using semi-structured interviews to identify information accessed by frontline OTs to address medical fitness to drive within their everyday practice. Interview findings will inform learning objectives and content for an educational module that is currently under development. Hence, ethics approval was not warranted for this project, as it was deemed by the university ethics board to be focused on informing this module and corresponding resources (personal communication, Hamilton Integrated Research Ethics Board (HiREB) December 21, 2016). Two theoretical frameworks for knowledge translation guided the data collection methods undertaken in this project, namely, the Knowledge-to-action (KTA) framework described by Graham and colleagues33 and the Understanding-User-Context (UUC) framework.34
The KTA framework is a process framework that describes phases of knowledge dissemination from knowledge creation to implementation and subsequent evaluation.33 As reflected in the second stage of the KTA framework, Adapt knowledge to local context, legislation and associated policies as well as clinical guidelines (ie, existing knowledge tools and products) should be tailored to the practice context in question.35 In turn, this framework can also serve as a guide for adapting and tailoring of clinical guidelines to ensure their relevance to practice contexts beyond those for which they were initially developed.36
As a determinant framework that specifies independent variables that influence implementation outcomes,37 the UUC outlines contextual domains that can influence the transaction between the user (clinician) and the (practice) context in which knowledge will be applied. These domains include (1) the user group; (2) the issue; (3) the research; (4) the knowledge translation relationship (ie, relationship between the researcher and the targeted user group); and (5) dissemination strategies.34 Within each domain, suggested prompts are outlined that allow researchers to explore the needs of the target audience, the practice context, and any other relevant knowledge tools and products. The UUC framework was utilized to complement the KTA framework by ensuring that key contextual factors that influence clinician awareness of legislative and professional responsibilities regarding medical fitness to drive were explored.
Target audience and key informants
In the current project, frontline OTs were the target audience (user group). Participants were purposefully selected to reflect a range of clinical practice settings. Additional informants involved in establishing, implementing, or adhering to reporting requirements were also purposefully selected. Informants included a geriatrician, an OT with advanced training in driver rehabilitation (ie, tier 3), representatives from provincial occupational therapy regulatory organizations (Ontario, Saskatchewan), as well as a policy maker from the Medical Review Section within the Ministry of Transportation (Table 2). The geriatrician was a medical doctor specializing in health and medical concerns of the geriatric population. Under legislation at the time, medical doctors were mandated to report medically at-risk drivers to the Medical Review Section of the provincial licensing authority and they continue to have this responsibility.38 As occupational therapy is a self-regulated profession in Canada, representatives from provincial occupational therapy regulatory organizations were invited to participate. The regulatory organization is responsible for overseeing the practice of OTs by assuring the public that their members meet necessary qualifications to practice. Their role includes enforcing continuing education requirements and developing and maintaining standards of practice. A representative from an occupational therapy regulatory organization in a second Canadian province (Saskatchewan) was sought, as legislation requiring OTs to report driving concerns to licensing authorities was previously enacted in this jurisdiction. A representative from the Medical Review Section of a transportation licensing authority was also invited, as this section is responsible for implementing legislation outlining medical standards for safe vehicle operation through a medical review process. This process enforces medical and vision standards for licensing based on national standards.39
Six tier 1 OTs and 5 informants known to the research team were invited to participate in semi-structured, one-on-one telephone interviews between January and March 2017. All participants informed the interviewer (R.S.) that they verbally consented to participate in the interview. Verbal consent was captured on the audio-recording of interviews and documented in a list of study participants. Prior to their respective interviews, individuals were e-mailed a brief outline of the project. Each interview lasted 45 to 90 minutes. Interviews with clinicians focused on the applicability of legislation in their practice settings, resources accessed, and to provide suggestions for strategies that would improve knowledge dissemination. Interviews with the additional informants focused on exploring their perspective of the role of OT in addressing medical risk and driving, awareness of legal procedures, experiences with implementing policies, and current and future opportunities for OTs in this area of practice.
All interviews were audio-recorded with the exception of one OT (due to technical issues) and the policy maker who declined to be audio-recorded. Written notes were taken during each interview by the first author (R.S.) and enhanced through playback of audio-recordings. An inductive content analysis approach was used to create a condensed and broad description of the phenomenon40; the phenomenon of interest in this study was OTs' and informants' perceptions of legislation, policies, and clinical practice in medical fitness to drive. An open coding process40 was used to analyze interview notes and to identify key categories (eg, current awareness of legislation, policies, and standards of practice; knowledge gaps; resources accessed; clinical challenges; and concerns with expected changes in OT responsibilities). Emergent categories were then used to generate learning objectives and content areas for the proposed educational platform. Trustworthiness of the findings from the interview was achieved through iterative review process with another member of the research team (B.V.), as well as by member-checking.41 Member-checking was conducted by providing each participant with a summary of findings from all interviews once interview notes were analyzed and inviting participants to share comments and clarifications. All but one participant provided feedback on the findings. This feedback confirmed study results of knowledge gaps, and additional resources were identified, clarifying issues related to clinical practice and professional regulation.
Interviews with frontline OTs provided unique insights into their individual awareness of roles and responsibilities related to medical fitness to drive. Contextual nuances that influenced understanding of licensing policies when screening medically at-risk drivers were shared by interviewees. Critical areas that were highlighted, specific to legislation and policies, included (1) awareness of the current medical review process for licensed drivers, including resources accessed; (2) clinical challenges and ethical tensions with addressing medical fitness to drive; and (3) the potential implications of changes in legislation with having to report medically at-risk-drivers.
Awareness of the medical review process for reporting medically at-risk drivers
All participants interviewed for this project were aware that frontline OTs are not among those expected to report medically at-risk drivers directly to licensing authorities. There was understanding among this group of their professional obligations within the health care system, as one OT explained: “Usually, it's the physician's call whether they can drive or not, not the OT.... We can advise the physician, but we can't write to the ministry [provincial licensing authority] ourselves.” Another OT similarly described how she saw her role within the medical review system specific to medical risk and driving:
My obligations are quite clear, if I have concerns, I have to write a letter outlining my concerns. What [the doctor] chooses to do is up to them. I have fulfilled my professional obligation. I will check ... to make sure they did get the fax. I want to ensure that it does not come back to me saying “oh we didn't know.”
However, when the notion of professional responsibilities was further explored, some participants responded that “the doctor will take away their license.” This interpretation is not correct, as decisions concerning licensure reside with transportation authorities alone. Some participants expressed a lack of awareness of how medical reports were actually handled by transportation authorities. They felt the medical review process should be more transparent, as one OT indicated: “I have no clue [about the medical review process] ... I know with the physician sending in the letter [to the Ministry] they look at physical reasons why or the cognitive reasons why and that's all I know ... never seen the letter.” Most wanted further detail about what happened once a driver was reported to the licensing authority. They asserted the OT's obligation to help clients understand and navigate the steps involved with the medical review process. A representative from one professional regulatory organization supported this assertion, meaning standards of practice and guidelines are in place to translate key aspects of legislation and policy to practice, where applicable. A geriatrician identified that her professional regulatory organization provides information on how to interpret the physician's role when it comes to addressing medical fitness to drive. She described how this information combined with her educational training helped her understand her clinical role and corresponding responsibility within the province's medical review process:
...lots of different sources, it's always learning and re-learning ... it's part of my training program, residency training program ... continuing medical education ... at both the local and international levels ... written material ... our own [professional regulatory organization] has a little blurb on what you should do ... so it's sort of continuous learning.
The policy maker also emphasized the critical role of frontline medical practitioners with identifying medically at-risk drivers, yet acknowledged that they [the licensing authority] could be more “active” in ensuring this knowledge was being translated to relevant frontline clinicians. Communication strategies employed by the licensing authority included posting information on their Web site or publishing articles in professional practice magazines distributed by regulatory organizations. They also liaised with professional associations to solicit input and feedback. However, the policy maker was not aware of any formal evaluation of their communication strategies that target health care professionals.
Most of the OTs interviewed for this project sought continuing education to address gaps in their knowledge and skills related to their roles and responsibilities in addressing medical fitness to drive. A number of resources were accessed using a variety of formats to address their respective knowledge-to-practice gaps (Table 3). However, many participants indicated that these supports were not profession-specific and so did not clearly outline OT responsibilities. OTs indicated communicating with colleagues and professional regulators to be the most informative means of understanding their roles and responsibilities.
Clinical challenges and ethical tensions with addressing medical fitness to drive
Clinicians described situations in which they had been confronted with issues specific to addressing medical fitness to drive in their practice. While frontline OTs understood the importance of raising these issues with their clients, they concurrently felt conflicted by their professional roles and responsibilities. For example, one OT described feeling like yet another barrier to recovery, rather than an “enabler,” when a client had expressed: “You're taking away my license, my freedom, my livelihood.” Others described circumstances where they felt their clinical role was being threatened: “Sometimes you get patients who are not compliant, patients who threaten you with legal action.” Such tensions sometimes extended beyond their clients to their interprofessional interactions. OTs described feeling upset, frustrated, or even angry when medical practitioners did not act on their recommendation that a client not return to driving, or conversely, when they were asked to “clear [a] patient to drive.” The geriatrician who was interviewed emphasized the importance of interprofessional collaboration when it came to addressing medical fitness to drive. Awareness of respective clinical roles and responsibilities in this practice area was seen as critical: “We're all in it together, particularly in the [hospital] wards ... there is a lot more gelling of responsibilities ... and you do get a sense of where everybody's role is.”
OTs saw their professional regulatory organization as being an important resource to ensure their clinical actions and professional responsibilities were aligned. While the representative from their regulatory body emphasized their role was to protect the public, rather than support clinical practice per se, one of their primary aims is to ensure legal requirements are understood and translated to OT practice. The representative shared case examples in which OTs sought guidance in their practice related to medical fitness to drive. For example, OTs often conduct cognitive assessments as part of their role. However, results of such assessments may indicate concerns with driving capacity and trigger follow-up or reporting the client to licensing authorities by the most responsible physician. The critical issue was the implication of the cognitive assessment that is distinct from its intended purpose. In such situations, clinicians appreciated guidance from their regulatory organization on their roles and responsibilities and wanted more support with navigating these types of situations. However, some OTs felt the strategies provided by regulators were too “abstract,” meaning case examples were either too broad or too specific that they did not or could not be applied within their own practice context. Hence, many opted for advice from colleagues. The policy maker saw OTs as strong and credible sources when addressing medical fitness to drive. Changing legislation to allow OTs to report directly to their licensing body was seen by most participants as a good strategic move, given their expertise in functional assessment.
Changes to legislation regarding reporting medically at-risk drivers and clinical considerations: A critical role for frontline OTs
Most of those interviewed were already aware of the changes in legislation through which OTs would be responsible, alongside other health care professionals, for reporting medically at-risk drivers directly to the licensing authority. While many felt having such legal requirements would not change their scope of practice, it would mean “increased vigilance in [my] assessment because you are making the call [choosing to report to licensing authorities] as opposed to the relying on the [geriatric] psychiatrist visit.” Frontline OTs were concerned that newfound legal responsibilities would influence perceptions of their role on health care teams (ie, they would assume legal responsibility for assessing medical risk and driving), as well as impact their treatment time. For example, one community-based OT stated:
It would increase the workload ... with the cuts we've had we're all pretty taxed. Our assessments are already so long ... usually an hour and a half for the initial assessment. So to potentially add another level onto that would be a bit heavy.
Many of the OTs interviewed wanted the licensing authority to be clear in their expectations of the profession, as one clinician stated: “If you are concerned about someone's driving, this is what an assessment would look like and the information we would need.” The geriatrician found that having a comprehensive understanding of the medical review process, and, in particular, the legal protections in place when reporting patients to the Ministry eased the “pressure” of being responsible for addressing medical fitness to drive.
A representative from the regulatory organization in the Canadian province that already had mandatory reporting for OTs indicated that 2-way communication between themselves and frontline clinicians had been critical to ensuring their new professional roles and responsibilities with reporting clients to the province's licensing authority were clear. In this jurisdiction, a partnership was struck between the professional regulatory organization and the transportation licensing authority. Clinicians were also assured of legal protections when reports were submitted in good faith and in accordance with legislation and licensing policies. Through this partnership, their shared aim had been to increase OT awareness of professional roles and responsibilities. OTs were offered avenues for confidential consultation and reporting of drivers as well as continuing education opportunities to improve their competence and confidence with screening medical fitness to drive. Despite these efforts, the representative acknowledged that it was not clear how clinicians had perceived this approach. The representative also highlighted the ongoing need for OTs to remain aware of emerging evidence and how it applied across practice settings. Although OTs in this province were able to successfully respond to legislative changes in reporting requirements, the transition required multidimensional strategies to facilitate understanding of how such changes apply in clinical practice.
Clinicians interviewed wanted to be ready to respond to upcoming changes in legislation, as they expected issues specific to medical fitness to drive will increase. Identified challenges included medical client factors (eg, impact of polypharmacy), ethical client factors (eg, implications to therapeutic rapport), scope of practice factors (eg, accountability to make a report), and clinical practice factors (eg, OT role on interprofessional teams). The challenges identified with regard to OT roles and responsibilities in this area of practice informed learning objectives for continuing education aimed at enhancing OTs' competency in addressing fitness to drive (see Document, Supplemental Digital Content 1, available at: http://links.lww.com/TGR/A4, which lists learning objectives). The identified challenges also informed recommendations for educational content specific to legislation, Ministry policies and procedures, standards of practice, and clinical competencies (see Document, Supplemental Digital Content 2, available at: http://links.lww.com/TGR/A5, which lists educational content). Preferred knowledge dissemination formats for educational content identified by OTs and informants included webinars, educational modules, workshops, online and in-person dialogues, walking through case scenarios with an expert clinician, print resources, and Communities of Practice (CoPs) in driving assessment and rehabilitation within national and provincial practice associations.
Addressing medical fitness to drive within a clinical context requires health care professionals to have a comprehensive understanding of not only best practices in assessment and intervention but also their legal and professional obligations.12 Results from the current project support previous findings where both physicians26 and OTs20 expressed concern about their competence in understanding legislation governing their role in relation to medical fitness to drive. Interview findings suggested a gap in OTs' awareness of legislation, licensing policies, and administrative procedures for medically at-risk drivers. Participants also highlighted ethical and professional concerns when addressing medical risk and driving, including client-therapist rapport. A dearth of context- and profession-specific resources that support clinical practice contributed to their heightened level of concern.
Educating clients on how health-related changes can impact their ability to perform meaningful occupations, such as driving, is critical to supporting the role of OT. Considering how larger systems (ie, health and transportation systems) can promote opportunities for occupational engagement among clients is equally important.48 Clinicians interviewed for this project varied in their level of understanding of licensing policies and procedures for medically at-risk drivers. Although the licensing authority used various dissemination strategies to improve knowledge uptake, the effectiveness of such strategies has not yet been formally evaluated. Kelly and colleagues49 emphasized that a more standardized approach for license renewal is needed for older drivers, which should be extended to include the medical review process. Such standardization can provide a starting point for educating health care professionals, including current and future OTs, on how to best address driving-related concerns with clients and ensure that appropriate supports are in place to facilitate their safe mobility, whether it be driving or other forms of transportation. Zur and Vrkljan19 recommended that entry-level OT programs include content specific to legislation and policies on medical fitness to drive with a particular focus on how such policies apply to clinical practice.
Jang and colleagues13 discussed the negative impact reporting drivers to licensing authorities can have on physician-patient relationships, which was echoed by all participants in the current project. Physicians have a responsibility to explain legislative requirements and administrative processes, including educating patients and families on how their illness can affect behind-the-wheel safety.27 With changes to legislation, this responsibility may be shared with OTs. While upcoming changes put the issue of reporting requirements front and center for OTs in the current jurisdiction, participants recognized the important role the profession already plays with addressing medical risk and driving.
The OTs interviewed shared how they independently sought out resources related to medically at-risk drivers to enhance their knowledge and support their practice. These resources ranged from best practice guidelines on fitness to drive for physicians (eg, CMA 2013 Driver's Guide44) to discussions with colleagues and other professionals. Goodman50 suggested that OTs develop CoPs to maintain practice competence within dynamically changing contexts. CoPs typically involve clinicians and researchers51 but could also include the perspectives of professional regulators as well as policy makers. For example, Wilding and colleagues51 noted that when various perspectives and methods of social learning are employed in CoPs, opportunities for professional development are enhanced. CoPs can support efficiency (ie, time management), networking capabilities, and mentorship.52 Within the proposed educational framework, a CoP will be part of a larger, multifaceted strategy to facilitate resource sharing, address clinical challenges, and provide a space for legislation and other policies to be disseminated and discussed.
Although Henderson and colleagues53 emphasized the need for OTs at tier 1 to understand the legal and regulatory requirements within their provincial contexts, legislative policies may not always be easy to access or interpret by frontline clinicians. OTs in the current project often relied on resources designed for physicians, rather than their own disciplines. Hence, there have been recent attempts by OTs to develop discipline-specific frameworks to support their practice. A recently published algorithm illustrates an OT-focused approach for clinical decisions specific to driver screening, assessment, and rehabilitation.53 Further evaluation of this algorithm is warranted to ensure its relevance beyond the jurisdiction in which it was designed. However, by including legislation and licensing policies and procedures as they influence OT roles and responsibilities when addressing medically at-risk drivers, this tool is the only framework to our knowledge that emphasizes the importance of understanding the impact of legislation within the OT practice context.
Given recent (July 2018) changes in reporting requirements for OTs in relation to medical fitness to drive in one North American jurisdiction, understanding how various factors can influence awareness of the profession's responsibilities and roles as they evolve in response to changes in legislation comes at a critical time for the profession. We anticipate similar changes are on the horizon for other jurisdictions. The KTA and UUC frameworks provide a guide through which to identify factors that influence how legislation is interpreted and correspondingly enacted in clinical practice. The process used in this study explored one context in which OTs practice (the user group) that highlighted their specific knowledge gaps and need for educational resources. Although our findings of education needs may be specific to this context, clinical practice concerns (eg, impact on client rapport) and access to practice resources are likely to be an issue in other jurisdictions. This study also highlights an opportunity to evaluate OTs' knowledge and practice competencies before, during, and after changes to legislation.
Interviewing clinicians and informants from various professional and clinical backgrounds elicited diverse perspectives. Although it was not possible to assess whether awareness of medical review processes was associated with access to key resources, findings indicated a dearth of tailored resources. The full scope of practice settings in which OTs encounter issues specific to medical risk and driving may not have been captured in the current sample. For example, accessing clinicians working in rural or remote practice settings could highlight similarities and/or variability in contextual considerations. Additional informants could also include members of the public (eg, older drivers and their caregivers), legal experts, or health care managers (eg, professional practice leads or department managers).
This study provided a unique opportunity to understand how changes in the legal context in one Canadian jurisdiction within which OTs are responsible for screening medically at-risk drivers has potential to affect practice implementation. Supporting OTs' understanding of their professional roles and responsibilities regarding medical fitness to drive is critical, given the impact legislation has on this area of practice. With recent changes to legislation in this jurisdiction, findings from this project confirm the imminent need to develop and disseminate tools and resources that support clinical practice. This project gathered data directly from users (clinical practice OTs) as well as other informants who share similar concerns specific to addressing medical fitness to drive. Findings will inform the development of an educational platform that is under development for OTs. Replicating such knowledge translation initiatives in other North American jurisdictions can ensure continuing education resources address context-specific responsibilities of OTs.
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