Defining OT Roles in Driving
Elin Schold Davis
The role of the occupational therapy assistant is not explicitly addressed in this article because this role relative to driving is being explored by the Commission on Practice and others. Generally, occupational therapy assistants interested in driving should use the same practice guidelines that they apply to other areas.
My wish for the future: When the question "Do you address driving?" is posed to occupational therapists, the answer will be "Yes, we do."
All occupational therapists possess the basic skill set necessary to help clients achieve and maintain community mobility, an instrumental activity of daily living (IADL) that includes driving. Driving requires readiness, skill, ability, and competence--activity demands that are addressed across practice areas. For instance, occupational therapists working with pediatric clients include intervention strategies that address driving activity demands and performance skills needed to optimize the possibility of driving, even at an early age when the child begins to play with toys that can be driven. Practitioners in the area of mental health must consider safety and competence in community mobility, which may include driving. Rehabilitative occupational therapists need to weave clients' goals for driving into the fabric of the intervention.
The American Occupational Therapy Association (AOTA) has identified driving as one of the top 10 emerging practice areas for the new millenium.1 Many opportunities exist for occupational therapists interested in the spectrum of activities associated with community mobility, including driving. Several different professional roles are available within driving that represent increasingly complex levels of specialization. At each level, therapists draw on their basic occupational therapy skills. But as roles progress, occupational therapists will require more specialized skills and encounter higher expectations. As a result, not all occupational therapists will possess the skill set necessary for all roles related to driving. Therapists who are interested in driving must decide at what level to become involved. Individual level of interest, practice setting, community resources, and educational opportunities are important factors in determining the degree to which each therapist will be able to build upon his or her existing practice skills.
Defining driving roles is a way to understand the progression of occupational therapists' knowledge and skill sets pertaining to driving. The levels of specialization support the need for training and for developing appropriate referral pathways to specialists. As occupational therapy programs expand to better address driving needs, it will be essential to clearly understand the specialized skills required for evaluating competence on the road, installing assistive technology in vehicles, teaching novice drivers, or retraining drivers. Defining the training required for specialization will assist clinicians who might simply be handed vehicle keys by program or facility managers and asked to start evaluating clients for driving. Above all, understanding and respecting driving roles within the profession will allow occupational therapists to better serve their clients' needs. This article focuses on three driving roles within occupational therapy: occupational therapy generalist, occupational therapist with advanced training, and driving specialist (certification and specialized training) (see Figure 1*).
Occupational Therapy Generalist
The first role is that of the occupational therapy generalist. All occupational therapists, across all practice areas, may have clients whose disability affects driving or the potential to drive. Client factors of muscle and movement functions and visual performance, and the performance skills of strength, coordination, temporal organization, and adaptation are also the subskills of driving. Occupational therapists practicing with clients of driving and pre-driving age should have general knowledge and understanding of how performance and process skills relate to driving. In fact, clients often identify driving as one of their most important IADL. At the generalist level, practitioners evaluate clients' driving subskills and consider the implications of the evaluation. In other words, occupational therapy generalists are responsible for asking clients whether driving is an occupational performance concern or a goal for them. Generalists do not evaluate driving competence; thus, no specialized or supplemental driving training is required of the generalist. Instead, occupational therapy generalists should be knowledgeable in two additional areas: driving programs and mobility resources available within their care systems or their communities. They should exercise the same clinical reasoning skills with driving as they do when evaluating clients engaging in other areas of occupation.
Occupational Therapist With Advanced Training
The second driving role is that of the occupational therapy generalist who has obtained additional training in the area of driving, such as continuing education courses. In addition to looking at driving concerns or goals, therapists at this level can evaluate the integration of and train clients in specific subskills associated with driving. Therapy interventions can be tailored to restore or modify performance skills, performance patterns, or activity demands that could affect driving. A client may be referred by physicians, driver rehabilitation specialists, state licensing agencies, or others to this mid-level therapist for intervention following an on-road driving assessment that identified problem areas. Occupational therapists with more specialized training can guide their facilities or programs in establishing protocols for addressing driving and transportation concerns with the specific client populations they serve. Counseling and advising clients about driving concerns and mobility alternatives is a more advanced role that takes driving into its overarching domain of community mobility.
Occupational Therapist With Specialized Training
The third role in this continuum of specialization is that of the occupational therapist who has obtained specialized training and expertise in the broader knowledge base and skill set of driving. An example of one such specialization is the certified driving rehabilitation specialist (CDRS) available through the Association for Driving Rehabilitation Specialists (ADED). Training in driver's education may also be pursued. Within this highly trained specialist role, the levels of training and knowledge differ from those of other occupational therapists. These therapists have expertise in targeted clinical assessment, on-road assessment, driver training for novice drivers, and driver retraining. In addition, they may be able to prescribe and train clients in the use of appropriate adaptive driving equipment (e.g., hand controls, computerized systems, etc.), or they may work with vendors who perform such services. Occupational therapists at this level require broad, expansive knowledge of driving components such as assessments, driver education, novice driver education, equipment prescription, installation, and training. These therapists are able to establish protocols to determine driving competence and appropriate training as well as provide information and counseling for pursuing transportation alternatives.
Some occupational therapists avoid driving in their practice because they fear that they will be asked to evaluate the client's ability to drive safely. Evaluating driving competence is a task for a driving specialist with advanced training, such as a CDRS. Only occupational therapists who undergo advanced training and certification have the ability to make this determination.
Many options exist for occupational therapists who want to become involved with driving at the general and middle levels. At the generalist level, therapists can obtain driving and mobility resources from national, state, and local sources such as their local area agencies on aging, state motor vehicle authorities, the National Highway Traffic Safety Administration, and the American Automobile Association. Occupational therapists who want training beyond the generalist level can complete continuing education courses offered through AOTA, ADED, and other organizations. In addition, AOTA maintains the Driving/Driver Rehabilitation Listserv, where therapists can share experiences and learn from one another about driving resources, research, conferences, and educational opportunities.
"The Profession" for Driving Concerns
Historically, some driving programs have had difficulty maintaining a client base. Clients who want or need driving assistance may face cost barriers because Medicare does not routinely reimburse for driver rehabilitation and training, and many people cannot pay for the services themselves. In addition, many people referred for driving services choose not to participate for fear of losing their driver's licenses. With the expectation that all occupational therapists will be a part of the continuum of professional expertise available to help drivers, the need for therapists to maintain a client base relative to driving and to establish relationships with driver educators will grow. Defining driving roles will be essential to developing a comprehensive progression of services that would likely include a broader referral base.
Occupational therapy needs to distinguish itself as "the profession" to go to for driving and mobility concerns. Driving and mobility contribute to many clients' independence and quality of life. Occupational therapy can play an important role in helping people deemed unsafe to drive address that decision and to help them maintain community participation without getting behind the wheel. However, to help clients meet their community mobility goals, occupational therapists need to get physicians and other referral sources to associate driving with occupational therapy.
Many physicians are not aware of the options available to persons who have driving difficulties or concerns. Often, they also are unaware of occupational therapy's role in helping address clients' driving and mobility needs. A guide to best physician practices scheduled to be published by the American Medical Association early this year will assist in this gap in communication and knowledge. In the meantime, occupational therapists need to increase communication with physicians about driving options. However, physicians do not necessarily need to understand the driving roles within the occupational therapy profession; occupational therapists do. Occupational therapists themselves can then refer clients to the most appropriate specialist within their program or community.
Driving and community mobility has emerged as a practice area with tremendous potential for occupational therapists to help clients engage in occupations to support participation in context(s) while increasing the scope and visibility of the occupational therapy profession.2 However, occupational therapists must clarify and respect the skills and expertise needed for this specialized area of intervention. To better serve their clients, all occupational therapists should approach driving as an IADL. They should also recognize that driving encompasses a range of responsibilities and expectations. Accepting a role in driving does not mean therapists must only evaluate driving competence. Occupational therapists of varying levels of driving expertise can address the broad IADL of mobility and determine appropriate action based on their progressive roles, from initially recognizing concerns at the generalist level to evaluating driving competence at the most specialized level.So the next time an occupational therapy clinician is asked, "Does occupational therapy address driving?" the answer will be, "Yes, we do, and let me direct you to the most appropriate therapist."
1. American Occupational Therapy Association. (2000). Top 10 emerging practice areas to watch in the new millennium. Retrieved October 22, 2002, from http://www.aota.org/nonmembers/ area1/links/link61.asp.
2. American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609Ð639.
Elin Schold Davis, OTR/L, CDRS, has been an occupational therapist for more than 20 years and has specialized in the area of brain injury and cognitive impairment for 15 years. She became involved in driving as she struggled to address driving competence issues in clients diagnosed with mild to moderate brain injuries. She is the coordinator of Multiservice Outpatient Rehabilitation and has a clinical practice in the Brain Injury Clinic at Sister Kenny Rehabilitation Services in Minneapolis, Minnesota. She is also coordinator of the AOTA Special Interest Section Driving Network Listserv.
For More Information
American Automobile Association Foundation for Traffic Safety
1440 New York Avenue, NW, Suite 201
Washington, DC 20005
AOTA Special Interest Section Driving Network Listserv
Go to www.aota.org, click on AOTA Listservs, then on Driving/Driver Rehabilitation.
Association for Driver Rehabilitation Specialists
711 S. Vienna Street
Ruston, LA 71270
800-290-2344 or 318-257-5055
National Highway Traffic Safety Administration
Older Driver Screening and Evaluation (AOTA Online Course)
For information, go to www.aota.org and click on Continuing Ed, then Online Courses.
Transportation Research Board
500 Fifth Street, NW
Washington, DC 20001