Older driver safety is, and will continue to be, an important focus for policy makers and health care practitioners as people over the age of 80 years, many of whom will continue to drive, represent the fastest growing segment of the Canadian population (Statistics Canada, 2010). In Canada, the majority of older adults are dependent on the private motor vehicle for transportation as they live in areas with few accessible, affordable transportation alternatives (Turcotte, Reference Turcotte2012). Concern about older drivers in North America stems from the observation of higher-than-average fatal motor vehicle crash (MVC) rates per kilometres/miles driven, especially for those over age 75 (e.g., Dellinger, Langlois, & Li, Reference Dellinger, Langlois and Li2002). However, there has been considerable debate in the literature about the validity of these observations (e.g., Hakamies-Blomqvist, Reference Hakamies-Blomqvist2006; Langford, Methorst, & Hakamies-Blomqvist, Reference Langford, Methorst and Hakamies-Blomqvist2006) and the use of mandatory age-based assessment of older drivers (Langford & Koppel, Reference Langford and Koppel2006; Siren & Meng, Reference Siren and Meng2012). Instead, there is growing support internationally for a more targeted approach to identifying those older drivers most at risk (Organization for Economic Co-operation and Development, 2001).

It is generally agreed that it is not age, per se, but associated medical conditions and/or treatment for these conditions that can adversely impact driving (Tuokko & Hunter, Reference Tuokko and Hunter2002). A number of medical conditions affecting both mental and physical health have been identified that affect driving abilities (e.g., American Association of Motor Vehicle Administrators, 2009; Canadian Medical Association, 2012). The most frequently reported chronic health conditions that have been shown to directly affect driving outcomes for older adults involve vision as well as cardiovascular, pulmonary, musculoskeletal, and neurological systems (Anstey, Wood, Lord, & Walker, Reference Anstey, Wood, Lord and Walker2005; Ruechel & Mann, Reference Ruechel and Mann2005). Arguably, cognitive decline and dementia are some of the most prevalent age-related conditions that are expected to have an impact on driving safety (Lloyd et al. Reference Lloyd, Cormack, Blais, Messeri, McCallum and Spicer2001; Man-Son-Hing, Marshall, Molnar, & Wilson, Reference Man-Son-Hing, Marshall, Molnar and Wilson2007), particularly as neurodegenerative diseases progress (Adler, Rottunda, & Kuskowski, Reference Adler, Rottunda and Kuskowski1999).

Physicians may be the first contact for many older drivers with these types of medical conditions. A number of studies within Canada, the United States, and abroad have examined physicians’ knowledge of, attitudes towards, and practices regarding issues relevant to older drivers. Although most physicians considered the assessment of fitness to drive of older people to be an important issue in their practices (Brooks et al., Reference Brooks, Dickerson, Crisler, Logan, Beeco and Witte2011; Jang et al., Reference Jang, Man-Son-Hing, Molnar, Hogan, Marshall and Auger2007; Ménard et al., Reference Ménard, Korner-Bitensky, Dobbs, Cascalenda, Beck and Gélinas2006), many did not consider themselves to be qualified to identify unsafe drivers and felt that their involvement in these assessments could adversely affect their relationship with their patients (Jang et al., Reference Jang, Man-Son-Hing, Molnar, Hogan, Marshall and Auger2007; Marshall & Gilbert, Reference Marshall and Gilbert1999; Ménard et al., Reference Ménard, Korner-Bitensky, Dobbs, Cascalenda, Beck and Gélinas2006). Moreover, in all studies, at least some physicians surveyed were unaware of or did not refer to professional guidelines concerning assessment of fitness to drive. Depending on the jurisdiction and area of practice, many were unsure of their legal responsibility to report unsafe drivers. Even when physicians reported being knowledgeable about reporting requirements and appropriate approaches to assessing fitness to drive, there was marked inconsistency as to the content of the assessment, particularly concerning cognitive functions (Wilson & Kirby, Reference Wilson and Kirby2008).

Given the lack of consistency in whether and how physicians address the issue of older driver safety, it is imperative that all health care practitioners working with older adults be cognizant of the types of medical conditions that can influence driving and ways to address these concerns with those in their care. In particular, those professionals most involved in assessment and rehabilitation of older adults with mental health disorders, including cognitive impairment and dementia, need to be particularly attuned to age-related conditions and disorders that may affect driving. Moreover, in some jurisdictions, clinical psychologists, like physicians, have a duty to report unsafe drivers to the local authorities and need to know if and when to have discussions about driving safety and how to provide support and assistance with driving decisions. In some jurisdictions, it is mandatory to report people with cognitive impairment or a diagnosis of Alzheimer’s disease (Reuben & St. George, Reference Reuben and St. George1996). This is not the case in Canada; instead, provinces may impose a duty on, or give discretion to, certain health care professionals to report patients who drive when it may be dangerous to do so (Tuokko & Hunter, Reference Tuokko and Hunter2002). The determination of when to report relies on subjective judgement of such individuals and the reporting requirements imposed on various branches of the health care profession differ by province. In Newfoundland, Prince Edward Island, Northwest Territories, and Nunavut, the duty is restricted to medical practitioners (i.e., typically referring to a person qualified as a member of a College of Physicians and Surgeons). In Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, and the Yukon, the duty is imposed upon medical practitioners and optometrists. In British Columbia, the duty is imposed upon psychologists, optometrists, and medical practitioners. In Nova Scotia, medical practitioners and registered psychologists are the only professionals with a duty to report.

The present study was an exploratory investigation of the knowledge, attitudes, and practices of registered psychologists from across Canada with respect to older driver safety concerns. Specifically, the study addressed: (1) attitudes and beliefs about the determination of fitness to drive; (2) knowledge of jurisdictional reporting requirements and policies and programs relevant to older driver safety; (3) knowledge concerning older driver risks; and (4) clinical practices of psychologists when evaluating for fitness to drive. This was a descriptive study using an online survey to examine the knowledge, attitudes, and practices of clinical psychologists in Canada to enhance our understanding of the roles that clinical psychologists play in identifying unsafe older drivers and their perceptions concerning older driver safety issues.

Method

Participants

Provincial bodies responsible for registration of psychologists and the Canadian Psychological Association were approached to contact registered psychologists in Canada. A description of the study was provided with a request that the survey be sent to their members or that they provide contact information for potential participants. Access to contact information for licensed clinical psychologists was only provided by one province. All other provincial bodies acted as mediators, forwarding our request to their members. Only Nunavut did not take part in this process. Given the process adopted by most jurisdictions, we were limited in the techniques we could use to maximize the response rate. Potential participants were directed to a URL link to complete the study. They were assured of their anonymity and that their information could not be linked to their email address. Only those individuals who answered “yes” to each of the following criteria were eligible to take part in the study:

1. (1) Are you a practising clinical psychologist at least two days per week?

2. (2) Do some of your clients hold driver’s licenses?

3. (3) Do you see older adults (over age 60) who could potentially be at risk due to their driving behaviours?

Measures and Procedure

Our online survey was based on mail-out questionnaires used in previous research to assess the knowledge, attitudes, and practices of physicians (Jang et al., Reference Jang, Man-Son-Hing, Molnar, Hogan, Marshall and Auger2007) and modified to pertain to clinical psychologists. In developing the content of their measure, Jang et al. (Reference Jang, Man-Son-Hing, Molnar, Hogan, Marshall and Auger2007) reviewed the literature and consulted with family physicians, occupational therapists, geriatricians, and rehabilitation specialists with expertise in driving assessment.

Our online survey contained 68 items (see Table 1). Responses for most of the questions were on a 5-point ordinal scale (i.e., strongly agree, agree, neither agree/disagree, disagree, strongly disagree) with one response category available for participants to express either no opinion or lack of knowledge. Participants were requested to provide a “single best” response. The survey was divided into five sections: (1) attitudes and opinions towards determining fitness to drive; (2) frequency of practices or activities pertaining to driving assessment; (3) knowledge of the driving policies and programs in the participant’s home province; (4) clinical practices when evaluating fitness to drive; and (5) demographic information pertaining to the practice. Those meeting eligibility criteria and volunteering to take part were informed that by completing the online survey, they agreed to have their data included and used in the study. Participants could end their participation in the study at any time and their data would be deleted. Prior to the study being conducted, the University of Victoria human research ethics board approved the project in accordance with the Canadian Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans.

Table 1:

Online survey

Please provide us with any additional comments that you would like to make about any of the topics raised or the survey itself.

Thanks very much for your participation!

Note: Your participation is voluntary. By completing this online questionnaire you are indicating that you agree to have your answers included with the dissemination of our findings.

Results

An overview of the characteristics of the 84 eligible respondents who completed the survey is shown in Table 2. Even though the survey was distributed nationwide, over 40 per cent of respondents were from British Columbia. The majority of the respondents were male, practicing in general private-practice settings in communities with populations larger than 100,000 residents. Tables 3, 4, 5, and 6 present the frequency of responses for items on the survey. The distributions of responses for each item were compared to the null hypothesis (i.e., occurred with equal probability or were normally distributed) using non-parametric statistics (i.e., one sample chi-square or one-sample Kolmogorov-Smirnov tests) using version 23 of IBM SPSS Statistics software (2015). The null hypothesis was rejected for each of the items on Tables 3, 4, 5, and 6.

Table 2:

Characteristics of clinical psychologist respondents (n = 84) with clients over age 60 who may have been at risk for unsafe driving practices

^a Two respondents chose not to answer this question, and valid percentage sums to greater than 100% because participants could answer “all that apply”.

Table 3:

Frequency of responses for questions concerning attitudes and beliefs about the determination of fitness to drive*

* The null hypothesis was rejected for each item.

Table 4:

Response percentages for questions concerning jurisdictional reporting requirements, policies, and programs relevant to older driver safety*

* The null hypothesis was rejected for each item.

Table 5:

Percentages of responses concerning perceived risks for older drivers

* The null hypothesis was rejected for each item.

Table 6:

Self-reported clinical practices regarding the information collected by psychologists when evaluating for issues relevant to fitness to drive*

* The null hypothesis was rejected for each item.

^a Respondents who had never assessed a patient’s fitness to drive were instructed to endorse the N/A (not applicable) option.

Table 3 provides the frequency of responses to questions concerning attitudes and beliefs about the determination of fitness to drive. Approximately half of the respondents reported that assessing fitness to drive was an important issue in their practice and that they believe psychologists are the most qualified professionals to identify clients with cognitive impairment who are unsafe to drive. Yet only 20.2 per cent reported feeling confident in their abilities to do so. Over 75 per cent stated that they would benefit from education concerning evaluation of fitness to drive while almost 70 per cent agreed that a clinical screening instrument to aid in identification of those at risk for accidents would be useful in their practice. Most of the respondents agreed that reporting clients with unsafe driving practices might negatively impact the psychologist-client relationship (60.7%), and that negative consequences might be experienced by clients who have had their license revoked (77.4%) and by their families (73.8%).

Table 4 provides the distribution of responses concerning jurisdictional reporting requirements, policies, and programs relevant to older driver safety. A large percentage of respondents did not know if programs on safe driving strategies for older adults were available in their communities free of charge (75%) or for a fee (65.5%). Over half of the respondents were not clear as to the procedures used for evaluating potentially unsafe drivers by the provincial agency responsible for motor vehicle licensing (60.7%) and did not know whether legislation in their provinces regarding reporting unsafe drivers provided protection from being sued for the person doing the reporting (56%). Similarly, over half of the respondents did not know whether restricted licenses were available in their provinces (51.2%) and had difficulty finding centres/specialists to assess fitness to drive (53.6%). Less than half of the respondents acknowledged that psychologists in their jurisdictions were required to report unsafe drivers (46.4%), knew the steps to take in reporting unsafe drivers to the authorities (46.4%), and were aware whether centres or organizations, other than the provincial agency responsible for motor vehicle licensing, were available in their communities (44%). Over 60 per cent reported feeling that appropriate driving assessment tools to assess driving competency of older adults were lacking.

It is apparent from Table 5 that most respondents perceived there to be increased crash risk per mile/km driven for very old drivers (i.e., over age 80 years) and for teenagers (58.4%), acknowledging that higher crash risk is related to ability and not age, per se. Moreover, most respondents acknowledged that medication use contributes to this increased risk per kilometres/miles driven (60.8%) and that psychologists should inquire about the driving ability of older adults more frequently than with middle-aged drivers (56.0%).

Of particular note in Table 5 is the percentage of respondents indicating that they have never conducted assessments relevant to fitness to drive as indicated by endorsing the N/A option (over 40%). Of those assessing for fitness to drive, most enquired about medical recreational alcohol and drug use (57.1%) and a variety of factors relevant to medical status (e.g., medical history, 57.4%; medications, 57.2%; current psychiatric symptoms, 57.2%). Current cognitive status was evaluated somewhat less frequently (47.1%).