Still in first gear: Exploration of barriers for implementing driving cessation support

Driving cessation is a major life transition; lack of support in this process may lead to deleterious outcomes in terms of physical, mental and social well‐being. Despite approaches to driving cessation being developed, their integration into ongoing geriatric clinical practice has been slow.


| INTRODUCTION
A range of health conditions may trigger driving cessation in later life.People who cease driving without support are at greater risk of premature admission to aged care, declines in both physical and mental health, negative changes to their sense of identity and their autonomy, fractured relationships with spouses and family and increased social isolation. 1,2Systematic reviews and qualitative work on the impact of driving cessation point to: the increase in risk for depression following driving cessation 3 ; difficulties enacting driving cessation support for people living with dementia 4,5 ; and the perceived high value of implementing individualised supportive approaches with respect to identity and emotional well-being. 6riving cessation often follows a process guided by law and local policy in relation to driving safety and 'medical fitness to drive' guidelines (e.g.Austroads 7 ).This may involve formal on-and off-road assessments, medical or performance assessments, and discussion with the healthcare team, family and driver.Most people cease driving without any attempt at a supported transition to alternative forms of transport.This lack of formal support may foster avoidance of approaching the issues, be it from a family or health professional perspective.
Globally, raising the issue of driving cessation is widely recognised as a difficult aspect of clinician practice with clients, families and health-care professionals characterising this task as challenging. 8Thus, planning, support and timely cessation may be delayed or avoided because of lack of health professional confidence, or to avoid conflict.However, intervention in the lead-up to driving cessation may change the person's trajectory towards reaffirmed autonomy and confidence in maintaining their activities and engagement. 9hile there are now evidenced resources to assist with driving cessation (e.g.Liddle et al. 10 ), there is recognition that there are still considerable barriers to routine consideration of driving cessation in practice. 11In promoting consideration and use of evidenced approaches to managing driving cessation, understanding key stakeholder views is vital.In the current study, a range of health-care implementation stakeholders' views were sought on barriers to the adoption of driving cessation intervention programs in public, private and community practice.

| METHODS
A qualitative descriptive exploration of Australian practices and considerations with people experiencing driving cessation was undertaken.Open-ended questions (see Appendix S1) were framed to capture workforce, clinical practice and reimbursement variables within public, private and community health-care settings.Responses were sought through online survey forms, emails and interviews, and circulated via professional networks.Ethics approval was obtained from the Human Ethics Committee at the University of Queensland (2022/HE000495); all participants gave informed consent prior to inclusion in the study.
Analysis was by inductive content analysis. 12Familiarisation with responses, consideration of responses across questions, constructing key areas reflecting practice, needs for practice and recommendations was undertaken.Initially, 12 content areas across practice approaches, across complexity of driving cessation experiences and unmet needs, barriers and enablers to changing practice were identified.Initial coding was conducted by JL and checked by NAP and AS.Key areas were synthesised through reflexive discussion of the team into six key areas-two being key understandings of driving cessation and four reflecting proposed actions to support practice.

| RESULTS
Surveys (N > 100) were sent to members of peak allied health bodies, primary health-care networks and public and private community outreach health services in Australia.Twentynine completed surveys were analysed from participants in four states (Queensland [24], New South Wales [2], Victoria [2] and South Australia [1]), who ranged in age from 30 to 65; 86% identified as female.They reported providing clinical services to a range of areas (72% major cities, 72% regional and 21% remote; with multiple options possible) and settings (public health settings 31%; private health including private practices 38%, aged care 7%; and other, including government/not for profits 24%).Most self-identified crossdisciplinary roles rather than specific disciplines.
Participants described how they had engaged with driving cessation-related concerns including directly seeing clients with driving cessation needs (including unmet needs); referring clients for driving assessment; delivery of driving cessation supports; formal driving assessments, research and personal experiences.In describing their experiences and perceptions of driving cessation supports, participants identified that an understanding of driving cessation and optimal driving cessation supports was required.Key points are highlighted below.

| Understanding driving cessation
Responses indicated that driving cessation and adjustment to it reflected a process, rather than a single event.

Practice Impact
Implementation of driving cessation supports requires multifaceted approaches that consider contextual barriers as well as creative, cooperative approaches stretching across settings and systems.Such supports can mitigate the negative impact of unsupported driving cessation.process, with careful timing of interventions and potential ongoing availability.Responses indicated the need to build general awareness of the issue, discuss current and future implications at key clinical times (diagnosis, assessment of performance facets or driving), obtain support when people are ready for it or as challenges arrive and iteratively improve what is currently available.

| Any approach will require multiple facets and players
In highlighting the range of ways people may improve outcomes of driving cessation (from raising awareness of issues, referring for supports or directly providing support and interventions), respondents indicated a wide range of people who should be involved in driving cessation, including people who initiate driving-related discussions or assess relevant performance components.More broadly, the entire medical, nursing and allied health team could engage with driving cessation.In some settings, this reflected current practice.Others indicated that while it was not consistently happening in current practice, health professionals engaging in discussing driving cessation should be discussing supports and initiating referrals to them accordingly.
Importantly, respondents indicated the need for the driver, family, friends and the wider community to be engaged with the issue of, and supports for, driving cessation.They also indicated that within health settings the whole team, including, for example, reception staff, should be informed and engaged.Others who could be involved included licensing bodies, police, care providers, support and peer workers and case managers.Transitions in health care, cross-organisation and funding body contexts were also raised as important considerations.
Informing people about a driving cessation intervention was also perceived as necessary-from general population awareness to delivery in contexts that were accessible and acceptable to particular clients.All respondents in clinical settings indicated awareness of driving cessation interventions and willingness to refer or implement programs if they were available.However, some identified that within current funding models or parameters of service delivery, driving cessation support was not their core business, even when they could see the unmet needs.

| Recommended approaches for supporting implementation
Participants identified four key approaches (practices, navigation of barriers and potential solutions) to support the implementation of driving cessation support.These are summarised, along with components and example quotes, in Table 1.These included the need to consider complexity in terms of managing timing, different clinical contexts and supporting relationships and emotional responses.Participants indicated a need for knowing and showing the outcomes in terms of clearly communicating the benefits and values to different stakeholders in different formats that might resonate (e.g.statistics and stories).Importantly, where supporting adjustment to driving cessation aligned with personal, disciplinary or organisational values, this was seen as supporting implementation.The recognition of known barriers was identified with advice to address each individual issue in managing systemic barriers.These included addressing workforce issues, funding models, the effort required for initiating a new program, and supporting its continuation in practice.Finally, participants indicated the importance of not doing it alone, and instead developing processes, expertise-based telehealth hubs, industry and community supports to work collaboratively on providing access to programs and addressing driving cessation across settings.

| DISCUSSION
This study provided initial insights into considerations for implementing driving cessation supports for older people into practice.There was broad awareness of driving cessation, the benefits of interventions and the challenges across settings.The characterisation of driving cessation as complex and process-based suggests that simple, brief, one-off resources are unlikely to support driving cessation well.Responses indicated that implementation would require navigating multiple settings and contexts, as well as involving multiple stakeholders including retired drivers, families and communities.The identified complexity means that co-adaptation of interventions, resources and programs for local relevance (including content, transportation and funding) will be needed for implementation.

| Limitations and future directions
This study involved a small group of participants who, while representing a range of regions and settings, volunteered to participate, potentially due to interest.The findings add to the current literature in terms interrogating systemic barriers and facilitators from the view of those residing within the extant system.Future research should expand the exploration of implementation issues by including a more diverse population, employing longer-term engagement in co-adapting approaches and measuring the identified barriers and outcomes of interest.
T A B L E 1 Approaches for supporting implementation.

Considering complexity
Driving cessation is personally, and contextually complex.Interventions require consideration of emotional and practical considerations.Implementation requires consideration of cross-organisational, crossdisciplinary, funding body and local contexts, or support will be unavailable or inconsistent A Raising awareness, support planning and ongoing engagement.B Finding the right context, right time in the process.C Managing and support relationshipsincluding overcoming avoidance.
Often our doctors don't raise driving cessation till just before discharge as they don't want this issue to impact on their rehab journey, so timing would be an issue for many inpatients.
[19] I have found that the earlier the better to allow the person time to grieve as well as practice alternatives.
[31] I think the tricky issues are mostly around people choosing to participate, [there] are complex emotions around ceasing driving (grief, sense of failure, loss, shame, change in identity), during this time people are in a vulnerable place and as such the idea of meeting new people, interacting with others and on the topic that is causing them pain is very challenging.[10]   Knowing and showing the outcomes Overcoming the reluctance to initiate and continue driving cessation support requires clearly arguing the benefits in ways that resonate with individuals, teams and systems.This needs evidence of effectiveness, stories of acceptance and impact and processes that ease access.A key identified issue was a need to demonstrate value and impact to the multiple stakeholders involved in the decision-making, practice and process of transitioning to driving cessation.Moreover, the costs and benefits of the provision of supports across contexts need to be clearly articulated to establish and ensure a sustainable funding model.At the same time, delivery models need to be adaptive and responsive to funding limitations and funding bodies' expectations.
Add in initial assessment sheet a tick box to refer yes/no in IADL section.[32]Because the patients who would be suitable come sporadically, might be hard … whoever delivers the program to remember what is involved.Maybe start with one facilitated telehealth session with local social worker and central [driving cessation support] provider (who does this work regularly) and the patient.[22]Apersonwith a public profile willing to share their having faced the same problem and given up driving.Strong engagement from RACQ and other motoring organisations, insurers and others with a vested interest in safe driving or driving alternatives e.g., taxis/uber.[11]