Assessing fitness to drive after stroke A survey investigating current practice among occupational therapists in Ireland

Purpose – The assessment of fitness to drive after stroke is an emerging area of occupational therapy practice in Ireland. Despite this, little is known about occupational therapists’ evaluation practices, and there are no internationally agreed clinical guidelines to inform best practice. The purpose of this paper is to investigate occupational therapy evaluation practices for fitness to drive after stroke in Ireland. Design/methodology/approach – This is a cross-sectional study design targeting occupational therapists working with people after stroke using an online survey. Summary and descriptive statistics were used to analyse the returned surveys . Findings – In total, 47 occupational therapists participated. Off-road driving assessment was completed by 68 per cent of respondents. Functional assessment and non-driving-specific assessments were most widely used and perceived to be the most useful in informing the off-road assessment. A total of 89 per cent referred clients for on-road assessments; however, some referred without first completing an off-road assessment. The therapists who completed formal post graduate education/training in driving assessment reported greater confidence and competence in their skills and ability to assess fitness to drive. A vast majority of participants agreed that clinical guidelines regarding best practice in this area would be beneficial. Research limitations/implications – A majority of occupational therapists are assessing fitness to drive after stroke in Ireland with non-driving-specific assessments and functional observations; however, there are many gaps and wide variations between services. Education/training in evaluating fitness to drive after stroke is recommended. The development of clinical guidelines to inform practice would facilitate a consistent approach nationally. © Aisling Helen Stack, Orla Duggan and Tadhg Stapleton. Published in Irish Journal of Occupational Therapy. Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http:// creativecommons.org/licences/by/4.0/legalcode IJOT 46,2


Introduction
Stroke is the third leading cause of death in Ireland and the leading cause of acquired disability and impairment, with over 7,000 people hospitalised post stroke each year (Irish Heart Foundation, 2015).Stroke has the potential to cause multiple impairments affecting cognition, perception, vision, visuo-spatial skills, hearing, sensorimotor skills and behaviour that may negatively impact on the person's ability to return to driving (Marshall et al., 2007).Aside from the obvious physical and sensory deficits which can occur post stroke, it is often the higher level thinking skills such as awareness and insight, executive functions, judgment, problem solving and reasoning that can result in concern regarding returning to driving or driving cessation (Stapleton et al., 2015;O'Dwyer and O' Neill, 2007).Research has highlighted varying levels of return to driving after stroke internationally.An Irish patient and carer survey found that 29 per cent of their sample of 139 people ceased driving after stroke (Irish Heart Foundation, 2008).Some US-based studies with slightly larger samples of stroke survivors reported a much higher rate of cessation of driving after stroke; results suggesting 70 per cent of their sample ceased driving (Aufman et al., 2013;Fisk et al., 1997).

Importance of driving
Driving is an important instrumental activity of daily living (IADL) (American Occupational Therapy Association, 2014), and for many people, driving may be considered as an "occupation enabler", providing the means by which people can maintain their social engagement and community interactions (Stav and McGuire, 2012).While stroke is not exclusive to older adults, the risk of stroke does increase with age, and studies have shown that driving is considered an important and meaningful IADL among older people (Dickerson et al., 2012;Fricke and Unsworth, 2001).Studies have demonstrated that driving status post stroke has a strong influence on community integration, with poorer community integration noted among the post-stroke non-drivers (Griffen et al., 2009).Those who do return to drive post stroke often report changes to their pre stroke driving patterns and behaviours, typically reduced driving frequency and exposure, as well as avoidance of driving or allowing others to drive instead (Fisk et al., 1997;Finestone et al., 2009).In addition to changes in transport and travel activities following stroke as reported by stroke survivors, research on long-term unmet needs after stroke has highlighted stroke survivors need for information and advice with regard to driving post stroke (McKevitt et al., 2011).Therefore, driving after stroke is an important consideration that needs to be addressed within stroke rehabilitation programmes.The focus of these interventions should not just be with regard to assessing fitness to drive but also on providing information and advice about driving and transport options post stroke.Occupational therapy is perhaps a well-placed profession to take a lead role in addressing driving and transport issues across the continuum of care after stroke.

Role of occupational therapy
The American Occupational Therapy Association (2014) have outlined that driving and community mobility are domains of concern for occupational therapy practice.There has been considerable research on assessing fitness to drive completed by occupational therapy Assessing fitness to drive after stroke researchers in recent years.Dickerson (2014) has emphasised that the "generalist" occupational therapist has an essential role to play in the continuum of assessment of fitness to drive.In addition, her research has highlighted the importance for all occupational therapists to view driving as an IADL and addressing driving should be part of routine occupational therapy practice (Dickerson et al., 2011;Dickerson andBédard, 2014a, 2014b).Indeed, others have stated that occupational therapists have an ethical obligation to address driving and community mobility (Hunt and Yarett Slater, 2012).Occupational therapists have the knowledge to understand how illness or injury impact on function, as well as the ability to analyse activity and understand the underlying component skills that facilitate execution of activity or occupations.There is a need for occupational therapists to apply these generalist skills to the complex task of driving just as they would for any other ADL or IADL task.In stroke rehabilitation, occupational therapists typically assess components such as cognition, perception, executive functions, as well as physical and sensory abilities.
Occupational therapists have the skills to determine whether the level of deficit in any of these component areas may potentially exceed the threshold for safe driving.Equally, therapists have the skills to determine when a good recovery has occurred with little or no residual deficit, indicative of a person who could perhaps return to drive without the need for specialised on-road testing (Dickerson, 2014;Stapleton et al., 2015).This contribution of occupational therapy in the clinical screening process after stroke to stratify the patients into those who are definitely unfit to drive, those who are fit to drive with no further assessment needed, and those who need to complete a more specialised on-road assessment within the Irish context of practice has been outlined previously (Stapleton et al., 2015;Tan et al., 2011).The distinction of occupational therapy levels of expertise in driving assessment has been highlighted by several occupational therapy researchers; from the generalist level of expertise possessed by all qualified occupational therapists, to the level of expertise facilitated by the completion of specialised post graduate education and training (Dickerson, 2014;Korner-Bitensky et al., 2007;Unsworth, 2007).However, everyday occupational therapy practice may not always reflect the advancements made within the literature.This was highlighted in a study where only 34 per cent of Canadian occupational therapists identified driving as a problem post stroke when presented with a specifically designed case vignette that contained a reference to driving (Petzold et al., 2010).

Guidelines
The National Clinical Guidelines and Recommendations for Stroke and Transient Ischaemic Attack (TIA) (Irish Heart Foundation, 2010) highlights the need to address driving among clients after stroke and TIA.The guidelines state that particular emphasis should be placed on the identification of any stroke-related impairment that may impact on the person's fitness to drive, particularly those that may result in a recommendation to cease driving.The Irish guidelines, in line with international research in the area (Korner-Bitensky et al., 2005;Unsworth et al., 2005), recommend that a comprehensive assessment of fitness to drive should comprise of a two phased approach consisting of a clinic-based assessment usually conducted by an occupational therapist and if required, an on-road test conducted by a suitably qualified on-road driving assessor.Assessment practices vary across jurisdictions.However, the literature identifies the role of occupational therapy in both the clinical off-road phase of testing and in the on-road phase of assessment (Unsworth, 2007).In the Irish context of practice, the occupational therapy contribution is mainly confined to the clinicbased off-road component of assessment.However, recent developments in individual services in Ireland have introduced the occupational therapy role within the on-road component of assessment similar to international practice.
The Irish Medical Fitness to Drive Guidelines, "Sláinte agus Tiomáint: Medical Fitness to Drive Guidelines" (National Office for Traffic Medicine, 2017) provides general guidance on fitness to drive after stroke.The Irish guidelines mirror international guidelines from Australia and the UK (Austroads, 2017;Driver & Vehicle Licencing Agency, 2018) with driving not permitted for four weeks after stroke and return to driving permitted after this period pending satisfactory recovery of function.The Irish guidelines highlight areas of particular concern following stroke such as impairments of limb function, cognition, visual fields, visual neglect and inattention deficits that may negatively impact fitness to drive.However, the guidelines are not prescriptive on what or how exactly that determination and decision of fitness to drive is reached, or what should be assessed in a fitness to drive assessment after stroke.For the occupational therapy clinic-based off-road assessment of fitness to drive, there is no one gold standard approach.

Assessment tools
International research has highlighted various standardised assessment tools typically used by occupational therapists in the off-road component of assessing fitness to drive (Cammarata et al., 2017;Dickerson, 2013;Unsworth et al., 2005).A previous Irish study identified cognitive, executive and visual perceptual components as important to be included in an occupational therapy off-road assessment (Stapleton and Connolly, 2010).This study also highlighted assessment tools therapists considered useful to guide the occupational therapy off-road assessment for people after stroke (Stapleton and Connolly, 2010).However, the empirical research on assessing fitness to drive after stroke provides various combinations of test tools with varying levels of predictive ability with regard to determining fitness to drive (Barco et al., 2014;Devos et al., 2011).More recently, specific offroad driving assessment batteries are available such as the Occupational Therapy Driver Off-Road Assessment Battery (OT-DORA) (Unsworth et al., 2011), the Rookwood Driving Battery (McKenna, 2009) and the stroke driver screening assessment (Nouri and Lincoln, 1992).However, to date, all assessment tools used in the published research typically have some margin of error and lacking some level of sensitivity and specificity in their predictive ability for return to driving.In addition to this, literature also cautions against the over reliance on scores on standardised off-road tests alone to predict driving ability.Research recommends the use of a combination of standardised assessments with careful observation of everyday functional performance to inform clinical decision making with regard to suitability to drive (Stapleton et al., 2015;Dickerson and Bédard, 2014a).
Given the wide variety of broad recommendations regarding assessment of fitness to drive after stroke, and the lack of definite guidance on what exactly occupational therapists should be including in their assessment of fitness to drive after stroke, this study was conducted to examine current occupational therapy practice in addressing driving issues and completing assessment of fitness to drive after stroke within the Irish context of practice.

Design
A cross-sectional study design was used via an online survey (www.surveymonkey.com, 2016).The survey explored occupational therapists' current practice with regard to driving assessment after stroke.The survey was specifically designed for the study but was informed by questionnaires used previously in a similar North American study (Korner-Bitensky et al., 2006).See Appendix for details of the survey.

Procedure
The survey was reviewed by all authors and piloted among five occupational therapists working with stroke patients from various practice settings to check for relevance and face validity.Amendments were made to the final survey based on feedback from the pilot.The final survey consisted of 44 questions subdivided into seven broad sections; respondent demographics, case load demographics, off-road assessment practices, on-road assessment practices, typical outcomes of assessment, guidelines and training needs.

Ethical approval
The ethical approval was sought and granted for the study from the Ethics Committee in University College Cork prior to commencement of data collection.

Recruitment
The study targeted occupational therapists working with stroke patients at any stage of the stroke rehabilitation trajectory.Notification of the survey and a link to the survey was emailed out to members of the Association of Occupational Therapists of Ireland (AOTI).AOTI members who were currently working with people after stroke were invited to participate in the survey.As not all therapists working with people after stroke are members of AOTI, snowball sampling was used where therapists were asked to forward the survey link to other occupational therapy colleagues working with stroke clients.Information on the study was also mailed out to members of the AOTI Neurology Advisory Group to specifically target therapists working with clients after stroke.Additionally, the first author contacted 35 stroke services listed in the National Audit of Stroke Care (Irish Heart Foundation, 2015) to alert them to the study.A follow-up reminder was mailed out via AOTI one week after the initial mail-out and the link to the survey remained active for a threeweek period.The survey was completed anonymously with no identifying information sought.Consent to participate was assumed upon submission of the completed survey.

Data analysis
The completed surveys were manually collated from the online Survey Monkey account and raw data was coded and inputted onto a Microsoft Excel worksheet.Simple summary statistics were applied to the demographic data.Summary and simple descriptive statistics were used to analyse survey responses.Comparisons between subgroups were completed using chi square test.

Results
Online surveys were returned by 69 respondents; however, 22 questionnaires were incomplete and were not included.In total, 47 completed surveys were included in the analysis.See Table I for details of demographics of respondent's including grades, experience, clinical settings and geographical spread.

Off-road driving assessment
Almost all of the respondents (n = 46, 98 per cent) reported that they consistently ask about driving during their initial interview with stroke patients.However, not all therapists went on to complete a structured off-road assessment.In total, 32 respondents (68 per cent) reported that they do complete off-road driving assessment with their stroke patients, while the other 15 respondents did not complete any off-road driving assessments.The majority of off-road assessment need was identified by the occupational therapist themselves during their initial assessment and interventions (n = 21, 66 per cent).Typical referral sources for off-road assessment were the consultant in stroke or geriatrics (n = 19, 59 per cent), with primary care and community-based therapists receiving referral from general practitioners (n = 13, 41 per cent).Other main sources of referral were other occupational therapy colleagues (n = 12, 38 per cent) and stroke specialist nurses (n = 4, 13 per cent), while a proportion of respondents indicated self or family referrals (n = 7, 22 per cent), and one respondent indicated having received referrals from an insurance company.
Factors influencing the therapist's decision to complete a driving assessment or not with their stroke patients are outlined in Tables II and III.The decision to complete a driving assessment was often triggered when the stroke symptoms were of a mild nature, particularly if the patient had deficits of functional sensorimotor ability, visual and visual perceptual, cognitive, awareness, judgement and impulsivity deficits.Other nonsymptomatic issues, for example, family concerns, if the person was the main driver in the household, and age, also influenced the decision to assess driving after stroke.The decision not to assess driving was usually associated with more severe deficits after stroke or when the person was for discharge to a long-term care facility (see Table III).The domains that were assessed with the occupational therapy off-road assessment are outlined in Figure 1, Assessing fitness to drive after stroke with assessment of cognition, perception and vision consistently included in off-road assessment practices.
The standardised assessments typically used by the respondents when completing offroad assessment are listed in Table IV in the order of frequency of use.Not all respondents who reported using the individual tests provided their ratings of usefulness of these tests in informing the outcomes or recommendations arising following the off-road assessment (see Table IV).The most frequently used tests during the off-road assessment were cancellation tests used by all respondents (n = 32, 100 per cent), with 97 per cent of the respondents finding these tests useful in informing the outcome of the off-road assessment.The use of functional assessment to inform the off-road driving assessment were reported by 94 per cent of respondents (n = 30), with 90 per cent reporting this form of assessment as useful in informing the outcome of the off-road assessment.
Of the 32 respondents who completed off-road assessment, 26 (81 per cent) completed a formal report of their off-road assessment findings.These formal occupational therapy offroad reports were typically forwarded to the general practitioner (n = 24, 92 per cent), 19 (73 per cent) placed a copy in the occupational therapy notes, and 13 (50 per cent) placed a copy of the report in the patient's medical file.A copy of the occupational therapy off-road report was forwarded with the referral for an on-road assessment in the majority of cases (n = 20, 77 per cent).However, six respondents (19 per cent) did not indicate if they completed a formal report of their off-road assessment.

On-road driving assessment
While 32 respondents reported that they do complete formal off-road assessment, 42 respondents reported that they refer stroke patients for on-road assessment, indicating that 10 respondents make referral for on-road without first completing an off-road assessment.
Of the 32 respondents who did complete off-road assessment, the majority (n = 23, 64 per cent) reported that there was a formal communication pathway in place between the referring therapist and the on-road driving assessor, but 13 (36 per cent) reported no formal communication pathway.
Of the 42 respondents who referred for on-road assessment, the majority (n = 31, 74 per cent) reported that they did not sit in on the on-road assessment.Eleven respondents (26 per cent) sat in on the on-road assessment, but this was rare with over half of these (n = 7, 64 per cent) sitting in on less than 25 per cent of on-road assessments, only two respondents reported sitting in on over 75 per cent of the onroad assessments.Therapists were more likely to sit in on the on-road assessment when the patient had significant cognitive or physical impairment.The respondents felt that the occupational therapist's knowledge of the client would be beneficial during the execution of the on-road assessment, and as the therapists would be known to the patient, their presence may help reduce anxiety associated with the on-road test.All the respondents reported that the outcome following on-road assessment matched their expectation of outcome based on their impression following the offroad assessment.Assessing fitness to drive after stroke

Education and training
With regard to their own levels of confidence and perceived competence to assess driving ability among people with stroke, the majority of respondents rated their confidence as moderate to high (n = 31, 67 per cent), while one-third rated their confidence as low (n = 15, 33 per cent).Self-perceived competence to assess driving varied from low or no competence reported by 17 (37 per cent) respondents, while 29 (63 per cent) rated their competence as moderate to very competent.Chi squared tests showed that respondents who had received formal training or attended education sessions on assessment of driving post stroke were significantly more likely to report higher levels of confidence (p = 0.001) and competence (p = 0.002) compared to respondents who had not received any formal training or attended any education sessions.

Guidelines
In total, 94 per cent of respondents (n = 44) were aware of the "Sláinte agus Tiomáint: Medical Fitness to Drive" Guidelines, with 38 (83 per cent) respondents consistently applying the guidelines in their practice.The majority of the respondents who were aware of the guidelines rated them as either useful or very useful (n = 28, 63 per cent).However, the vast majority of respondents (n = 44, 94 per cent) agreed that a more structured and standardised nationally agreed pathway would be beneficial to guide the assessment of fitness to drive post stroke.

Discussion
The purpose of this study was to investigate current evaluation practices among occupational therapists regarding fitness to drive after stroke in the Irish context.The findings represent practice among 47 occupational therapists with considerable experience in stroke rehabilitation; the majority practicing at senior level and with more than five years of clinical experience.A range of practice areas spanning hospital and community-based settings was achieved in the survey.While recruitment methods were used to try and ensure good geographical spread in the responses, a majority were from three regional areas.The findings perhaps suggesting that this area of practice is better developed in some geographical areas compared to others.Also, this may highlight inequalities in service provision for clients with stroke depending on which part of the country they reside in.
An encouraging finding was the high proportion of therapists who reported consistently addressing driving within their initial occupational therapy interview.This finding is reflective of international research highlighting the contribution of occupational therapists in addressing driving issues (Dickerson, 2014;Korner-Bitensky et al., 2007;Unsworth, 2007).It is also consistent with the AOTA occupational therapy practice framework highlighting driving and community mobility as a domain of practice for occupational therapists (American Occupational Therapy Association, 2014).However, the findings show that a smaller number of therapists reported continuing on to complete an occupational therapy off-road assessment, which may be of concern.
The findings provide insight into the factors that influence the therapist's decision to assess driving or not following stroke.It appears that therapists are more likely to assess driving ability after stroke when the client presents with deficits of a mild nature with less functional impact.Whereas when the deficits are moderate to severe, it seems less likely that driving would be formally assessed or indicated.Visual field deficits such as hemianopia and quadrantanopia were included as factors that would likely trigger a driving assessment consistent with the medical guidelines on fitness to drive and EU directives on visual requirements for driving (National Office for Traffic Medicine, 2017).Therapists reported that driving assessment was indicated when clients post stroke presented with deficits in the areas of cognition, visual perception, executive functions, behaviour (awareness, impulsivity, etc.), as well as physical and sensory deficits impacting on everyday function.These factors that influence the decision to assess fitness to drive correspond to the recommendations of component skills that should be assessed when evaluating fitness to drive after stroke as well as in other medical conditions (National Office for Traffic Medicine, 2017; Stapleton and Connolly, 2010).
One of the most influential factors underpinning the decision to assess fitness to drive in the current study was when concerns were raised by family members.This involvement of the proxy in the process of evaluating fitness to driving has been highlighted in previous research (Classen and Alvarez, 2016;Stapleton et al., 2012).It is important to consider if therapists' decision to commence formal driving assessment is triggered solely by family concerns or if the decision to complete driving assessment was made independent of the concerns raised by the family.Therapists should continue to proactively take a leading role in assessing fitness to drive as appropriate in their everyday practice and should not address this issue as a reactive response only when concerns are raised by others.
Non-stroke-related issues such as age was an influential factor in the decision to assess fitness to drive particularly if the person was over 70.While this factor demonstrates awareness of age-related current legislation around licence duration and renewal for people over the age of 70, caution needs to be exercised to ensure that decisions regarding fitness to drive for stroke survivors are based on functional capacity to drive regardless of age.It is equally important to assess fitness to drive among younger stroke clients who are of working age, as re-engagement in important occupations may be dependent on being able to return to drive after stroke across all age groups.
The findings within the study indicate that component skills such as cognition, perception, vision and motor were consistently assessed as part of the off-road driving assessment.However, it is worrying that other skills such as sensation, proprioception and praxis were not consistently assessed, despite the negative impact a deficit in any of these skills could potentially have on ability to drive.
There was a wide variety of assessment tools used by occupational therapists when conducting their occupational therapy off-road driving assessment.The vast majority of assessment tools reportedly used are non-driving-specific assessments.The therapists chose these assessments to specifically target skill component areas considered important for the execution of the driving task.This finding is consistent with findings from other international research (Cammarata et al., 2017;Dickerson, 2013;Korner-Bitensky et al., 2006).Some of the non-driving-specific assessments such as the trail making test B, various cancellation tests, Montreal Cognitive Assessment and Assessment of Motor and Process Skills (AMPS) have been shown to have elements of predictive ability with regard to the outcome of an on-road driving assessment.However, this evidence is only emerging and the predictive ability of any test varies across the research studies published.It is evident that respondents are using tests that are readily available to them in their clinical practice settings and tests that they would use as part of their typical clinical interventions with clients post stroke.It is interesting to see that some driving-specific assessments such as the OT-DORA, stroke driver screening assessment and the Rookwood driving battery are being used by therapists in their clinic-based assessment; however, they are among the less frequently used measures.
The therapists in the current study highlight the importance and perceived usefulness of function-based assessment.The evaluation of the person's ability to perform everyday functional tasks informed their clinical assessment of fitness to drive after stroke.This function-based assessment is supported in previous research.The standardised functionbased AMPS assessment has been shown to be an effective predictor of driving ability among older drivers (Dickerson et al., 2011).Standardised table top assessments will inform the process but should not be used in isolation or exclusively to inform the fitness to drive decision (Stapleton et al., 2015;Dickerson et al., 2014).A combination of a battery of standardised assessments as well as functional observation-based assessments is considered best practice to inform decision making regarding fitness to drive.
Although not specifically asked in the survey, the findings suggest that a proportion of therapists appear to refer clients post stroke for on-road assessment without first completing an occupational therapy off-road assessment.This practice would be contrary to the research and literature that recommend a two phase process of assessing fitness to drive consisting of an off-road assessment followed by an on-road assessment if indicated (Korner-Bitensky et al., 2005;Unsworth et al., 2005).While it cannot be substantiated in the current study, the practice of referring directly for an on-road assessment without first completing an occupational therapy off-road assessment could be considered an abdication of responsibility on the part of the therapist, not to mention the added stress and financial implication for the client to have to undergo an on-road assessment.
The therapists who engaged in formal training and education in assessing driving post stroke feel more confident and competent in their skills and abilities to assess fitness to drive.This corresponds to findings by Meuser et al. (2010) who found that allied health professionals and physicians had significantly improved confidence, clinical practice and adherence to practice guidelines after formal training on assessing driving.This demonstrates that training should be encouraged, continued and facilitated by services to improve the skills of therapists in relation to evaluating fitness to drive post stroke.Formal training in driving should be part of professional development plans and competencies for therapists working with clients post stroke.
There are some limitations identified within the study.The overall sample size of 47 participants is small and there were 22 incomplete surveys, which is a significant number.The therapists who are less active in the process of driving evaluations and have reduced confidence in this area of practice may have been less likely to commence and/or complete the survey.However, in saying this, it is likely that only one clinician per service would have completed the survey.Therefore, it can be assumed that the data collected were from 47 different occupational therapy stroke services which is a significant number.Responses were clustered to three main geographical areas and therefore may not be reflective of national practice.When asked about factors that influence decisions on whether or not to assess driving, therapists may have interpreted this question differently.For example, for clients with moderate to severe stroke, some therapists may interpret this as clients who require a passive hoist transfer and full nursing care.Another therapist may interpret a moderate to severe stroke as someone with a non-functional left upper limb.Further research should focus on more specific client cases which would eliminate any interpretation into the severity of the stroke symptoms.However, useful information was gathered through this research and will aid in the development of clinical guidelines in the assessment of fitness to drive post stroke.Further qualitative research into the rationale of when therapists would or would not assess driving is recommended.

Conclusion
Although the findings demonstrate variance in how fitness to drive after stroke is being addressed in Ireland, the results do show that current practice is in line with and supported by the published research.The majority of occupational therapists are actively engaging in the assessment of fitness to drive after stroke and are not shying away from this role.This is encouraging to see.However, there are still gaps within practice.Occupational therapists are choosing non-driving-specific assessments are that readily available to them, to assess the different skill components that may affect client's ability to drive.In addition, therapists place significant importance to the value of functional assessment in determining fitness to drive post stroke and are not relying solely on the results of standardised assessments.There is a lot of variation in assessment practices across the different geographical regions.Also, the study highlighted evidence of poor practice by some therapists that are not in line with driving guidelines available to them; such as therapists referring for on-road driving assessments without completing an off-road clinical evaluation first.This could be attributed to no nationally or internationally agreed guidelines to inform best practice.Clinical guidelines would encourage participation and engagement by therapists in the process of driving assessment after stroke in Ireland, create a consistent approach across the country and improve therapists' confidence in their ability to assess this complex IADL.Finally, clinicians are encouraged to engage in training and education sessions to improve their sense of confidence but also competence in their ability to assess fitness to drive after stroke.
Figure 1.Proportion of respondents assessing skill domains

Table I .
Demographic data