The increasing older population and demand for higher quality care for nursing facility residents resulted in the enactment of the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). This study focuses on the Residents' Rights provisions of OBRA-87 addressing use and reduction of physical restraints. It introduces the concept of Geriatric Rehabilitation Orientation (GRO) and its impact on physical restraint use in nursing facilities.

This dissertation describes and assesses GRO components and physical restraint use among nursing facilities from California and Missouri (n = 82). Data for this research, collected in the fall of 1990 immediately following the implementation of OBRA-87 regulations, were obtained from two sources: (1) surveys mailed to a random sample of non-profit and for-profit nursing facilities in California and Missouri; and (2) three case studies; one each in California, Missouri and Massachusetts.

Characteristics of GRO components include approaches to care, physical facility, activity programs, staffing, education and training, discharge and reimbursement. Relationships among GRO components and physical restraint use are examined. Discriminant step-wise function analysis distinguishes between levels of physical restraint use.

As expected, results suggest that this sample of facilities, in general, has minimal GRO reflected by a task-oriented approach to care, lack of resident autonomy, high turn-over among nurses' aides, questionable safety procedures, high restraint use, and few restraint alternatives implemented. Of particular importance is the finding that California and Missouri differed significantly on how restraints were defined. Consistent barriers to restraint reduction are fear of falls and family resistance. Interference with medical interventions (e.g., pulling out feeding tube) was the primary predictor of very high restraint levels; the next most important factors were fall risk and difficulty convincing staff to decrease restraints. Case study results confirmed much of the survey results with education and training and integration of nurses' aides into the care process enhancing quality care and lowering restraint use.

Results suggest that a more autonomous rehabilitative environment may lead to the reduction of physical restraints. Challenges are presented and recommendations included.