Nurses’ Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities

Abstract

Aim. Diagnostic uncertainty, risk perceptions, time constraints, and pressure from resident/family members and nurses have been identified as potential barriers to reducing antibiotic prescribing in residential aged-care facilities. The current study investigated the relationship between nurses’ anxiety, clinical tolerance of uncertainty, and behaviors that favor antimicrobial initiation. Methods. A cross-sectional online survey was used to present a clinical vignette with measures of situational anxiety, clinical tolerance to uncertainty using the Physicians Reactions to Uncertainty Scale (adapted for nurses), and self-reported behavior on the Immediate Assessment and Antibiotics scale. The vignette described a hypothetical resident with a potential upper respiratory tract infection. Incremental information was provided with varying levels of symptoms, input from aged-care staff, and the availability of test results. Results. A total of 157 registered and enrolled nurses completed the survey from August 2021 to August 2022. Nurses’ anxiety fully mediated on the relationship between clinical tolerance of uncertainty and perceived need for antibiotics and immediate assessment ( P = 0.004), with 6% of variation explained by the model. Significant effects of clinical tolerance of uncertainty on anxiety ( P < 0.001) and anxiety on antibiotic initiation ( P = 0.002) were found, but there was no significant direct effect between clinical tolerance of uncertainty and antibiotic initiation ( P = 0.34). Conclusions. This is the first study that links perceived need for antibiotics and assessment to nurses’ anxiety and clinical tolerance of uncertainty. Thus, it may be that providing strategies for the management of anxiety related to uncertainty could nullify some processes contributing to inappropriate prescribing in aged-care settings Highlights The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs). A significant relationship was found between nurses’ anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment. As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e.g., family members) when making clinical decisions in the RACF setting.