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International Journal of Nursing Practice 2016; 22: 538–545

RESEARCH PAPER

Work related stress, burnout, job satisfaction and

general health of nurses: A follow-up study
Natasha Khamisa
Department of Public Health, School of Health Sciences, Monash South Africa, Johannesburg, South Africa
Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia

Karl Peltzer
HIV/AIDS/STIS and TB Research Unit (HAST), Human Sciences Research Council, Pretoria, South Africa
Department of Psychology, University of Limpopo, Polokwane, South Africa
ASEAN Institute for Health Development, Mahidol University, Salaya, Thailand

Dragan Ilic
Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia

Brian Oldenburg
School of Population and Global Health, University of Melbourne, Melbourne, Australia

Accepted for publication 30 April 2016

Khamisa N, Peltzer K, Ilic D, Oldenburg B. International Journal of Nursing Practice 2016; 22: 538–545
Work related stress, burnout, job satisfaction and general health of nurses: A follow-up study

Nurses experience high levels of work related stress and burnout as well as low job satisfaction and poor general health owing to the
nature of their work. This paper seeks to provide a better understanding of the nature of relationships between work related stress,
burnout, job satisfaction and general health of nurses over one year. This study involved a longitudinal design. Two hundred and
seventy seven nurses from four hospitals completed a follow up survey consisting of five questionnaires. Data were collected
between 2013 and 2014. The data were analysed using generalized estimation equation analysis. Lack of support was associated
with burnout, patient care was associated with job satisfaction and staff issues were associated with general health of nurses. Burnout
is more strongly related to job satisfaction than general health. The findings of this study could inform evidence based policy and
practice through interventions aimed at improving job satisfaction and reducing the impact of burnout on general health of nurses.
Key words: burnout, general health, job satisfaction, nurses, work related stress.

WHAT IS ALREADY KNOWN ABOUT physical and psychological health outcomes

THIS TOPIC • There is limited evidence regarding the relationship
• Nurses experience high levels of work related stress and between job satisfaction and burnout, especially in devel-
burnout oping contexts
• Work related stress and burnout are associated with poor

Correspondence: Natasha Khamisa, Department of Public Health, School WHAT THIS PAPER ADDS
of Health Sciences, Monash South Africa, 144 Peter Road, Roodepoort, • Lack of support is most significantly associated with
1725 Johannesburg, South Africa. Email: natasha.khamisa@monash.edu burnout among nurses

© 2016 John Wiley & Sons Australia, Ltd doi:10.1111/ijn.12455

WRS, BO, JS and GH of nurses: follow-up study
• Contrary to existing literature, stress related to patient
care is more strongly associated with job satisfaction
• Emotional exhaustion is more significantly associated
with job satisfaction than general health
THE IMPLICATIONS OF THIS PAPER
FOR POLICY/PRACTICE/RESEARCH/
EDUCATION
• Findings provide potential solutions to the consequences
of work related stress, and burnout whilst improving
job satisfaction and general health of nurses
• Findings could inform policy and practice through the
development of interventions aimed at creating better
work environments, whereby nurses can successfully
perform their jobs.
• Findings confirming the relationship between burnout
and job satisfaction can be further examined to determine
potential mediation of these variables.
INTRODUCTION
Burnout is a psychological syndrome resulting from
prolonged exposure to work related stress.1 Burnout is
associated with lower job satisfaction2 and poor physical
and mental health outcomes such as frequent headaches
and insomnia.3,4
Research shows that health professionals experience
higher levels of burnout than professionals in other sectors
of employment.4 This has been attributed to the frequency
and severity of exposure to stressors including patient care,
staff issues, job demands, lack of support and overtime.5
Burnout among nurses in particular has been found to be
higher than in other health professionals, as well as workers
across other employment sectors, owing to the nature of
their work.6 Close contact of an emotional nature with a
large number of patients significantly contributes to burnout
among nurses.7 With scores of 27 or higher on the three
sub-scales of Maslach’s Burnout Inventory, nurses are more
burnt out than other health professionals.8 This statement
can be substantiated by findings suggesting that burnout
among nurses is almost twice as high as burnout among phy-
sicians and medical technicians.9 Burnout among South Af-
rican nurses in particular is reported to be high in
comparison to burnout among nurses in other parts of the
world owing to difficult working conditions.5,7
In addition to higher burnout levels, lower job satisfac-
tion levels have also been reported among nurses.10 Studies
show that work related stress contributing to higher burn-
out levels among nurses are associated with lower job
539
satisfaction.11,12 Dissatisfaction with pay, promotion,
supervision, fringe benefits, operating conditions, contin-
gent rewards, co-workers, nature of work and communica-
tion has been reported among nurses.13,14 Extended work
related stress and burnout negatively affect physical and
mental health outcomes among nurses.3,15
The relationship between work related stress, burnout,
job satisfaction and general health of nurses can be explained
by Maslach’s Burnout Model, whereby prolonged exposure
to environmental and situational stressors result in work
related stress. This contributes to emotional exhaustion,
depersonalization and a lack of personal accomplishment.1
Work related stress is also thought to contribute to lower
job satisfaction as a result of mismatch between job expec-
tations and actual working environments.14 Prolonged
exposure to stressors leads to an imbalance in homeostasis,
resulting in a breakdown of the biological system. This
prevents compensatory and anticipatory changes that aid
in coping, thereby resulting in poor health outcomes.1,4
Stressors are conditions and events that induce strain.
According to Rothmann et al. five specific stressors associ-
ated with patient care, staff issues, job demands, lack of
support and overtime contribute to work related stress
among South African nurses.5 Idris affirms that with contin-
uous application of pressures to conform, employees
exhaust energy resulting in physiological, psychological
and behavioural responses characterized by emotional
exhaustion and lack of personal accomplishment. Failing
to meet the demands made upon them, employees experi-
ence a loss of job satisfaction. These lead to poor health
outcomes.15
Although it is known that work related stress and burn-
out are associated with poor physical and psychological
health outcomes,4 there is limited evidence regarding the
relationship between job satisfaction and burnout, especially
in developing contexts.16,17 This lack of evidence is empha-
sized by few longitudinal studies examining causation, espe-
cially in developing countries such as South Africa. A recent
systematic review,16 found that only three studies simulta-
neously exploring these variables have been conducted in
developing contexts over 22 years. Some existing studies
suggest that work related stress contributing to lower job
satisfaction leads to burnout and poor health outcomes.
Others suggest that work related stress contributes to lower
job satisfaction, which leads to poor health outcomes18,19
Considering high burnout among South African nurses as
well as difficult working conditions for nurses in developing
contexts, a better understanding of the nature of
© 2016 John Wiley & Sons Australia, Ltd
540
relationships between work related stress, burnout, job
satisfaction and general health of nurses is required. This
study is particularly important given the impact of work
related stress, burnout, low job satisfaction and poor
general health of nurses on work productivity, patient care
and turnover rates.16 These have severe implications for
patient outcomes with up to an 18% increase in patient
mortality rates during a six year period.20
The current study seeks to answer the research question
‘what is the nature of relationships between work related
stress, burnout, job satisfaction and general health of nurses
in developing contexts’. It is important to identify the most
significant relationships between work related stress, burn-
out, job satisfaction and general health over time so as to
develop evidence based policy and practice aimed at im-
proving working environments for nurses in developing
countries including South Africa.
It was hypothesized that over time work related stress is
associated with burnout, job satisfaction and general health;
burnout and job satisfaction are associated with general
health; burnout is more strongly associated with general
health.
METHODS
Participants
Of 1200 nurses invited to participate in the study, 277
agreed to be followed up a year later, where they
completed a survey consisting of five questionnaires.
Owing to difficult working conditions, South Africa is
reported to have one of the highest attrition rates among
nurses. Many nurses leave their jobs soon after starting, in
search for better opportunities in other parts of the world.20
This could explain the high dropout rate in this study.
Measurement tools
Participating nurses received five questionnaires. These in-
cluded a socio-demographic questionnaire (SDQ), Nursing
Stress Inventory (NSI),5 Maslach Burnout Inventory-
Human Services Survey (MBI-HSS),21 Job Satisfaction
Survey (JSS)14 and General Health Questionnaire (GHQ-
28).22
The SDQ included questions about age, gender, popula-
tion group, level of education, level of experience and num-
ber of days/hours worked per week.
The NSI was designed to measure frequency and severity
of work related stressors particularly among South African
nurses. Factor analysis of interview responses were used
to identify five work related stressors (patient care, staff
© 2016 John Wiley & Sons Australia, Ltd
N. Khamisa et al.
issues, job demands, lack of support, overtime). Of 78
items, the first 39 statements were rated on a nine-point
scale, ranging from 1 (low) to 9 (high) according to
perceived intensity experienced by each stressor. Using a
ten-point scale ranging from 0 (no days) to 9+ (more than
9 days), the remaining 39 statements were rated in terms
of the frequency with which stressors were experienced.
Items such as patient demands and death of a patient are
used to measure stress resulting from patient care. Staff
issues include items such as staff shortages and poorly moti-
vated coworkers. Job demands include items such as meet-
ing deadlines and insufficient time to perform tasks. Items
such as lack of recognition for good work and inadequate
support form supervisor/manager are used to measure lack
of support. Overtime is measured by items pertaining to
emergency hours and moonlighting. Cronbach alpha coeffi-
cients range between 0.91 and 0.93 for all items. The mean
inter-item correlation coefficients are in the recommended
range (0.15 < r < 0.50).5
The MBI-HSS was designed to measure burnout among
individuals working in the human services and health care
occupations including nursing. This questionnaire is made
up of three sub-scales and 22 statements based on personal
feelings and attitudes. A statement such as ‘I feel used up at
the end of the work day’ is used to measure emotional ex-
haustion, a statement such as ‘I feel I treat some recipients
as if they were impersonal objects’ is used to measure de-
personalization and a statement such as ‘I feel I am making
an effective contribution to what this organization does’ is
used to measure personal accomplishment. The frequencies
(scored 0–6) are categorized according to high, moderate
and low for each subscale. Cronbach alpha values of 0.90
have been reported for EE, 0.71 for DP and 0.79 for PA.21
With 36 items across nine facets (pay, promotion, super-
vision, fringe benefits, operating conditions, contingent
rewards, co-workers, nature of work and communication),
the JSS was designed to measure job satisfaction within
organizations in the social sector of employment. Pay
includes items such as ‘raises are too few and far between’.
Promotion includes items such as ‘those who do well on the
job stand a fair chance of being promoted’. Supervision
includes items such as ‘my supervisor is unfair to me’. Fringe
benefits include items such as ‘the benefits we receive are as
good as most other organizations offer’. Operating condi-
tions include items such as ‘my efforts to do a good job
are seldom blocked by red tape’. Contingent rewards
includes items such as ‘I do not feel that the work I do is
appreciated’. Co-workers include items such as ‘I find I have
WRS, BO, JS and GH of nurses: follow-up study
to work harder at my job because of the incompetence of
people I work with’. Nature of work includes items such
as ‘I like doing the things I do at work’. Communication
includes items such as ‘the goals of this organization are
not clear to me’. Responses are rated by how true the state-
ment is (higher scores indicate ‘truer’ statements). These
are rated on a six-point rating scale ranging from ‘disagree
very much’ (1) to ‘agree very much’ (6). The JSS has been
found to be reliable among nurses (Cronbach alpha = 0.89)
and shows good construct validity.14
Containing 28 items and four sub-scales (somatic symp-
toms, anxiety and insomnia, social dysfunction and severe
depression) the GHQ-28 was developed to measure current
psychological states and perceived quality of health. The
somatic symptom sub-scale includes items such as ‘been
having hot or cold spells’ and ‘been getting pains in the
head’. The anxiety and insomnia sub-scale contains items
such as ‘having difficulty staying asleep’ and ‘feeling nervous
and strung up all the time’. The social dysfunction sub-scale
contains items such as ‘taking longer on things’ and
‘enjoying normal day to day activities’. The severe
depression sub-scale includes items such as ‘feeling
worthless’ and ‘feeling that life is not worth living’.
Positive items are scored from 0 (always) to 3 (never)
and negative items are scored from 3 (always) to 0
(never). High scores indicate poor general health and
low scores indicate good general health. Cronbach alpha
between 0.70 and 0.83 for all sub-scales has been
reported. The GHQ-28 is also valid (pclose fit = 1.00).22
Procedure
Data were collected between 2013 and 2014. Informed
consent was obtained for all participants before inclusion
in the study. The study protocol was approved by the Ethics
Committee of Human Sciences Research Council (HSRC)
(REC 3/20/03/12). The study was conducted in accor-
dance with the Declaration of Helsinki and following ethics
approval from the Human Sciences Research Council
(HSRC) as well as permission from the Department of
Health (South Africa), stratified random sampling was used
to identify four hospitals across Gauteng. Stratification of
private and public hospitals by area and size allowed for
the random selection of two private and two public hospi-
tals. Hospital and nurse managers at each of the chosen hos-
pitals were contacted for permission to conduct the study.
Unit managers distributed invitation packs consisting of
an explanatory statement, consent form, five questionnaires
and a sealable envelope in which to return completed
541
questionnaires. Participants were asked to return com-
pleted questionnaires within three weeks. Sealed envelopes
were placed in sealed boxes situated around the hospital.
These were only accessible to the researchers. Reminders
were issued two weeks after questionnaire distribution ver-
bally by the unit managers during meetings by the nurse
manager as well as in the form of posters placed on notice
boards. These methods were evaluated prior to data collec-
tion and were found to be feasible within the chosen
context.23
Design and analysis
Given that the effects of stress manifest over time, with
burnout occurring within a year after exposure to stress,1
this study examines the relationships that are most signifi-
cant over a period of time.
Following data collection, the questionnaires were
scored and data were entered into a statistical package (SPSS
version 20). The data were analysed using generalized esti-
mating equation (GEE) analysis to determine the most sig-
nificant factors associated with each outcome over time.
This method allows for analysis of repeated observations
with reasonable statistical efficiency.24 Factors and out-
comes were fitted into models as described below.
The factors contributing to work related stress (patient
care, staff issues, supervision/management issues, overtime
and job demands) were entered into models with facets of
burnout (emotional exhaustion, depersonalization and per-
sonal accomplishment), job satisfaction (pay, promotion,
supervision, fringe benefits, operating conditions, contin-
gent rewards, co-workers, nature of work and communica-
tion) and general health (somatic symptoms, anxiety and
insomnia, social dysfunction and severe depression) as out-
comes. Facets of burnout (emotional exhaustion, deperson-
alization and personal accomplishment) were also entered
into models with facets of job satisfaction (pay, promotion,
supervision, fringe benefits, operating conditions, contin-
gent rewards, co-workers, nature of work and communica-
tion) and general health (somatic symptoms, anxiety and
insomnia, social dysfunction and severe depression) as out-
comes. Facets of job satisfaction (pay, promotion, supervi-
sion, fringe benefits, operating conditions, contingent
rewards, co-workers, nature of work and communication)
were entered with facets of burnout (emotional exhaustion,
depersonalization and personal accomplishment) and gen-
eral health (somatic symptoms, anxiety and insomnia, social
dysfunction and severe depression) as outcomes.
© 2016 John Wiley & Sons Australia, Ltd
542
Odds ratios (OR) were calculated as EXP (regression co-
efficient) and indicate the odds of factors being associated
with outcomes over time. GEE analysis involved indepen-
dent correlation matrix. Missing data were treated accord-
ing to the method described by Diggle et al.25
RESULTS
Participants who were followed up included nurses from
various population groups; between an age range of less
than 20 years to over 50 years; having obtained a
diploma/certificate, undergraduate degree, postgraduate
degree; with up to less than 1 year to over 25 years’ work-
ing experience; working between 1 and 7 days a week;
between 11 and 20 to over 60 h per week.
Tables 1–3 show odds ratios (OR) and confidence inter-
vals (CI) for associations between factors and outcomes.
Table 1 shows that all stressors except job demands (OR
1.80, 95% CI 0.97–3.32) are significantly associated with
burnout. All five stressors are significantly associated with
job satisfaction and general health. Lack of support is
strongly associated with burnout over time (OR 4.37,
95% CI 2.89–6.62), patient care is associated with job
satisfaction over time (OR 2.63, 95% CI 1.35–5.16) and
staff issues is associated with general health over time
(OR 3.88, 95% CI 1.41–10.73).
Table 2 shows that of the three burnout sub-scales,
emotional exhaustion is most significantly associated with
job satisfaction (OR 2.37, 95% CI 2.13–2.63) and general
health (OR 1.93, 95% CI 1.81–2.06).
Table 3 shows that job satisfaction with promotion is
most significantly associated with burnout (OR 1.14, 95%
CI 1.05–1.23). Job satisfaction with nature of work is most
significantly associated with general health (OR 1.34, 95%
CI 1.21–1.49). Job satisfaction with supervision (OR 1.10,
95% CI 0.98–1.23; OR 0.93, 95% CI 0.86–1.01),
Table 1 GEE analysis of work related stress associated with burnout, job satisfaction and general health
Burnout
Work related stress
Parameters OR 95% CI
Patient care 2.24 1.94–2.59
Staff issues 4.18 2.93–5.96
Job demands 1.80 0.97–3.32
Lack of support 4.37 2.89–6.62
Overtime 2.12 1.78–2.53
© 2016 John Wiley & Sons Australia, Ltd
N. Khamisa et al.
operating conditions (OR 0.87, 95% CI 1.00–1.15; OR
1.08, 95% CI 0.99–1.16) and contingent rewards (OR
0.95, 95% CI 0.89–1.01; OR 0.99, 95% CI 0.93–1.06)
are not associated with burnout or general health. Job satis-
faction with pay (OR 0.91, 95% CI 0.84–0.99), fringe
benefits (OR 1.08, 95% CI 1.01–1.15) and co-workers
(OR 0.70, 95% CI 0.64–0.76) are not associated with
burnout but are significantly associated with general health.
DISCUSSION
This study was aimed at examining work related stress in
relation to burnout, job satisfaction and general health
among South African nurses over time. Instruments mea-
suring each of these variables have been psychometrically
tested with respect to reliability and validity.21,22,26–28
According to the hypotheses, it was expected that over
time, work related stress is associated with burnout, job
satisfaction and general health; burnout and job satisfaction
are associated with general health; burnout is more strongly
associated with general health.
The findings of this study suggest that of all the five
stressors contributing to work related stress, job demands
do not have an effect on burnout. Although job demands
can be harmful to employee well-being through burnout,29
the relationship between job demands and burnout is de-
pendent on a number of variables. The role stress theory
suggests that non-work life demands influence the impact
of job demands on burnout.30 Cognitive appraisal of stress
related to job demands also determines whether burnout
is experienced or not.31 Therefore, job demands do not
affect burnout unless influenced by intervening variables.
Lack of support is most significantly associated with
burnout among nurses in this study. Research has shown
that support in working environments possesses motiva-
tional potential for the achievement of goals through
Job satisfaction General health
OR 95% CI OR 95% CI
2.63 1.35–5.16 2.50 1.32–4.73
2.04 1.02–4.09 3.88 1.41–10.73
1.20 1.06–1.35 2.83 1.63–4.90
1.70 1.41–2.03 1.83 1.33–2.53
1.89 1.48–2.40 1.15 1.02–1.30
WRS, BO, JS and GH of nurses: follow-up study 543

Table 2 GEE analysis of burnout associated with job satisfaction and general health

Job satisfaction General health

Burnout
Parameters OR 95% CI OR 95% CI

Emotional exhaustion 2.37 2.13–2.63 1.93 1.81–2.06

Depersonalization 0.87 0.78–0.96 1.22 1.13–1.32
Personal accomplishment 1.49 1.36–1.63 1.08 1.01–1.14

increased work engagement and improved performance. This study found that stress related to staff issues is
Given that support is a performance protection strategy, a mostly associated with general health. Staff issues including
lack thereof results in compensatory adjustments reduced nursing budgets and increasing nursing shortages
(narrowing attention and increased selectivity) and subse- has been associated with poor health outcomes among
quently fatigue (drained energy levels), resulting in nurses. Nurses working under these conditions are ex-
breakdown.1,13,26 pected to perform additional tasks using minimal resources,
Stress related to patient care has mostly been associated which depletes coping resources over time. This stress–
with burnout,32,33 whereas this study shows that it is more strain response results in poor physical and mental health
strongly associated with job satisfaction. The association manifestations such as headaches and depression.36,37
between work related stress and job satisfaction is not Although burnout and job satisfaction are also associated
extensively researched, especially in developing contexts with general health of nurses, this study found that burnout
with only 16 studies identified between 1990 and 2012.16 is most significantly associated with general health.
In a first study of its kind, Kalisch et al. found that American Emotional exhaustion is more strongly associated with
nurses who perceived patient care as being less stressful general health over time owing to the depletion of coping
were more likely to be satisfied with their jobs owing to resources leading to somatization and social withdrawal.38
feelings of motivation and positive difference.34 The reverse Interestingly, the findings of this study also show that
is also true, whereby nurses’ awareness of stress related to emotional exhaustion is more significantly associated with
patient care compromises their ability to meet patient job satisfaction than general health. In examining the rela-
demands, thus resulting in job dissatisfaction.35 tionship between burnout and job satisfaction, burnout af-
fects job satisfaction than vice versa. This might be a
result of emotional exhaustion depleting energy and
Table 3 GEE analysis of job satisfaction associated with burnout and compromising ability to perform tasks, which affects the at-
general health tainment of goals at work, thereby influencing job satisfac-
tion. It is also evident that nurses experiencing
Burnout General health depersonalization and personal accomplishment are more
Job satisfaction satisfied with their jobs. Depersonalization involves emo-
Parameters OR 95% CI OR 95% CI tional and cognitive distancing, which might reduce nega-
tive effects of burnout on job satisfaction. Similarly, a
Pay 1.07 0.99–1.15 0.91 0.84–0.99
sense of personal accomplishment would indicate achieve-
Promotion 1.14 1.05–1.23 1.22 1.14–1.31
Supervision 1.10 0.98–1.23 0.93 0.86–1.01
ment of goals at work, which might positively influence
Fringe benefits 1.03 0.97–1.10 1.08 1.01–1.15 job satisfaction.1,14,39
Operating conditions 0.87 1.00–1.15 1.08 0.99–1.16 The relationship between burnout and job satisfaction is
Contingent rewards 0.95 0.89–1.01 0.99 0.93–1.06 not clear with research producing contrary findings.
Co-workers 0.95 0.88–1.03 0.70 0.64–0.76 Although there are studies suggesting that job satisfaction
Nature of work 1.07 0.96–1.20 1.34 1.21–1.49 affects burnout,12,40 it is important to note is that most
Communication 0.92 0.85–0.98 0.85 0.79–0.93 studies examining the relationship between burnout and
job satisfaction adopted cross-sectional designs.

© 2016 John Wiley & Sons Australia, Ltd

544
Further research examining causality is needed to better
understand the complexity around multiple relationships
between work related stress, burnout, job satisfaction and
general health of nurses. The role of specific stressors on
burnout, job satisfaction and general health among nurses
in varying contexts should be conducted using a number
of measurement instruments at several measurement
points. The relationship between burnout and job satisfac-
tion must be further examined to determine potential
mediation of these variables.
The findings of this study must be interpreted with
caution owing to its focus on one province in South Africa,
a lower follow-up rate and the short duration between base-
line data collection and follow-up. The use of biomarker
assessment such as levels of white blood cells and other
cellular variables might be more accurate indicators of the
health impact of stress, burnout and job satisfaction.
CONCLUSION
The findings of this study provide potential solutions to the
consequences of work related stress, burnout, low job
satisfaction and poor general health (high turnover, poor
job performance and low quality patient care). Promoting
personal accomplishment will improve job satisfaction
whilst reducing the negative impact of burnout on physical
as well as mental health of nurses in developing countries.
Such evidence could inform policy and practice through
the development of interventions aimed at creating better
work environments, whereby nurses can successfully
perform their jobs.
Policy related to health workforce wellbeing is not prior-
itized and mostly lacking in developing contexts, with
existing policies failing to address psychosocial stressors
among nurses in developing countries. Considering this as
a major barrier in implementing evidence based practice,
this study provides substantial evidence for policy develop-
ment in developing countries.
AUTHOR CONTRIBUTIONS
All authors contributed to this manuscript. N.K. and B.O.
conceived and designed the study; N.K. executed the study;
K.P. and D.I. contributed reagents/materials/analysis
tools; N.K. and K.P. analysed and interpreted the data;
N.K. wrote and revised the paper. All authors read and
approved the final manuscript.
© 2016 John Wiley & Sons Australia, Ltd
N. Khamisa et al.
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.
ACKNOWLEDGEMENTS
The study was conducted using a small grant from Monash
South Africa (230059-9999). This study would not have
been possible without the support from hospital, nurse
and unit managers at each chosen hospital. We would like
to particularly thank the participants of this study without
whom this study could not have been accomplished.
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