Neurology, Psychiratry and Research
Neurology, Psychiratry and Research
Neurology, Psychiratry and Research
Effect of Balint group training on burnout and quality of work life among T
intensive care nurses: A randomized controlled trial
Huigen Huanga,*,1, Huashuang Zhangc,1, Yongbiao Xiea, Shi-Bin Wangb, Hong Cuia, Lihua Lib,
Hua Shaob, Qingshan Genga,*
a
Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
b
Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
c
Institute for Brain Research and Rehabilitation, South China Normal University, Guangzhou, China
Keywords: Background: Burnout and low quality of work life were linked to poor professional conduct, increased risk of
Balint group medical errors and suicide for intensive care nurses. This study was to examine whether the Balint group training
Burnout intervention could relieve burnout and improve the quality of work life for ICU nurses.
Quality of work life Methods: We conducted a randomized controlled trial at five ICUs in Guangdong province, China. Totally 152
nurses were randomly assigned to the Balint group with 8 weekly 1.5 -h training sessions and the control group
with no interventions. The outcomes were assessed at pre-, mid- and post-training intervention with the Maslach
Burnout Inventory (MBI) and Quality of Nursing Work Life Scale (QNWLS) questionnaires.
Results: At pre-training intervention, the scores of QNWLS and MBI for both groups ranged in 131.63–133.43
and 69.96–70.07, respectively, suggesting the high burnout and low quality of work life for ICU nurses. At mid-
intervention, no significant differences were observed. At post-training intervention, the scores of QNWLS for the
intervention group (141.93 ± 13.61) was significantly higher than the control group (132.39 ± 10.66), which
was mainly contributed by the improvement in the work life-home life and work world dimensions. For MBI, the
burnout for intervention group (58.33 ± 7.38) was significantly lower than the control group (70.50 ± 7.01) at
post-training intervention, which was contributed by the improvement in the depersonalization and emotional
exhaustion dimensions.
Limitation: the ‘healthy worker effect’ cannot be excluded.
Conclusion: Balint group training was an effective way to relieve burnout and improve the quality of work life for
ICU nurses.
Corresponding authors at: No. 102 Zhongshan Er Road, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou,
⁎
https://doi.org/10.1016/j.npbr.2019.12.002
Received 8 August 2019; Received in revised form 5 November 2019; Accepted 11 December 2019
Available online 17 December 2019
0941-9500/ © 2019 Published by Elsevier GmbH.
H. Huang, et al. Neurology, Psychiatry and Brain Research 35 (2020) 16–21
areas, including sociology, psychology, education, management, health were informed about the objective of the study and the option to ter-
care, and nursing (Fu et al., 2015; Vagharseyyedin, Vanaki, & minate participation at any time. Informed consent was obtained from
Mohammadi, 2011). Previous studies suggested that the recruitment all participants before starting the study.
and retention for ICU nurses were also related to their QWL (Fu et al.,
2015; Vagharseyyedin et al., 2011). 2.2. Participants
Burnout and low quality of work life has been linked to hastened
retirement, poor professional conduct, increased risk of medical errors, G*Power software (University of Dusselldorf, Germany, version 3.1)
as well as deleterious effects on personal health and relationships was used to calculate the optimal sample size for each of the two
(Kavalieratos et al., 2017; Vagharseyyedin et al., 2011). Some physi- groups. The following parameters were entered: alpha error probability
cians and nurses could be described symptoms of overt depression, then = 0.05, power = 0.8, effect size = 0.55 and allocation ratio (n2/n1) =
a progression to clinical depression and suicide (Bagwell et al., 2017). 1, computed for independent sample t-test for two groups. The sample
Moreover, the negative emotion is contagious, which may cross over size was estimated as 63 for each group. Accounting for participant
from one nurse to another in ICU (Li et al., 2015). Given the importance dropouts, the optimal sample size for each group was determined to be
of ICU nurses, these psychological problems mentioned above may 76.
threat the strength and sustainability of ICU. Thus, effective strategies Participants were ICU nurses recruited from 13 intensive care units
should be adapted to relieve the burnout and improve their quality of in 5 hospitals in Guangzhou, China from May 2016 to September 2016.
work life. In previous studies, there are some psychological intervention The inclusion criteria encompassed (1) working in an ICU as a licensed
methods were reported to relieve the burnout and other psychological nurse for at least one year and working in hospitals with at least 1000
problems for nurses and medical doctors, such as the Mindfulness-Based beds and 100 ICU nurses; (2) nurses have no difficulty in communica-
Stress Reduction (MBSR), Cognitive Behavior Therapy (CBT), Balint tion with others; and (3) nurses who agreed to participate in the present
Group (BG) and so on (Asuero et al., 2014). study. The exclusion criteria were: (1) Participants who have neu-
Balint groups training, named after the founder–Michael Balint, MD, ropsychiatric disorders; (2) Participants in pregnancy or lactation; (3)
consists of case presentations by group members and group discussions Participants who incomplete or invalid questionnaire. As a result, the
facilitated by experienced trainers (Dorte, Inger, & Urban, 2004; Roy, total number of the whole participants was 152. Out of the participants,
Vanheule, & Inslegers, 2015). In recent years, interventions based on 20 were from the First Affiliated Hospital of Guangzhou Medical
Balint groups training were widely used in medical practices in many University, 20 were from the First People’s Hospital of Guangzhou, 20
countries and were included in some training programs in other fields were from The Second Affiliated Hospital of Sun Yat-sen University, 20
(Roy et al., 2015). As a result, for physicians and nurses, Balint group were from Guangdong Traditional Chinese Medicine Hospital, and 72
training will increase the competency of general practitioners (GPs) in were from Guangdong General Hospital.
patient encounters and enables them to endure in their job and find joy
and challenge in their relationships with patients (Airagnes et al., 2014; 2.3. Arms
Dorte et al., 2004; Kjeldmand & Holmström, 2008; Roy et al., 2015).
Thus, Balint groups may help GPs handle a demanding work life and Balint group training, including the case reports and group discus-
prevent burnout (Dorte & Inger, 2008). sions, attempt to throw light on the doctor-patient relationship. The
However, previous studies on Balint group training is mostly re- detailed process of Balint group training was showed in Table 1. The
stricted to short-term interventions in faculty settings (Airagnes et al., control group received no interventions. All participants in the control
2014; Sekeres et al., 2003). There are limited studies reported on ICU group finished online questionnaires at the same time as the Balint
nurses. The aim of this RCT study was to explore the experience of group.
participation in a Balint group among ICU nurses and its effect on
burnout and the quality of nursing work life. We believe that this study 2.4. Assessment
was the first attempt to report that whether the Balint group inter-
vention can alleviate the job burnout and improve the Quality of Work Three questionnaires were used for assessing the effectiveness of
Life for the ICU nurses. Balint group training, including general survey for collecting demo-
graphic information (age, sex, marital status, number of children),
2. Methods Maslach Burnout Inventory (MBI) and Quality of Nursing Work Life
Scale (QNWLS) (Fu et al., 2015; Matilda, Kaisa, & Tatiana, 2017).
2.1. Design The Maslach Burnout Inventory (MBI) is a comprehensive, multi-
dimensional questionnaire that was created by Susan Jackson, Michael
This work was conducted with a two-arm randomized clinical trial Leiter and Christina Maslach in 1996 and has been widely used (De
under the leadership of Guangdong General Hospital from May 2016 to Oliveira et al., 2011; Tartakovsky & Walsh, 2016). It is a self-assessed
November 2016. The participants were selected through random sampling reported questionnaire consisting of 22 items, evaluating the 3 di-
first, then they were divided into two groups (i.e. the intervention group mensions of burnout: depersonalization (DP, 5 items), personal ac-
and the control group) with a random number generator. For the inter- complishment (PA, 8 items) and emotional exhaustion (EE, 9 items)
vention group, participants will receive Balint group training consisting of (Kroska, Calarge, O’Hara, Deumic, & Dindo, 2017; Maslach et al.,
eight weekly 1.5 -h sessions, which was conducted by senior Balint trainers 2001). The frequency of experiencing items was measured on a 7-point
from Guangdong Balint Society. While for participants in the control Likert scale, ranging from 0 (never) to 6 (everyday). The score for each
group, they will receive no interventions. All participants in both groups sub-scale is obtained by summing the items (the range of the DP score is
were asked to complete an anonymous online questionnaire of MBI and 0–30, of the PA score is 0–48, and of the EE score is 0–54). High scores
Quality of Nursing Work Life (QNWL) at three time points: pre-interven- on EE and DP and low scores on PA indicate a high level of burnout
tion, mid-intervention (4 weeks) and post-intervention (8 weeks). The (Guo et al., 2016). In the current study, the definition of burnout was
online questionnaires were available at https://www.wjx.cn/wjx/design/ adopted from a recent survey of hospital resident staff in the United
previewq.aspx?activity=10069045&s=1, and the primary outcomes of States: EE > 26 and/or DP > 9 and/or PA < 34 (Guo et al., 2016;
this study were the scores of MBI and QNWL. Rachid, Emmanuel, & Lucie, 2017). Reported internal consistencies
The study was approved by the Research Ethics Committee of were acceptable with Cronbach’s α of 0.89 for EE, 0.69 for DP and 0.84
Guangdong General Hospital & Guangdong Academy of Medical for PA (Guo et al., 2016; Rachid et al., 2017).
Sciences in February 2015 (No.GDREC2014260 H(R1)). Participants The Quality of Nursing Work Life (QNWL) questionnaire has been
17
H. Huang, et al. Neurology, Psychiatry and Brain Research 35 (2020) 16–21
volunteer from being criticized; leaded the discussion focus on the nurse-patient
aspects of nursing work life (Fu et al., 2015). In this study, the QNWL
Stimulated the other group members to reflect on issues and prevented the
was adapted from Fu et al. (2015), and the QNWL’s test-retest reliability
tients; and 4) the work world (WW), which consists of 5 items mea-
Express thanks to all group members suring the effects of broad social influences and changes on nursing
relationship and controlled the time
practice.
SPSS 20.0 (IBM, New York State, USA) software was used for sta-
tistical analyses. All normally distributed continuous variables were
compared by t-test. The dependent variables were the difference in
Trainer
burnout (continuous variable) and QNWL among ICU nurses before and
after Balint group intervention. The independent variables included
gender, age, education level, personal income, working time, marital
Expressed their feelings and reactions about the cases
Asked the presenter some questions concerned about
statistically significant.
3. Results
Totally 152 ICU nurses were randomized equally to the two arms of
Listened to the volunteer
the study. The CONSORT flow diagram in Fig. 1 depicted the number of
Other group members
Listened to presenter
Answered the questions of the other group members and supplied related
Rejoined the group and summarized the new feelings and thoughts about
Metaphorically ‘sit back’ from the group and listened to the discussion
In this questionnaire survey, both the scores for DP for the inter-
vention group and control group were ∼21.6, which were much higher
than the threshold of burnout (DP > 9), while the scores for PA for both
groups were ranged in ∼25.13–25.21, which were much lower than the
threshold of burnout (PA < 34). Thus, the ICU nurses suffered from
obvious burnout.
For QNWLS, the scores at baseline were 131–134 for both the in-
tervention group and control group. Compared with the result of a
questionnaire survey conducted by Huang et al. (2013) on nurses in
Guangdong province, China (156.49 ± 25.12), the scores for ICU
nurses was much lower, suggesting a lower Quality of Nursing Work
Life (QNWLS).
information
this case
QNWLS) (Table 4). The result suggested that the Balint group inter-
10∼15
15∼20
Time
<2
vention could relive burnout and promote the quality of work life for
40
10
ICU nurses.
Table 1
Steps
makes no difference for both the MBI and QNWLS. While there was
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H. Huang, et al. Neurology, Psychiatry and Brain Research 35 (2020) 16–21
Table 2 Table 3
Demographics and clinical characteristics of intention-to-treat sample. The Baseline Measures for the two groups.
Characteristics Intervention Control X2 P Characteristics Group Score (mean ± SD) t p
Group (n) Group
(n) MBI Control Group 70.07 ± 6.78 1.28 0.92
Intervention Group 69.96 ± 6.67
Gender Male 21 20 1.122 0.289 DP Control Group 21.66 ± 2.95 3.25 0.61
Female 55 56 Intervention Group 21.67 ± 2.51
Age (year) 18-25 15 14 0.188 0.910 EE Control Group 23.20 ± 2.79 2.57 0.82
26-30 39 40 Intervention Group 23.16 ± 3.12
31-40 22 21 PA Control Group 25.21 ± 3.50 5.23 0.26
Education level Junior college 16 13 0.384 0.536 Intervention Group 25.13 ± 4.01
Undergraduate 60 63 QNWLS Control Group 133.43 ± 14.52 4.38 0.31
Personal 5,000-8,000 16 20 0.582 0.445 Intervention Group 131.63 ± 12.28
income WL-HL Control Group 22.04 ± 2.98 3.21 0.69
(Yuan per Intervention Group 21.97 ± 3.29
month) WC Control Group 34.76 ± 7.03 2.32 0.90
> 8,000 60 56 Intervention Group 34.79 ± 4.72
Working time ≤3 12 15 0.903 0.825 WD Control Group 61.39 ± 5.49 3.33 0.53
(year) 4-6 26 25 Intervention Group 59.69 ± 6.24
7-9 18 20 WW Control Group 15.24 ± 2.94 1.20 0.96
≥10 19 16 Intervention Group 15.17 ± 2.91
contract labor 59 62
Marital status Single 37 34 0.422 0.516 MBI: Maslach Burnout Inventory; DP: depersonalization; EE: emotional ex-
Married 39 42 haustion PA: personal accomplishment; QNWLS: Quality of Nursing Work Life;
Number of Single and no 37 34 0.454 0.929 WL-HL: work life-home life dimension; WC: work context dimension; WD: work
offspring children design dimension; WW: work world.
Married and no 5 6
children
One child 26 28 (DP > 9), while the PA scores (26.30 ± 3.27) were lower than the
Many children 8 8 threshold of burnouts, which suggested that there was also burnout for
ICU nurses after 8 weeks intervention. For QNWLS, at the post-inter-
vention, the high QNWLS scores were mainly contributed by the WL-HL
significant difference with 8 times intervention, which suggested that and WW, while the scores for WC and WD remains unchanged.
the duration of intervention and number of sessions was critical im-
portant in practice.
For MBI, significant decrease in DP and EE were observed after 8 4. Discussion
times intervention, while PA was somewhat increase with no statisti-
cally significance (Table 5). At the post-intervention, the DP scores To our knowledge, this is the first randomized controlled trial of
(13.19 ± 3.39) were slightly higher than the threshold of burnouts Balint group training intervention on ICU nurses’ burnout and quality of
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H. Huang, et al. Neurology, Psychiatry and Brain Research 35 (2020) 16–21
Table 4
Comparisons of control group and intervention group for the total scores of MBI and QNWLS at pre-intervention (Pre), mid-intervention (Mid) and post-intervention
(Post).
Assessment Time No. MBI QNWLS
Note: Pre: baseline; mid: mid-intervention; post: post-intervention; MBI: Maslach Burnout Inventory; QNWLS: Quality of Nursing Work Life. *P < 0.05, **P < 0.01.
work life. In this study, we firstly evaluated whether the ICU nurses et al., 2015). Furthermore, the challenges from work/family balance
suffered from burnout and have lower quality of work life. also contributed the job burnout (Bagwell et al., 2017; Dissanaike,
Subsequently, we adapted a Balint group-based intervention to relieve 2016). They will spend a long time in the ICU before feeling confident
the burnout and promote the quality of work life for ICU nurses. As a and competent. Moreover, social support, experiential avoidance and
result, the ICU nurses suffered from burnout and have lower quality of certain health habits were closely related to burnout (Li et al., 2015).
work life, and the Balint group intervention could significant relieve The results of this study illustrated the potential of intervention
burnout and improve the quality of work life. In addition, the differ- approach to the current crisis of ICU nurse’s burnout and quality of
ences of these positive effects from Balint group-based intervention work life, which consisted with the study of Dorte et al. (2004), who
became more apparent with more session of intervention, which sug- found that doctor participation in a Balint group contributes to a sense
gested that although 8 times intervention could have a positive effect of accomplishment and reduced burnout level. Turner and Malm (2004)
on ICU nurse’s burnout and quality of work life, a longer intervention also found improvements in self-reported psychological skills, abilities,
time was needed for a better result. For different dimensions, DP and EE and confidence among family medicine residents after 9 months of
for MBI decreased markedly in the intervention group at the post-in- Balint training. Balint-type case discussion groups (CDGs) were devel-
tervention, compared with the control group. While the WL-HL and oped to improve the psychological skills of participants (Airagnes et al.,
WW for QNWLS increased dramatically in the intervention group at the 2014; Rabin et al., 1996). During Balint group meetings, distressing
post-intervention. Thus, more cases and practices should focus on PA, patient situations are discussed and thus the ICU nurses may gain better
WC and WD in the future study. insight, and the sharing of difficult experiences is beneficial in de-
Studies suggested that the burnout for ICU nurses was higher than creasing the burden of caring for others (Roy et al., 2015; Spickard,
that in the general wards, and low Quality of Work Life were also very Gabbe, & Christensen, 2002). According to qualitative studies, joining a
common for ICU nurses in China (Fu et al., 2015; Li et al., 2015). Guo Balint group may assist general practitioners in rediscovering the joy of
et al. (2016) conduct surveys for nurses from ICUs and general de- practicing medicine (Kjeldmand & Holmström, 2008). Furthermore, a
partments in China, and the results suggested that ICU nurses have a qualitative study revealed that participation in a Balint group reduced
higher level of burnout than the nurses from general departments, and sensitivity to stress and burnout level among general practitioners
the scores of Personal Accomplishment dimension for ICU nurses was (Kjeldmand & Holmström, 2008). Such a comprehensive approach has
distinctly lower than that of nurses from other departments (p < 0.01). the potential to replace a culture of distress among ICU nurses with a
Li et al. (2015) also performed a cross-sectional study of 356 ICU nurses culture of thriving and flourishing
using self-reported questionnaires under the instruction of trained in- The result of this study also emphasizes the duration of Balint group
vestigators, and the results also consisted with our observations. training intervention time to the final effects. Prior studies have con-
For ICU nurses, burnout and low Quality of Work Life may resulted firmed this finding. For example, in a meta-analysis including 1521
from different reason. Lederer, Kinzl, Traweger, Dosch, and Sumann studies, one year of intervention was most beneficial for EE and DP
(2008)) suggested that advanced technology in the ICU can be a stressor while 6 months of coping strategies was optimal for PA (Lee, Kuo,
to burnout. The overwork-demanding work and frequency “on call” Chien, & Wang, 2016). A study by Rabinowitz, Kushnir, and Ribak
make the nurses often feel overwhelmed and stressed when they first (1996) suggests that 10–12 months of psychological intervention sig-
start working in the ICU (Bagwell et al., 2017; Dissanaike, 2016; Li nificantly increases self-efficacy while short-term psychological
Table 5
Comparisons of control group and intervention group for the scores with different dimensions for MBI and QNWLS at pre-intervention (Pre), mid-intervention (Mid)
and post-intervention (Post).
Assessment Time No. DP EE PA WL-HL WC WD WW
Control Group Pre (mean ± SD) 76 21.66 ± 2.95 23.20 ± 2.79 25.21 ± 3.50 22.04 ± 2.98 34.76 ± 7.03 61.39 ± 5.49 15.24 ± 2.94
Mid (mean ± SD) 76 21.22 ± 2.33 23.03 ± 2.05 24.65 ± 3.34 20.62 ± 3.05 34.84 ± 4.05 61.43 ± 5.40 15.24 ± 2.70
Post (mean ± SD) 76 21.37 ± 2.23 23.68 ± 2.45 25.45 ± 3.37 22.96 ± 3.50 34.08 ± 3.28 60.68 ± 5.72 14.67 ± 2.98
Intervention Group Pre (mean ± SD) 76 21.67 ± 2.51 23.16 ± 3.12 25.13 ± 4.01 21.97 ± 3.29 34.79 ± 4.72 59.69 ± 6.24 15.17 ± 2.91
Mid (mean ± SD) 76 20.47 ± 2.06 24.11 ± 2.26 24.40 ± 3.65 25.93 ± 3.53 34.97 ± 3.92 55.09 ± 5.64 16.97 ± 2.86
Post (mean ± SD) 76 13.19 ± 3.39 18.84 ± 3.18 26.30 ± 3.27 29.17 ± 3.43 33.53 ± 3.40 57.66 ± 8.79 21.57 ± 2.58
F (Intervention main effect) 128.34** 15.80** 0.31 28.32** 96.32 22.32 131.20**
F (Time main effect) 125.32** 22.52** 5.20* 25.69** 89.36 21.58 152.21**
F (Time and intervention interaction) 104.58** 31.33** 0.82 38.62** 70.56 30.21 142.32**
MBI: Maslach Burnout Inventory; DP: depersonalization; EE: emotional exhaustion; PA: personal accomplishment; QNWLS: Quality of Nursing Work Life; WL-HL:
work life-home life dimension; WC: work context dimension; WD: work design dimension; WW: work world;Pre: pre-intervention; mid:mid-intervention; post: post-
intervention. *P < 0.05, **P < 0.01.
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H. Huang, et al. Neurology, Psychiatry and Brain Research 35 (2020) 16–21
intervention (less than 6 months) had no obvious effect. Thus, a longer anesthesiology: Should we be taking better care of our leaders? Anesthesiology,
intervention time was needed for a better result in the future work. 114(1), 181–193.
Dissanaike, S. (2016). How to prevent burnout (maybe). American Journal of Surgery, 212,
This study provides evidence that Balint group training has the 1251–1255.
potential to decrease burnout and elevate the quality of nursing work Dorte, K., & Inger, H. (2008). Balint groups as a means to increase job satisfaction and
life among Chinese ICU nurses. Therefore, it is significant for ICU nurses prevent burnout among general practitioners. Annals of Family Medicine, 6, 138–145.
Dorte, K., Inger, H., & Urban, R. (2004). Balint training makes GPs thrive better in their
to understand and take part in Balint group training. In addition, it job. Patient Education and Counseling, 55(2), 230–235.
could play the part of good groundwork for hospital administrators and Fu, X., Xu, J. J., Song, L., Li, H., Wang, J., Wu, X. H., et al. (2015). Validation of the
ICU nurses to develop such training program and promote ICU nurses’ Chinese version of the quality of nursing work life scale. PloS One. https://doi.org/10.
1371/journal.pone.0121150.
mental health. Hamberg, K., Johansson, E., & Lindgren, G. (2004). Scientific rigour in qualitative re-
search-examples from a study of women’s health in family practice. Family Practice,
4.1. Limitations 11(2), 176–218.
Kamal, A. H., Bull, J. H., & Wolf, S. P. (2016). Prevalence and predictors of burnout
among hospice and palliative care clinicians in the U.S. Journal of Pain and Symptom
While the results of the current study are informative and valuable, Management, 51, 690–696.
there are several limitations. Firstly, the participants of this study were Kavalieratos, D., Siconolfi, D. E., Steinhauser, K. E., Bull, J., Arnold, R. M., Swetz, K. M.,
recruited from ICUs in Guangzhou city of China, which may limit the et al. (2017). “It is like heart failure. It is chronic and it will kill you”: A qualitative
analysis of burnout among hospice and palliative care clinicians. Journal of Pain and
generalization of the findings to other situations and locations Symptom Management, 53(5), 901–910.
(Hamberg, Johansson, & Lindgren, 2004). Secondly, the current study Kroska, E. B., Calarge, C., O’Hara, M. W., Deumic, E., & Dindo, L. (2017). Burnout and
excluded nurses with illness and those who had left their job due to depression in medical students: Relations with avoidance and disengagement. Journal
of Contextual Behavioral Science, 6, 404–408.
pressure-related problems. Therefore, the “healthy worker effect” (Last, Guo, J., Chen, J., Fu, J., Ge, X., Chen, M., & Liu, Y. (2016). Structural empowerment, job
1995) cannot be excluded. Thirdly, the current study did not explore stress and burnout of nurses in China. Applied Nursing Research, 31, 41–45.
possible negative aspects of Balint group that may arise with inter- Huang, H. G., Xu, J. J., Zhang, R., & Fu, X. (2013). Quality of work life among nurses
working in different level hospitals in Guangdong province. Journal of Nursing
vention dropouts. Science, 28(14), 56–58.
Kjeldmand, D., & Holmström, I. (2008). Balint groups as a means to increase job sa-
5. Conclusion tisfaction and prevent burnout among general practitioners. Annals of Family
Medicine, 6(2), 138–144.
Last, J. (1995). A dictionary of epidemiology (3rd ed.). Oxford, UK: Oxford University Press.
Among the nurses who work in ICU, Balint group training, com- Lederer, W., Kinzl, J. F., Traweger, C., Dosch, J., & Sumann, G. (2008). Fully developed
pared with no intervention, resulted in a greater reduction in burnout burnout and burnout risk in critical care personnel at a university hospital.
Anaesthesia Critical Care, 36, 208–213.
and improvement in quality of nursing work life.
Lee, H. F., Kuo, C. C., Chien, T. W., & Wang, Y. R. (2016). A meta-analysis of the effects of
coping strategies on reducing. Applied Nursing Research, 31, 100–110.
Declaration of Competing Interest Li, L., Rong, H., & Yuan, W. (2015). The relationship between social support and burnout
among ICU nurses in shanghai: A cross-sectional study. Chinese Nursing Research,
2(2), 70–77.
None. Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of
Psychology, 52(1), 397–422.
Acknowledgements Matilda, S., Kaisa, A., & Tatiana, V. (2017). A person-oriented approach to sport and
school burnout in adolescent student-athletes: The role of individual and parental
expectations. Psychology of Sport and Exercise, 28, 58–67.
This work was supported by the Guangdong Science and Rabin, S., Herz, M., Stern, M., Vaserfirer, I., Belakovsky, S., Mark, M., et al. (1996).
Technology Project (grant number 2013B021800184) and Guangzhou Improving the professional self-efficacy cognitions of immigrant doctors with Balint
groups. The Israel Journal of Psychiatry and Related Sciences, 33(4), 253–259.
Science and Technology Project (grant number 201804010084). Rabinowitz, S., Kushnir, T., & Ribak, J. (1996). Preventing burnout: Increasing profes-
sional self-efficacy in primary care nurses in a Balint Group. AAOHN Journal, 44(1),
References 28–32.
Rachid, C., Emmanuel, H., & Lucie, G. (2017). Factors associated with burnout among
French digestive surgeons in training: Results of a national survey on 328 residents
Airagnes, G., Consoli, S. M., Morlhon, O. D., Galliot, A. M., Lemogne, C., & Jaury, P. and fellows. American Journal of Surgery, 213(4), 754–762.
(2014). Appropriate training based on Balint groups can improve the empathic Roy, K. V., Vanheule, S., & Inslegers, R. (2015). Research on Balint groups: A literature
abilities of medical students: A preliminary study. Journal of Psychosomatic Research, review. Patient Education and Counseling, 98, 685–694.
76, 426–429. Sekeres, M. A., Chernoff, M., Lynch, T. J., Kasendorf, E., Lasser, D. H., & Greenberg, D. B.
Asuero, A. M., Queraltó, J. M., Pujol-Ribera, E., Berenguera, A., Rodriguez-Blanco, T., & (2003). The impact of a physician awareness group and the first year of training on
Epstein, R. M. (2014). Effectiveness of a mindfulness education program in primary hematology-oncology fellows. Journal of Clinical Oncology, 21(19), 3676–3682.
health care professionals: A pragmatic controlled trial. Journal of Continuing Education Sharmila, D. (2016). How to prevent burnout (maybe). American Journal of Surgery, 212,
in the Health, 34(1), 4–12. 1251–1255.
Bagwell, C. E., Chiu, P., Fecteau, A., Gow, K., Muelle, C. M., Price, D., et al. (2017). 2016 Spickard, A. J., Gabbe, S. G., & Christensen, J. F. (2002). Mid-career burnout in generalist
CAPS ethics session/Ein debate: 1. Regionalization of pediatric surgical care 2. and specialist physicians. JAMA, 288(12), 1447–1450.
Ethical introduction of surgical innovation 3. Addressing stress in a surgical practice: Turner, A. L., & Malm, R. L. (2004). A preliminary investigation of Balint and non- Balint
Resiliency, well-being, and burnout. Journal of Pediatric Surgery. https://doi.org/10. behavioural medicine training. Family Medicine, 36(2), 114–117.
1016/j.jpedsurg.2017.01.025. Tartakovsky, E., & Walsh, S. D. (2016). Burnout among social workers working with
Bagwell, C. E., Chiu, P., Fecteau, A., Fecteau, K. W., Mueller, C. M., Price, D., et al. (2017). immigrants from the Former Soviet Union and Ethiopia in Israel: Testing the con-
2016 CAPS ethics session/Ein debate: 1. Regionalization of pediatric surgical care 2. nections between personal value preferences, immigrant appraisal and burnout.
Ethical introduction of surgical innovation 3. Addressing stress in a surgical practice: International Journal of Intercultural Relations, 53, 39–53.
Resiliency, well-being, and burnout. Journal of Pediatric Surgery Vagharseyyedin, S. A., Vanaki, Z., & Mohammadi, E. (2011). Quality of work life:
S0022346817300581. Experiences of Iranian nurses. Nursing & Health Sciences, 13, 65–75.
De Oliveira, G. S., Jr., Ahmad, S., Stock, M. C., Harter, R. L., Almeida, M. D., Fitzgerald, P.
C., et al. (2011). High incidence of burnout in academic chairpersons of
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