The Effect of Balint Approach Group Intervention on Burnout and Communication Skills in Nurses
Phase: NA
Conditions: Burnout, Communication Skills, Psychosocial Well-being
Sponsor: Yuksek Ihtisas University

STUDY PROTOCOL  
The Effect of Balint-Based Group Intervention on Burnout and Communication Skills in 
Nurses 
 
Sponsor / Responsible Party: 
Reyhan Doğan, PhD, RN 
Bilecik Şeyh Edebali University, Faculty of Health Sciences 
 
Study Type: 
Two-arm Parallel Randomized Controlled Trial 
 
NCT Number: XXXX 
 
Document Type: Study Protocol With Statistical Analysis Plan And Informed Consent Form 
 
Document Date: 19 September 2024 
 
Version: Version 1.0 
 
 
 
 
 
 
 
 
 
 
 

The Effect of Balint Approach Group Intervention on Burnout and Communication 
Skills in Nurses 
Background 
Nurses experience burnout as a response to prolonged exposure to stressors (Hetherington et 
al., 2024). Burnout encompasses emotional exhaustion, depersonalization as a self-protective 
mechanism, withdrawal from communication when feeling inadequate, and a diminished sense 
of personal accomplishment (Zhang et al., 2020). A comprehensive meta-analysis reported that 
approximately three out of ten nurses experience burnout, highlighting the considerable 
prevalence of this issue (Li et al., 2024). The increasing prevalence of burnout in the nursing 
profession negatively impacts not only nurses’ mental health but also their ability to 
communicate effectively (Cohen et al., 2023). Burnout substantially reduces nurses’ capacity 
for therapeutic communication by impairing empathy and active listening skills (Mao et al., 
2024; Yang et al., 2021). Hetherington et al. (2024) reported that burnout causes nurses to 
experience conflicting emotions and engage in increased avoidance behaviors. Additionally, 
higher communication competence among nurses has been found to be associated with lower 
levels of burnout (Lee et al., 2022). Challenges related to burnout and communication threaten 
not only nurses’ mental well-being but also patient safety and the quality of care (Zhang et al., 
2020). The COVID-19 pandemic has particularly highlighted the increased need for 
interventions aimed at improving nurses’ well-being (Cohen et al., 2023). In this context, 
implementing programs that alleviate nurses’ emotional burden and enhance their therapeutic 
communication skills is essential for promoting effective coping strategies and improving 
patient satisfaction (Li et al., 2024; Zhang et al., 2020). Various approaches, including 
Emotional Freedom Techniques (Dincer & Inangil, 2021), Mindfulness-Based Stress Reduction 
training (Talebiazar et al., 2025), and the Communicating Oncologic Prognosis with Empathy 
Guide (Lippe et al., 2020), have shown positive outcomes.  However, despite these results, 
burnout and patient-nurse relationship problems continue to increase among nurses (Cohen et 
al., 2023). A meta-analysis has highlighted that health policies should prioritize protecting 
healthcare workers, in addition to improving working conditions (Quesada-Puga et al., 2024). 
In this context, Balint therapy has been proposed as a novel and effective counseling approach 
to support nurses. 
In Balint groups, nurses explore strategies to better manage challenging patient–nurse 
relationships and enhance their interpersonal skills (Huang et al., 2020). These groups are 
particularly effective in raising awareness of the emotions and thoughts associated with patients 
perceived as “difficult” (Yousefzadeh et al., 2024). Balint-based interventions also provide 
social support by creating a relatively safe environment while respecting nurses’ professional 
experiences (Lv, 2023). Moreover, considering nurses’ working conditions, Balint-based 
interventions are regarded as easily implementable, time-efficient, and evidence-based 
approaches (Yang et al., 2021). 
 
 

Rationale 
Previous studies have primarily examined the effectiveness of Balint therapy among residents 
and medical students (Huang et al., 2020a; McCarron et al., 2024). In recent years, there has 
been growing interest in implementing Balint groups with nurses (Lu et al., 2020). Existing 
literature indicates that Balint therapy is effective in reducing burnout and enhancing self-
efficacy (Shan et al., 2024), improving communication skills (Yang et al., 2021), and promoting 
quality of work-life among nurses (Huang et al., 2020). However, further research is needed to 
examine the long-term effects and sustainability of this intervention among nurses. To the best 
of our knowledge, this study represents the first application of a Balint-based intervention with 
nurses in the country, highlighting a gap in the literature regarding its effectiveness. Given the 
demanding working conditions of nurses, a Balint-based group intervention may provide 
meaningful support for their psychosocial well-being and facilitate positive patient care 
outcomes. 
 The current study aims to measure the effect of a Balint-based group intervention on burnout 
and communication skills in nurses. The research hypotheses are as follows: 
H0-1: There is no significant difference in burnout levels between the intervention and control 
groups. 
H0-2: There is no significant difference in communication skills between the intervention and 
control groups. 
Study design 
The study used a two-arm parallel-group randomized controlled design with pre-test and post-
test measurements and follow-up assessments at one and three months.  
Methods 
Participants were nurses recruited through purposive sampling in 2025. A power analysis was 
conducted to determine the required sample size for the intervention and control groups. Based 
on a previous study examining the effect of Balint group training on burnout (Huang et al., 
2020), the minimum required sample size was calculated as 28 participants, with an alpha (α) 
level of 0.05, an effect size (d) of 1.70, and a power of 99%. Considering the nurses’ shift 
schedules, potential attrition was anticipated. 
 All nurses working in hospitals across various cities nationwide where the study was conducted 
were invited to participate through announcements posted on social media platforms. The 
inclusion criteria were: (i) having worked as a nurse in the same clinical setting for at least one 
year and (ii) providing informed consent to participate. The exclusion criterion was the presence 
of a communication impairment that could hinder participation (e.g., hearing or speech 
disorder). The criteria for discontinuation from the study included: (1) voluntary withdrawal, 
(2) missing at least two sessions, and (3) incomplete or missing data on the study instruments. 
A total of 50 nurses contacted the research team and underwent eligibility screening. Of these, 
17 declined participation after learning that session attendance was mandatory, and three did 

not meet the inclusion criteria. Ultimately, 30 nurses who met the inclusion criteria were 
enrolled in the study, taking anticipated attrition into account.  
Randomization and prevention of bias 
Participants were randomly assigned to either the intervention or control group at a 1:1 ratio 
using simple randomization. An independent academic not involved in the study generated a 
random number list via a computer program to minimize selection bias. Eligible nurses were 
then sequentially allocated to the intervention (n = 15) and control (n = 15) groups according 
to the random sequence. Group assignments were determined using a lottery method conducted 
by two independent academics unaffiliated with the study. The letter “X” represented the 
intervention group, while “Y” represented the control group. Due to the nature of the Balint 
group intervention, blinding of participants and researchers was not feasible. Nevertheless, 
allocation concealment was maintained: data were coded (Group X/Group Y) and analyzed by 
an independent statistician blinded to group assignments to minimize bias. 
Procedure  
This study will be conducted on an online platform from December 2024 to May 2025. 
Participating nurses received an online information form and a voluntary consent form. After 
reviewing the information, participants provided electronic consent. Only those who consented 
were included in the online intervention sessions. 
Intervention group sessions were held once a week, each lasting 45–50 minutes, without 
disrupting nurses’ rest periods or shift schedules. The intervention group was organized as a 
closed group. Session days were scheduled according to nurses’ weekly work schedule. The 
groups were facilitated by two academically qualified researchers specializing in psychiatric 
nursing, each trained in psychotherapy techniques, including psychodrama and cognitive 
behavioral therapy. Sessions were conducted online in a quiet environment, with the screen 
layout designed to allow participants to see one another clearly. Nurses participated in Balint-
based group counseling for six weeks. Post-tests were administered immediately after the final 
session (Session 6). The first follow-up assessment was conducted one month after the 
intervention, and the second follow-up assessment took place three months post-intervention. 
Intervention 
The intervention in this study consisted of nurse-led group counseling based on the Balint 
approach. The primary objectives of a Balint group are to deepen understanding of the nurse–
patient relationship, enhance nurses’ awareness of their own emotions, thoughts, and behaviors 
within that relationship, and provide a supportive environment for participants (Huang et al., 
2020). In this study, weekly sessions followed a structured format adapted from the 
recommendations 
of 
the 
International 
Balint 
Federation 
(https://www.americanbalintsociety.org/reference_library.php). The first session included an 
additional 30 minutes to explain the study’s purpose and procedures, establish a confidentiality 
agreement, and clarify group rules and expectations (e.g., maintaining confidentiality, being 
respectful and non-judgmental, ensuring all members have an opportunity to speak, and 

attending sessions punctually). This preparation ensured that participants were fully prepared 
to engage in the intervention. 
Phase 1 (Case Presentation): In each session, a different group member (the case presenter) 
shared a case involving a patient interaction that elicited intense or challenging emotions (e.g., 
distress, helplessness, frustration, anger). The case presenter elaborated on their feelings, 
thoughts, and behaviors regarding the situation, providing details about when, where, and how 
it occurred. 
Phase 2 (Exploration): Group members asked questions to better understand the dynamics of 
the nurse–patient relationship in the case, while avoiding direct advice or criticism. The case 
presenter clarified ambiguous points and had the opportunity to explore their own experiences 
more deeply. 
Phase 3 (Group Discussion): The group leader asked the case presenter to temporarily withdraw 
and remain silent during the discussion. Group members then discussed various aspects of the 
nurse–patient relationship, sharing their own feelings and perspectives. The group leader 
encouraged members to explore their emotions in depth and guided the discussion toward the 
dynamics of the nurse–patient relationship. By preventing criticism directed at the case 
presenter, the leader ensured a safe environment and effectively managed session time. 
Phase 4 (Feedback): After the discussion, the case presenter rejoined the group to share new 
perspectives and emotional insights gained from the discussion. Group members then provided 
general evaluations of the process and highlighted their learning points. 
Phase 5 (Closing): The group leader summarized the prominent themes that emerged during the 
session, offered a brief evaluation, and concluded the session in a structured manner. 
Control group 
Nurses in the control group continued their routine work schedules and did not receive any 
additional training or psychosocial support during the study period. Data collection instruments 
were administered to the control group concurrently with the intervention group. Because the 
nurses in the control group were employed at different hospitals and were unfamiliar with one 
another, the risk of information sharing between groups was minimized. After the study was 
completed, the control group was informed about the intervention; however, no additional 
counseling services were provided due to scheduling constraints related to their working hours. 
Outcome measures 
The Participant Information Form was prepared by the researchers based on literature (Huang 
et al., 2020; Elzain et al., 2023). This form consists of seven questions to determine 
participatians age, gender, educational status, marital status, physical and mental health status, 
years of employment. 
Primary Outcome Measure: The Maslach Burnout Inventory (MBI) was developed by Maslach 
and Jackson (1981), and its Turkish validity and reliability were established by Ergin (1992). 
The MBI is a self-report instrument used to assess burnout levels and consists of 22 items across 

three subscales: Emotional Exhaustion, Depersonalization, and Personal Accomplishment. 
Each item is rated on a 0–4 scale. Higher scores on the Emotional Exhaustion and 
Depersonalization subscales indicate greater burnout, whereas higher scores on the Personal 
Accomplishment subscale indicate lower burnout. In this study, the Personal Accomplishment 
subscale was reverse-coded so that all subscales aligned in the same direction, with higher total 
scores reflecting higher levels of burnout. Ergin (1992) reported Cronbach’s alpha (α) 
coefficients for the Emotional Exhaustion, Depersonalization, and Personal Accomplishment 
subscales as .83, .65, and .72, respectively. In the present study, Cronbach’s alpha coefficients 
for the pre-test, post-test, first follow-up, and second follow-up assessments were .85, .89, .87, 
and .88, respectively. 
Secondary Outcome Measures:The Communication Skills Scale for Health Professionals 
(CSSHP) was developed by Leal-Costa et al. (2016), and its Turkish validity and reliability 
were established by Mendi et al. (2020). The scale is a self-report instrument designed to assess 
the communication skills of health professionals. It comprises 18 items across four subscales, 
with each item rated on a 1–6 Likert scale. Higher scores indicate better communication skills. 
Mendi et al. (2020) reported Cronbach’s alpha (α) values for the subscales ranging from .72 to 
.79. In the present study, Cronbach’s alpha coefficients for the pre-test, post-test, first follow-
up, and second follow-up assessments were .89, .88, .92, and .92, respectively. 
Statistical analysis 
Data analysis was conducted using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., 
Armonk, NY, USA). The dataset was screened for missing values and assessed for normality 
assumptions prior to analysis. Differences between the intervention and control groups were 
examined using Pearson’s chi-square test for categorical variables and the independent samples 
t-test for continuous variables. Fisher’s exact test was applied when the expected cell count was 
less than five. A two-way mixed ANOVA was performed to evaluate between-group, within-
time, and group × time interaction effects. Bonferroni correction was applied for multiple 
comparisons. Effect sizes were reported using Cohen’s d for within-group comparisons and 
partial eta squared (η²) for the mixed ANOVA. The interpretation of partial eta squared values 
followed the classifications proposed by Cohen (1992): η² ≥ .01 was considered small, η² ≥ .06 
moderate, and η² ≥ .14 large. Statistical significance was set at p < .05. 
Ethical considerations 
Ethical approval for this study was obtained from the Bilecik Seyh Edebali University Non-
Interventional Clinical Research Ethics Committee (19.09.2024 – 280361). Prior to 
participation, nurses were provided with detailed information about the purpose of the study, 
the procedures to be performed, and the voluntary nature of participation. Informed consent 
was obtained electronically from all participants via an online consent form. Participants were 
assured of confidentiality, the right to withdraw from the study at any time, and that their 
personal information would not be shared. 
 
 

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Flow diagram 
 
 
Assessed for eligibility (n=50) 
Excluded (n=20) 
Not meeting inclusion criteria (n=3) 
Declined to participate (n=17) 
Allocated to intervention group (n=15) 
 
Randomised (n=30) 
1-Month Follow-up (n = 15) 
3-Month Follow-up (n = 15) 
Intervention group (n=15) 
 
Control group (n= 15)  
 
Allocated to control group (n=15) 
 
1-Month Follow-up (n = 15) 
3-Month Follow-up (n = 15) 
Follow-up 
Enrolment 
Allocation 
Intervention 
Analyzed (n= 15) 
Analyzed (n= 15) 
Analysis