Balint Approach Group Intervention

Nurses experience burnout as a response to prolonged exposure to stressors. Burnout significantly reduces nurses' capacity for therapeutic communication by weakening their empathy and active listening skills. Balint therapy is a reflective approach focused on the patient-nurse relationship. In Balint groups, nurses discover how to better manage challenging patient-nurse relationships and strive to improve their interpersonal relationships. Balint groups are particularly helpful in recognizing feelings and thoughts related to patients who are perceived as "difficult." Balint-based interventions are conducive to providing social support by creating a relatively safe atmosphere while respecting nurses' experiences. Furthermore, considering nurses' working conditions, Balint-based interventions are considered an easy-to-implement, time-efficient, and evidence-based approach.

The present study aims to measure the effect of Balint-based group intervention on burnout and communication skills among 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.

This study was conducted using a two-armed parallel group randomized controlled design with pre-test and post-test measurements, and follow-up assessments were performed at one and three months. Participants included nurses recruited using a purposive sampling method. 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: (i) voluntary withdrawal, (ii) missing at least two sessions, and (iii) incomplete or missing data on the study instruments. A total of 50 nurses were contacted by the research team and underwent eligibility screening. A total of 30 nurses who met the inclusion criteria were enrolled in the study, taking into account a potential dropout rate. The study was completed with a total of 30 nurses, 15 in the intervention group and 15 in the control group. Participants were randomly assigned to either the intervention or control group at a 1:1 ratio using simple randomization.

The primary outcome of the study is burnout, measured using the Maslach Burnout Inventory. Higher scores indicate higher levels of burnout. The secondary outcome is communication skills, measured using the Communication Skills Scale for Health Professionals, with higher scores indicating better communication skills. Both outcomes were assessed at baseline, after the intervention, and at one- and three-month follow-ups.

This study conducted from December 2024 to April 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.

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. In this study, weekly sessions followed a structured format adapted from the recommendations of the International Balint Federation. 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.

Data were collected at baseline, immediately after the intervention, and at one- and three-month follow-ups. Sociodemographic characteristics of the groups were compared using chi-square tests or Fisher's exact tests for categorical variables and independent samples t-tests for continuous variables. A two-way mixed-design ANOVA was performed to examine between-group, within-time, and group × time interactions; the Bonferroni test was used for multiple comparisons. Paired sample t-tests were also used to compare pre-test and post-test scores in the intervention group. Effect sizes were reported using Cohen's d for within-group comparisons and partial eta-squared (η²) for the mixed ANOVA. Statistical significance was set at p \< .05.

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.