Neurology, Psychiatry and Brain Research 35 (2020) 16–21

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Neurology, Psychiatry and Brain Research

journal homepage: www.elsevier.com/locate/npbr

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

ARTICLE INFO ABSTRACT

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.

1. Introduction accomplishment, which is very common in physicians and nurses (Li

Nurses working in intensive care units (ICU) may experience mental
overload, poor professional conduct and a feeling of loss of control and
conflicts of values, which are significant factors resulted in burnout and
other psychological problems for ICU nurses (Fu et al., 2015; Maslach,
Schaufeli, & Leiter, 2001). There has been a recent surge of interest
regarding the psychological problems among ICU nurses, and several
studies have reported a high prevalence rate of burnout and emotional
strain among ICU nurses (Fu et al., 2015; Li, Rong, & Yuan, 2015).
Burnout is a negative psychological state characterized by emo-
tional exhaustion, depersonalization, and a low sense of personal
et al., 2015; Tartakovsky & Walsh, 2016). Studies suggested that more
than 60 % of clinician members of the American Academy of Hospice
and Palliative Medicine (AAHPM) experienced burnout (Bagwell et al.,
2017; Kamal, Bull, & Wolf, 2016; Sharmila, 2016). In China, 50 % of
nurses were dissatisfied with their job-related burnout (Fu et al., 2015).
‘Quality of work life (QWL)’ is being used by organization as an
extent to which an employee is satisfied with personal and working
needs through participating in the workplace while achieving the goals
of the organization. It relates to job satisfaction, intent to leave, turn-
over rate, personality and work stress (Fu et al., 2015; Huang, Xu,
Zhang, & Fu, 2013). The QWL has been studied in a wide variety of

Corresponding authors at: No. 102 Zhongshan Er Road, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou,
⁎

Guangdong, 510080, China.

E-mail addresses: gdpphhuanghuigen@163.com (H. Huang), gengqsh@163.net (Q. Geng).
1
These authors contributed equally to this work.

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.
areas, including sociology, psychology, education, management, health
care, and nursing (Fu et al., 2015; Vagharseyyedin, Vanaki, &
Mohammadi, 2011). Previous studies suggested that the recruitment
and retention for ICU nurses were also related to their QWL (Fu et al.,
2015; Vagharseyyedin et al., 2011).
Burnout and low quality of work life has been linked to hastened
retirement, poor professional conduct, increased risk of medical errors,
as well as deleterious effects on personal health and relationships
(Kavalieratos et al., 2017; Vagharseyyedin et al., 2011). Some physi-
cians and nurses could be described symptoms of overt depression, then
a progression to clinical depression and suicide (Bagwell et al., 2017).
Moreover, the negative emotion is contagious, which may cross over
from one nurse to another in ICU (Li et al., 2015). Given the importance
of ICU nurses, these psychological problems mentioned above may
threat the strength and sustainability of ICU. Thus, effective strategies
should be adapted to relieve the burnout and improve their quality of
work life. In previous studies, there are some psychological intervention
methods were reported to relieve the burnout and other psychological
problems for nurses and medical doctors, such as the Mindfulness-Based
Stress Reduction (MBSR), Cognitive Behavior Therapy (CBT), Balint
Group (BG) and so on (Asuero et al., 2014).
Balint groups training, named after the founder–Michael Balint, MD,
consists of case presentations by group members and group discussions
facilitated by experienced trainers (Dorte, Inger, & Urban, 2004; Roy,
Vanheule, & Inslegers, 2015). In recent years, interventions based on
Balint groups training were widely used in medical practices in many
countries and were included in some training programs in other fields
(Roy et al., 2015). As a result, for physicians and nurses, Balint group
training will increase the competency of general practitioners (GPs) in
patient encounters and enables them to endure in their job and find joy
and challenge in their relationships with patients (Airagnes et al., 2014;
Dorte et al., 2004; Kjeldmand & Holmström, 2008; Roy et al., 2015).
Thus, Balint groups may help GPs handle a demanding work life and
prevent burnout (Dorte & Inger, 2008).
However, previous studies on Balint group training is mostly re-
stricted to short-term interventions in faculty settings (Airagnes et al.,
2014; Sekeres et al., 2003). There are limited studies reported on ICU
nurses. The aim of this RCT study was to explore the experience of
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
was the first attempt to report that whether the Balint group inter-
vention can alleviate the job burnout and improve the Quality of Work
Life for the ICU nurses.
2. Methods
2.1. Design
This work was conducted with a two-arm randomized clinical trial
under the leadership of Guangdong General Hospital from May 2016 to
November 2016. The participants were selected through random sampling
first, then they were divided into two groups (i.e. the intervention group
and the control group) with a random number generator. For the inter-
vention group, participants will receive Balint group training consisting of
eight weekly 1.5 -h sessions, which was conducted by senior Balint trainers
from Guangdong Balint Society. While for participants in the control
group, they will receive no interventions. All participants in both groups
were asked to complete an anonymous online questionnaire of MBI and
Quality of Nursing Work Life (QNWL) at three time points: pre-interven-
tion, mid-intervention (4 weeks) and post-intervention (8 weeks). The
online questionnaires were available at https://www.wjx.cn/wjx/design/
previewq.aspx?activity=10069045&s=1, and the primary outcomes of
this study were the scores of MBI and QNWL.
The study was approved by the Research Ethics Committee of
Guangdong General Hospital & Guangdong Academy of Medical
Sciences in February 2015 (No.GDREC2014260 H(R1)). Participants
17
Neurology, Psychiatry and Brain Research 35 (2020) 16–21
were informed about the objective of the study and the option to ter-
minate participation at any time. Informed consent was obtained from
all participants before starting the study.
2.2. Participants
G*Power software (University of Dusselldorf, Germany, version 3.1)
was used to calculate the optimal sample size for each of the two
groups. The following parameters were entered: alpha error probability
= 0.05, power = 0.8, effect size = 0.55 and allocation ratio (n2/n1) =
1, computed for independent sample t-test for two groups. The sample
size was estimated as 63 for each group. Accounting for participant
dropouts, the optimal sample size for each group was determined to be
76.
Participants were ICU nurses recruited from 13 intensive care units
in 5 hospitals in Guangzhou, China from May 2016 to September 2016.
The inclusion criteria encompassed (1) working in an ICU as a licensed
nurse for at least one year and working in hospitals with at least 1000
beds and 100 ICU nurses; (2) nurses have no difficulty in communica-
tion with others; and (3) nurses who agreed to participate in the present
study. The exclusion criteria were: (1) Participants who have neu-
ropsychiatric disorders; (2) Participants in pregnancy or lactation; (3)
Participants who incomplete or invalid questionnaire. As a result, the
total number of the whole participants was 152. Out of the participants,
20 were from the First Affiliated Hospital of Guangzhou Medical
University, 20 were from the First People’s Hospital of Guangzhou, 20
were from The Second Affiliated Hospital of Sun Yat-sen University, 20
were from Guangdong Traditional Chinese Medicine Hospital, and 72
were from Guangdong General Hospital.
2.3. Arms
Balint group training, including the case reports and group discus-
sions, attempt to throw light on the doctor-patient relationship. The
detailed process of Balint group training was showed in Table 1. The
control group received no interventions. All participants in the control
group finished online questionnaires at the same time as the Balint
group.
2.4. Assessment
Three questionnaires were used for assessing the effectiveness of
Balint group training, including general survey for collecting demo-
graphic information (age, sex, marital status, number of children),
Maslach Burnout Inventory (MBI) and Quality of Nursing Work Life
Scale (QNWLS) (Fu et al., 2015; Matilda, Kaisa, & Tatiana, 2017).
The Maslach Burnout Inventory (MBI) is a comprehensive, multi-
dimensional questionnaire that was created by Susan Jackson, Michael
Leiter and Christina Maslach in 1996 and has been widely used (De
Oliveira et al., 2011; Tartakovsky & Walsh, 2016). It is a self-assessed
reported questionnaire consisting of 22 items, evaluating the 3 di-
mensions of burnout: depersonalization (DP, 5 items), personal ac-
complishment (PA, 8 items) and emotional exhaustion (EE, 9 items)
(Kroska, Calarge, O’Hara, Deumic, & Dindo, 2017; Maslach et al.,
2001). The frequency of experiencing items was measured on a 7-point
Likert scale, ranging from 0 (never) to 6 (everyday). The score for each
sub-scale is obtained by summing the items (the range of the DP score is
0–30, of the PA score is 0–48, and of the EE score is 0–54). High scores
on EE and DP and low scores on PA indicate a high level of burnout
(Guo et al., 2016). In the current study, the definition of burnout was
adopted from a recent survey of hospital resident staff in the United
States: EE > 26 and/or DP > 9 and/or PA < 34 (Guo et al., 2016;
Rachid, Emmanuel, & Lucie, 2017). Reported internal consistencies
were acceptable with Cronbach’s α of 0.89 for EE, 0.69 for DP and 0.84
for PA (Guo et al., 2016; Rachid et al., 2017).
The Quality of Nursing Work Life (QNWL) questionnaire has been
H. Huang, et al. Neurology, Psychiatry and Brain Research 35 (2020) 16–21

demonstrated to be a valid and reliable measurement tool for various

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

Prevented other members from giving advices or criticism to volunteer

was 0.90, and the Cronbach’s α values were > 0.55 for each subscale.
The QNWL tool includes the 4 subscales: 1) work life-home life di-
mension (WL-HL), which consists of 7 items measuring the interaction
between the nurse’s work and home life; 2) the work design dimension
(WD), which consists of 10 items measuring the composition of nursing
work, such as work load, staffing, and autonomy; 3) the work context
dimension (WC), which consists of 20 items measuring the nurses’ work
Invited the case presenter to rejoin the group
settings and the impact of the work environment on nurses and pa-
Controlled time and content appropriately

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.

2.5. Statistical analysis

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

status and number of offspring. A p-value of ≤ 0.05 was considered

the details of the cases in order to better understand

statistically significant.

3. Results

3.1. Sample characteristics and baseline measures

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

individuals enrolled in the study, as well as retention numbers at the

one-month and two-month post-treatment follow-ups. Baseline char-
acteristics for the two arms were shown in Table 2. No statistically
the issues

significant differences were observed.

Table 3 displayed the total scores of MBI and QNWLS at baseline, as
　

well as the scores for different dimensions. As a result, there were no

significant differences in baseline between the intervention group and
issues rather than diagnostic or treatment dilemmas from memory without

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

control group for MBI and QNWLS.

Presented cases that involved challenging nurse–patient relationship

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).

3.2. Comparison of control group and intervention group at different

the aid of notes

intervention time points

Case presenter

information

this case

The 76 participants analyzed in the control group showed no sig-

nificant change for different intervention times, while the scores of MBI
　
Procedure of Balint group.

and QNWLS for the intervention group at post-intervention was sig-

nificantly different from those at mid-intervention (i.e. 58.33 ± 7.38 vs.
68.99 ± 5.66 for MBI and 141.93 ± 13.61 vs. 132.96 ± 10.05 for
(minutes)

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

For different intervention times, in this study, 4 times intervention

1

makes no difference for both the MBI and QNWLS. While there was

18
H. Huang, et al. Neurology, Psychiatry and Brain Research 35 (2020) 16–21

Fig. 1. The CONSORT flow diagram.

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

19
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

Control Group Pre (mean ± SD) 76 70.07 ± 6.78 133.43 ± 14.52

Mid (mean ± SD) 76 68.91 ± 7.07 132.13 ± 8.59
Post (mean ± SD) 76 70.50 ± 7.01 132.39 ± 10.66
Intervention Group Pre (mean ± SD) 76 69.96 ± 6.67 131.63 ± 12.28
Mid (mean ± SD) 76 68.99 ± 5.66 132.96 ± 10.05
Post (mean ± SD) 76 58.33 ± 7.38 141.93 ± 13.61
F (Intervention main effect) 39.47** 315.22**
F (Time main effect) 28.08** 332.26**
F (Time and intervention interaction) 38.97** 394.10*

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
suffered from burnout and have lower quality of work life.
Subsequently, we adapted a Balint group-based intervention to relieve
the burnout and promote the quality of work life for ICU nurses. As a
result, the ICU nurses suffered from burnout and have lower quality of
work life, and the Balint group intervention could significant relieve
burnout and improve the quality of work life. In addition, the differ-
ences of these positive effects from Balint group-based intervention
became more apparent with more session of intervention, which sug-
gested that although 8 times intervention could have a positive effect
on ICU nurse’s burnout and quality of work life, a longer intervention
time was needed for a better result. For different dimensions, DP and EE
for MBI decreased markedly in the intervention group at the post-in-
tervention, compared with the control group. While the WL-HL and
WW for QNWLS increased dramatically in the intervention group at the
post-intervention. Thus, more cases and practices should focus on PA,
WC and WD in the future study.
Studies suggested that the burnout for ICU nurses was higher than
that in the general wards, and low Quality of Work Life were also very
common for ICU nurses in China (Fu et al., 2015; Li et al., 2015). Guo
et al. (2016) conduct surveys for nurses from ICUs and general de-
partments in China, and the results suggested that ICU nurses have a
higher level of burnout than the nurses from general departments, and
the scores of Personal Accomplishment dimension for ICU nurses was
distinctly lower than that of nurses from other departments (p < 0.01).
Li et al. (2015) also performed a cross-sectional study of 356 ICU nurses
using self-reported questionnaires under the instruction of trained in-
vestigators, and the results also consisted with our observations.
For ICU nurses, burnout and low Quality of Work Life may resulted
from different reason. Lederer, Kinzl, Traweger, Dosch, and Sumann
(2008)) suggested that advanced technology in the ICU can be a stressor
to burnout. The overwork-demanding work and frequency “on call”
make the nurses often feel overwhelmed and stressed when they first
start working in the ICU (Bagwell et al., 2017; Dissanaike, 2016; Li
et al., 2015). Furthermore, the challenges from work/family balance
also contributed the job burnout (Bagwell et al., 2017; Dissanaike,
2016). They will spend a long time in the ICU before feeling confident
and competent. Moreover, social support, experiential avoidance and
certain health habits were closely related to burnout (Li et al., 2015).
The results of this study illustrated the potential of intervention
approach to the current crisis of ICU nurse’s burnout and quality of
work life, which consisted with the study of Dorte et al. (2004), who
found that doctor participation in a Balint group contributes to a sense
of accomplishment and reduced burnout level. Turner and Malm (2004)
also found improvements in self-reported psychological skills, abilities,
and confidence among family medicine residents after 9 months of
Balint training. Balint-type case discussion groups (CDGs) were devel-
oped to improve the psychological skills of participants (Airagnes et al.,
2014; Rabin et al., 1996). During Balint group meetings, distressing
patient situations are discussed and thus the ICU nurses may gain better
insight, and the sharing of difficult experiences is beneficial in de-
creasing the burden of caring for others (Roy et al., 2015; Spickard,
Gabbe, & Christensen, 2002). According to qualitative studies, joining a
Balint group may assist general practitioners in rediscovering the joy of
practicing medicine (Kjeldmand & Holmström, 2008). Furthermore, a
qualitative study revealed that participation in a Balint group reduced
sensitivity to stress and burnout level among general practitioners
(Kjeldmand & Holmström, 2008). Such a comprehensive approach has
the potential to replace a culture of distress among ICU nurses with a
culture of thriving and flourishing
The result of this study also emphasizes the duration of Balint group
training intervention time to the final effects. Prior studies have con-
firmed this finding. For example, in a meta-analysis including 1521
studies, one year of intervention was most beneficial for EE and DP
while 6 months of coping strategies was optimal for PA (Lee, Kuo,
Chien, & Wang, 2016). A study by Rabinowitz, Kushnir, and Ribak
(1996) suggests that 10–12 months of psychological intervention sig-
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.

20
H. Huang, et al.
intervention (less than 6 months) had no obvious effect. Thus, a longer
intervention time was needed for a better result in the future work.
This study provides evidence that Balint group training has the
potential to decrease burnout and elevate the quality of nursing work
life among Chinese ICU nurses. Therefore, it is significant for ICU nurses
to understand and take part in Balint group training. In addition, it
could play the part of good groundwork for hospital administrators and
ICU nurses to develop such training program and promote ICU nurses’
mental health.
4.1. Limitations
While the results of the current study are informative and valuable,
there are several limitations. Firstly, the participants of this study were
recruited from ICUs in Guangzhou city of China, which may limit the
generalization of the findings to other situations and locations
(Hamberg, Johansson, & Lindgren, 2004). Secondly, the current study
excluded nurses with illness and those who had left their job due to
pressure-related problems. Therefore, the “healthy worker effect” (Last,
1995) cannot be excluded. Thirdly, the current study did not explore
possible negative aspects of Balint group that may arise with inter-
vention dropouts.
5. Conclusion
Among the nurses who work in ICU, Balint group training, com-
pared with no intervention, resulted in a greater reduction in burnout
and improvement in quality of nursing work life.
Declaration of Competing Interest
None.
Acknowledgements
This work was supported by the Guangdong Science and
Technology Project (grant number 2013B021800184) and Guangzhou
Science and Technology Project (grant number 201804010084).
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