Effect of Balint training in gastroenterology intern nurse practitioners

Abstract Background: This study aims to assess the effect of Balint training (BT) in gastroenterology intern nurse practitioners (GINP) systematically. Methods: This study will search EMBASE, MEDLINE, PsycINFO, Web of Science, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and China National Knowledge Infrastructure from inception to the September 30, 2019 with no language limitation. In addition, we will also search grey records, such as conference abstracts and dissertations. Study quality will be checked using Cochran risk of bias tool. Statistical analysis will be performed using RevMan 5.3 software. Results: This study will systematically evaluate the effect of BT in GINP and will provide evidence to judge whether BT is effective for GINP clinically. Conclusion: The results of this study may provide helpful evidence of BT in GINP in the clinical training.


Introduction
Balint training (BT) is a group-training method, which often consists of 6 to 12 physicians and 2 group facilitators. [1][2][3] It refers to a method designed to helping physicians better understand their roles in the doctor-patient relationship, and also help to enhancing their interpersonal skills. [4][5][6] It is also a patientcentered approach, which helps to aware and understand of how physicians' emotions impact patients' state of mind, rather than just deal with the diagnosis and treatment alone for the patients. [7][8][9][10][11] Previous studies have reported that BT can help physicians to prevent their dimensions of emotional exhaustion, depersonalization, behavioral and psychological disorders, such as depression and anxiety. [12][13][14] It can be applied for a variety of clinical practitioners training, including gastroenterology intern nurse practitioners (GINP). [15][16][17][18][19][20][21][22][23][24][25][26] Although several studies have assessed the effect of BT for GINP, no results are consistent from those studies. [18][19][20]23] Thus, this study will systematically explore the effect of BT for GINP.

Ethics and dissemination
This study will not use individual patient data, thus no ethics approval is required. This study will be published at a peerreviewed journal or a conference presentation.
2.2. Eligibility criteria 2.2.1. Study types. This study will include randomized controlled trials (RCTs) on assessing the effect of BT in GINP. Any other non-RCTs will be excluded.

Intervention types.
The participants in the experimental must undergo BT alone.
However, the participants in the control group can receive any interventions, except BT.

Participant types.
Participants of GINP who receive BT will be included without any limitations of their gender, age, and economic status.
2.2.4. Outcome measurement. The primary outcomes are psychological disorders, including depression and anxiety, as measured by Hamilton Depression Scale or Hamilton Anxiety Scale, or any other relevant scales.
The secondary outcomes are clinical knowledge or skills, as measured using mini-Clinical Evaluation Exercise (mini-CEX) or any instruments; and satisfaction, as measured by any relevant surveys or scores; and examination scores.

Search strategy
We will comprehensively search for studies published in the following bibliographic databases: MEDLINE, EMBASE, PsycINFO, Web of Science, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and China National Knowledge Infrastructure, which cover records in the domains of health cares, medicine, nursing, allied health, health education and its training. Study searches through those databases will cover publication from their inception to the September 30, 2019 with no language limitation. The detailed search strategy for MEDLINE is presented in Table 1. We will also adapt similar search strategies to any other bibliographic electronic databases. In addition, we will also search grey records, such as conference abstracts, dissertations and reference lists of relevant reviews.

Study selection
Two authors will carry out study selection independently and respectively. First, titles and abstracts of all identified records will be scanned to remove any irrelevant and duplicated studies. Second, we will collect full-text of all remaining articles to further judge if they meet all inclusion criteria. All excluded studies will be recorded with specific reasons. We will demonstrate the whole process of study selection in the flowchart.

Data collection and management
Two authors will independently extract information from the included studies. Any differences and discrepancies will be reconciled with the help of a third author through discussion. The extracted information include first author, country of study, research study, research setting, participant characteristics, sample size and methods, research methods, interventions, controls, outcome measurements, and any other associated information.

Dealing with missing data
If any missing or unclear data will be identified, we will contact primary authors to inquire those data. If we cannot get reply, we will analyze available data and will discuss its potential effects.

Study quality
Two authors will independently evaluate research quality. Any discrepancies between two authors will be solved by consensus through arbitration by a third author. We will use Cochrane risk of bias tool to assess the study quality for each included study. We will assess each included study through 7 aspects, and each item will be assessed as "high," "unclear," or "low" risk of bias.

Data synthesis
We will use RevMan 5.3 software to perform statistical analysis. Continuous data will be calculated as standardized mean difference and 95% confidence intervals (CIs). Dichotomous data will be exerted as risk ratio and 95% CIs. We will calculate I 2 statistic to determine the proportion of variation in effect size across included trials due to the heterogeneity regarding I 2 50% as acceptable heterogeneity, and I 2 > 50% as obvious heterogeneity. If I 2 50%, we will use a fixed-effect model, and will conduct meta-analysis. If I 2 > 50%, we will utilize a random-effect model, and will carry out subgroup analysis to investigate its possible reasons. If there is still obvious heterogeneity after subgroup analysis, we will report outcome results as a narrative summary.

Subgroup analysis
We will perform subgroup analysis according to the different interventions, comparators, and outcomes.

Sensitivity analysis
Sensitivity analysis will be conducted to check robustness of synthesized results by excluding studies with high risk of bias.

Reporting bias
If there are at lest 10 studies, we will conduct Funnel plot and Egger's regression test to identify any possible reporting bias.

Discussion
Previous studies have reported BT as a required component of the clinical practice. They hypothesized that BT has been used for the management of GINP. [18][19][20]23] However, there are still not consistent results regarding this issue. Thus, considering several previous studies on investigating the effect of BT for GINP through measuring outcomes, such as mini-CEX, this study will Table 1 Search strategy for database of MEDLINE.

Number
Search terms