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3/2020 ST 1
May-June 2020 • Vol. 29/No. 3192
Patricia Maguire, MA, BSN, RN, CMSRN®, is Clinical Nurse IV and Senior Fellow, Professional
Nursing Research Scholarship Program, Pennsylvania Hospital, Philadelphia, PA.
Ann Coughlan, BSN, RN, CMSRN®, is Clinical Nurse II, Pennsylvania Hospital, Philadelphia,
PA.
Deborah Drayton, EdD, MSN, RN, NE-BC, CMSRN®, is Clinical Director of Nursing,
Emergency Department, Medicine, Surgery, and Oncology, Pennsylvania Hospital,
Philadelphia, PA.
Hannah Lacko, MA, CSSBB, is Director of Quality and Patient Safety, Musculoskeletal &
Rheumatology Service Line, Pennsylvania Hospital, Philadelphia, PA.
Jessie Reich, MSN, RN, ANP-BC, CMSRN®, is Magnet® Program Director, Hospital of the
University of Pennsylvania, Philadelphia, PA.
Linda Hatfield, PhD, NNP-BC, FAAN, is Associate Professor of Evidence-based Practice,
Department of Family and Community Health, University of Pennsylvania School of Nursing;
and Director of Research and Evidence-based Practice, Pennsylvania Hospital, Philadelphia,
PA.
Acknowledgment: The authors acknowledge David A. Sandmire, MD, MA, Professor of
Biology, University of New England, for his endorsement of the HeartMath emWave technology
system to measure participants’ heart rate variability.
The Effect of Coloring Mandalas on
the Anxiety of Medical-Surgical
Nurses and Nursing Support Staff
Patricia Maguire
Ann Coughlan
Deborah Drayton
Hannah Lacko
Jessie Reich
Linda Hatfield
I
ncreasing levels of anxiety in
nursing environments is a chal-
lenge for nurses (Paul et al.,
2017). Within acute care institu-
tions, 92% of nurses rate their work-
related anxiety as moderate to very
high. Within those institutions, 39%
of nurses assigned to medical-surgi-
cal or intensive care units report
high or very high symptoms of anx-
iety compared to nurses assigned to
other units in the hospital (18%)
(Jordan et al., 2016). The association
between workplace anxiety and neg-
ative health outcomes (e.g., in –
creased systolic blood pressure, corti-
sol, heart rate) is well documented
(Pascoe et al., 2017; Scott et al., 2015;
Yoshioka et al., 2018). To mitigate
these adverse effects, nurses are
encouraged to integrate individual
evidence-based coping skills such as
coloring mandalas to reduce and
manage anxiety (Jordan et al., 2016;
Roberts & Grubb, 2014). This study
addressed coloring mandalas during
medical-surgical nurses’ break as a
strategy to decrease nurses’ anxiety
compared to conducting regular
activities during the break.
Normal variation in heart rate
(HR) occurs because of actions of two
branches of the autonomic ner vous
system: sympathetic (increases HR)
and parasympathetic (slows HR).
Heart rate variability (HRV) increases
Research for Practice
The increasing complexity of nursing duties and the drive to control
costs are producing considerable pressure in nursing work environ-
ments. Findings of this study suggest coloring pre-drawn mandalas
is an effective, individualized way to lower anxiety in medical-sur-
gical nurses and nursing staff.
when the heart is beating slowly dur-
ing calming and recuperating activi-
ties (Badke et al., 2018; Kim et al.,
2018; Wehrwein et al., 2016) and
decreases as the heart beats more
quickly during anxiety (Chalmers et
al., 2014). Regular, repeating, and
highly ordered HR patterns indicate
a healthy heart (Badke et al., 2018;
Kim et al., 2018; Wehrwein et al.,
2016), as well as a coherent state
characterized by greater emotional
stability, in creased mental clarity,
and im proved cognitive function
(McCraty & Shaffer, 2015; McCraty
& Zayas, 2014).
May-June 2020 • Vol. 29/No. 3 193
Art created with or within a circu-
lar form is called a mandala (Sanskrit
for circle). Research suggests creating
or coloring a mandala promotes
calm and meaningful self-reflection
through integration of an individ-
ual’s conscious and unconscious
(Potash et al., 2016; Quinn, 2019).
Some studies suggest the focused
attention meditative state that may
be produced by coloring mandalas
reduces biomarkers evaluated in
response to anxiety, such as systolic
blood pressure, cortisol, HR, HRV, C-
reactive protein, triglycerides, and
tumor necrosis factor-alpha (Maron
& Nutt, 2017; Pascoe et al., 2017).
See Figure 1 for a depiction of a
mandala (Johnson, 2019).
Review of the Literature
Original studies examining the
effectiveness of coloring mandalas
to reduce anxiety were identified
from electronic databases PubMed
and Medline (January 2014-
December 2018). Search terms were
anxiety, state-trait anxiety, heart rate
variability, autonomic nervous system,
coloring, and mandalas.
A seminal review by Lupien and
coauthors (2009) used data from
animal and human studies to exam-
ine the effects of stress throughout
the lifespan (prenatal to older adult)
on an individual’s central nervous
system, behavior, and cognition.
The review demonstrated continu-
ous presence of stress hormones is
responsible for the development of
anxiety. Anxiety causes dendritic
atrophy in hippocampal CA3 pyra –
midal neurons (responsible for long-
term memory) and dendritic retrac-
tion and a reduction in spine num-
ber in pyramidal neurons in layers
II/III of the prefrontal cortex (neces-
sary for focus, identifying irrelevant
information, and solving problems).
Authors found individuals who
develop moderate-to-severe anxiety
experience the effects of neuronal
atrophy and reduction-confusion,
difficulty concentrating, trouble
learning new information, and diffi-
culties making decisions.
Original research and systematic
reviews have reported the conse-
quences of job anxiety for nurses.
Nursing job anxiety was associated
with decreased job satisfaction in a
systematic review of six studies
(Friganovic et al., 2017). An associa-
tion with increased absenteeism was
found in a randomized controlled
trial (N=413) by Noben and col-
leagues (2015) and increased physi-
cal complaints in a cohort study
(N=138,360) by Huang and associ-
ates (2018). Kuhl (2019) identified
an association between nursing job
anxiety and decreased mental
health, while Hall and colleagues
(2016) identified links to reduced
levels of patient safety and increased
errors. Insomnia, depression, feel-
ings of irritability, lowered self-
esteem, self-doubt, inadequacy, and
somatic illness also have been
reported as anxiety-related out-
comes (Huang et al., 2018; Roberts
& Grubb, 2014). Finally, evidence
points to job anxiety as partially
responsible for the disproportion-
ately high rates of outpatient psy-
chiatric consultation and psychi-
atric admissions among nurses
(Davidson et al., 2018).
HRV is an essential indicator of
an individual’s ability to adapt to
psychological or physiological strain
or environmental tension (Kim et
al., 2018). In their meta-analysis of
37 studies, Kim and coauthors estab-
lished HRV as an objective measure
of anxiety. The meta-analysis did
not describe the study design of the
included studies; however, inclusion
criteria for studies used in the analy-
sis were as follows: the study in –
volved human participants, HRV
was an objective measure of psycho-
FIGURE 1.
Flower Mandala
Source: Image by GDJ on Pixabay
The Effect of Coloring Mandalas on the Anxiety of Medical-Surgical Nurses and Nursing Support Staff
May-June 2020 • Vol. 29/No. 3194
logical stress, and HRV reactivity
was measured and evaluated by any
calculated HRV variables using fre-
quency-based or time-based criteria.
The use of coloring therapy has
emerged as a modality that combines
art therapy and meditation to reduce
anxiety in adolescents (Kostyunina &
Drozdikova-Zaripova, 2016), univer-
sity students (Mehmood Noor et al.,
2017), and medical students (Potash
et al., 2016). Potash and colleagues
conducted a qualitative study
involving 320 Chinese third-year
medical students who were asked to
attend a 2.5-hour art-making work-
shop. During the workshop, they
were asked to color mandalas based
on their emotional state and then to
write a description and discuss their
experiences. Authors found coloring
mandalas promoted self-reflection
through an integration of the con-
scious and unconscious. Mehmood
Noor and associates (2017) found
mandala coloring was an effective
therapeutic intervention to reduce
state and trait anxiety in 100
Pakistani university students. Kost –
yunina and Drozdikova-Zaripova
(2016) concluded a school art thera-
py program that included coloring
mandalas was an effective method
for preventing anxiety disorders in
79 Russian children and adoles-
cents. In a systematic review of ran-
domized and nonrandomized con-
trolled trials (n=162) conducted by
Abbing and colleagues (2018), how-
ever, the low quality of evidence
made it difficult to confirm the
effectiveness of art therapy for
decreasing anxiety in adults.
Eaton and Tieber (2017) recruited
85 undergraduate students to test if
coloring an image free-choice (they
could choose the colors) or forced-
choice (they had to copy the colors
or a pre-colored image) reduced anx-
iety. Results demonstrated a greater
reduction in anxiety in the free
choice coloring group compared to
the forced choice coloring group.
Authors suggested anxiety reduction
may be facilitated by a coloring
activity that provides structure and
engages the participant. In another
university study (Flett et al., 2017),
104 female students were assigned
randomly to a coloring mandala
intervention or a logic puzzle inter-
vention. A seven-item Hospital
Anxiety scale measured participant
anxiety pre- and post-intervention.
Participants in the coloring group
showed significantly lower levels of
anxiety compared to those using the
logic puzzle intervention.
In a randomized controlled trial
that assigned 88 university students
to an unguided mandala coloring
group or a mindfulness-guided col-
oring group (mandala coloring with
mindfulness breathing meditation),
the mindfulness-guided coloring
group demonstrated lower anxiety
(Mantzios & Giannou, 2018).
However, in exit interviews, some
participants did not like the voice
guiding them during coloring, sug-
gesting the voice was disruptive to
their flow and engagement. The
introduction of a unique voice
mindfulness environment may have
mitigated the effects of mandala col-
oring. These studies concluded col-
oring mandalas may decrease anxi-
ety disorders effectively.
Some studies can neither confirm
nor deny coloring mandalas de –
crease anxiety. Duong and col-
leagues (2018) recruited 93 graduate
students and provided either man-
dalas or blank sheets of paper for the
students to color before class.
Students completed the State-Trait
Anxiety Inventory for Adults™
(STAI) before and after the coloring
intervention. Results indicated col-
oring mandalas and coloring a
blank sheet of paper were both effec-
tive measures to decrease anxiety.
Research Question
The research question for this
investigation was as follows: among
medical-surgical nurses and support
staff, does coloring mandalas during
a break increase HRV and reduce
state and trait anxiety compared to
conducting regular activities?
Ethics
The study was approved by the
University of Pennsylvania Insti –
tutional Review Board (Protocol
number 824072).
Sample Selection
To achieve 0.80 power to detect a
significant difference of 20% reduc-
tion in short-term state anxiety
scores between the pre- and post-
intervention (at the two-sided, 0.05
level of significance) and a loss to
attrition of 20%, 40 participants
were required (Faul et al., 2007). All
registered nurses (RNs), licensed
practical nurses, patient care techni-
cians (PCTs), and unit clerks (UCs)
who worked on the unit or floated
among all medical-surgical units
were eligible to participate in the
study, which was conducted at a 43-
bed medical-surgical unit in a 515-
bed urban teaching hospital in the
northeastern United States. Con –
ven ience, purposeful, and snowball
sampling were used to identify par-
ticipants.
Design and Method
A mixed-methods, crossover pre –
test-posttest quasi-experimental de –
sign was used to examine if coloring
mandalas during a participant’s
break increases HRV and decreases
state and trait anxiety levels of med-
ical-surgical staff compared to regu-
lar activities. In conjunction with
the research team, the principal
investigator (PI) posted flyers on the
charge nurse office door describing
the goals of the study and inclusion
criteria. Interested participants were
asked to register in one of 45 avail-
able positions. The research team
also introduced the study at unit
meetings and encouraged staff to
participate. Staff were not obligated
or coerced to participate in the study.
Two members of the research
team approached individuals who
indicated interest during change of
shift huddles and asked them if they
were interested in hearing about the
study. If the individual was interest-
ed in the study, the PI explained the
study and allowed participants to
ask questions about the study.
Consent to have HRV measured and
completion of the STAI survey
before the intervention implied
consent. Participants were informed
they would be compensated for
their time after completing both
Research for Practice
May-June 2020 • Vol. 29/No. 3 195
parts of the study with a $5.00 gift
card to the hospital cafeteria. Forty-
five staff members consented to par-
ticipate and completed both ses-
sions of the study.
Each participant was assigned a
consecutive number for use during
the study to protect confidentiality
and anonymity. Individuals partici-
pating in the study were asked to
surrender their work telephones and
were escorted to a private room. A
researcher reviewed the study proto-
col and answered any questions.
Participants were informed they
could withdraw from the study at
any point without consequences.
Staff who declined participation did
not disclose their reasons, but one
individual volunteered she disliked
coloring since childhood.
Nurses and support staff partici-
pated in the study twice, acting as
their own controls. During the first
session, participants were escorted
to a quiet room away from the nurs-
ing unit to complete the STAI-Form
Y. Data from the form were collected
online and maintained on the Mind
Garden website (Spielberger, 1977).
After participants completed the
STAI-Form Y, HRV was recorded for
5 minutes on a secured computer
using the emWave Pro, a scientifical-
ly validated heart-rate monitoring
system by HeartMath (Boulder
Creek, CA). All Emtrac Wave Pro
data were collected and stored on a
password-protected laptop secured
in the nurse manager’s office.
Following the STAI-Form Y and HRV
data collection, participants had a
20-minute uninterrupted break dur-
ing which they could do whatever
they normally did on an uninter-
rupted break (e.g., watch television,
use personal telephones, rest quiet-
ly) while remaining in the room.
Immediately following the 20-
minute uninterrupted break, the
STAI-Form Y and HRV were re –
assessed following the same proce-
dure as before the break.
After a 2-week washout period,
each participant repeated the
process. Instead of a regular break,
however, participants were asked to
spend 20 minutes coloring a prese-
lected, standard mandala. Parti –
cipants were provided the mandala
and coloring pencils. The STAI-Form
Y and HRV were assessed before and
after the break following the same
procedure as the first episode.
Measurement/Instruments
The STAI-Form Y (Spielberger et
al., 1970) was used to measure anxi-
ety in medical-surgical nurses and
nursing support staff. This inventory
distinguishes between the temporary
condition of short-term state anxiety
and the more general and long-
standing quality of trait anxiety.
Forty statements, divided into two
20-question sections, measure short-
term state anxiety and trait anxiety
independently. Individuals score
each statement subjectively using a
4-point Likert scale (1=almost never,
4=almost always). Range of scores for
the STAI is 20-80, with higher scores
indicating greater anxiety. Reliability
and validity alpha coefficients of
0.92 and 0.90 were determined for
the combined state and trait por-
tions (Spielberger et al., 1983). Addi –
tionally, reliability coefficients of
0.92 and 0.89 were determined indi-
vidually for state and trait anxiety
sections (McEwan & Goldenberg,
1999).
The emWave Pro biofeedback
monitor measured and recorded
pulse rate variability (PRV) to esti-
mate HRV that occurred pre- and
post-control and intervention. A
photoplethysmograph sensor was
attached to the participant’s earlobe
or the finger, based on preference, to
measure and record pulse rate.
emWave software is required to
access measurements and raw file
extractions from recorded sessions.
The data set consists of an initial
timestamp indicating the start of
the recording and interbeat intervals
or intervals between heartbeats per
second. The emWave has estab-
lished validity and reliability as a
measure for HRV. It is highly accu-
rate for 6 of 10 HRV parameters (Lo
et al., 2017).
Findings
Participants included 28 RNs
(75.7%), 12 PCTs (75%), 4 UCs
(80%), and 1 float pool RN. Five par-
ticipants failed to complete both sec-
tions of the study because of work
absenteeism or difficulty scheduling
the tests. Data were missing for one
participant who resigned before com-
pleting the intervention. See Table 1
for characteristics of staff who com-
pleted both parts of the study.
Two-tailed paired student’s t-tests
were performed to compare pre- and
post-intervention mean scores for
the two measures (HRV and STAI
scores) and two intervention types
(normal break and coloring man-
dala break). Practical clinical signifi-
cance (effect size) and statistical sig-
nificance (p-value) are both needed
to allow a reader to make an
informed decision about the effec-
tiveness of an intervention. Cohen
classified effect sizes as small
(d=0.2), medium (d =0.5), and large
(d≥0.8) (Sullivan & Feinn, 2012).
Cohen’s d effect size was used to
quantify the size of the effect for sta-
tistically significant results.
emWave
Comparing the mean difference in
HRV (before normal break minus
after regular break [c–=0.07, SD=0.35])
to the mean difference in HRV (before
coloring break minus after coloring
break [c–=-0.13, SD=0.39]) revealed
anxiety decreased after the coloring
break. This represents a significant
change in HRV (t[df]=2.286(38),
p=0.03, d=0.37). See Table 2; data are
missing for one participant who was
unable to complete the intervention.
State-Trait Anxiety
Inventory-Form
The pre- and post-STAI-Form Y
short-term state anxiety scores
decreased significantly after the reg-
ular break and after the coloring
mandala intervention break (p=0.00
0002915, t[39]=5.46 and p=0.000
002694, t[39]=5.48, respectively).
Trait anxiety scores also de creased
following the regular break and the
coloring mandala intervention
break (p=0.003, t[39]=3.09 and
p=0.003, t[39]=3.14, respectively).
However, a comparison of the effect
of coloring mandalas on short-term
anxiety following a regular break to
the effects of coloring mandalas fol-
lowing a coloring mandala break
The Effect of Coloring Mandalas on the Anxiety of Medical-Surgical Nurses and Nursing Support Staff
Table 1.
Summary of Sample Characteristics
Gender Identity Female 37 (92.5%)
Male 3 (7.5%)
Age Group 18-24 6 (15%)
25-34 14 (35%)
35-44 9 (22.5%)
45-54 9 (22.5%)
55-64 2 (5%)
Highest Level of Education High school graduate 3 (7.5%)
Some college 7 (17.5%)
Trade/Technical/Vocational training 5 (12.5%)
Associate degree 1 (2.5%)
Bachelor’s degree 20 (50%)
Master’s degree 4 (10%)
Role on the Unit RN 24 (60%)
PCT/PCA 13 (32.5%)
UC 3 (7.5%)
Years of Experience in Role 0-5 14 (35%)
6-10 12 (30%)
11-15 5 (12.5%)
16-20 4 (10%)
21-25 3 (7.5%)
26-30 0
31-35 1 (2.5%)
36-40 1 (2.5%)
PCT/PCA = patient care technician, patient care assistant, RN = registered nurse, UC = unit clerk
Paired t-test for comparison of means
HRV = heart rate variability
TABLE 2.
Two-Tailed, Paired Samples t-Test for Mean Pre and Post Session Change in HRV Values
Mean
Difference SD SE Mean
95% CI of Difference
t df
p Value
a=0.05
Cohen’s d
Effect SizeUpper Lower
HRV Before
Normal Break –
After Normal
Break
0.067 0.348 0.055 0.170 -0.046 1.195 38 0.239 0.19
HRV Before
Coloring Break –
After Coloring
Break
-0.133 0.385 0.061 -0.008 -0.258 -2.160 38 0.037 -0.345
HRV Paired
Differences:
Normal Break vs.
Coloring Break
0.2 0.546 0.087 0.377 0.022 2.286 38 0.027 0.366
Research for Practice
May-June 2020 • Vol. 29/No. 3196
May-June 2020 • Vol. 29/No. 3 197
found no significant difference in
short-term state anxiety between
regular and coloring mandala breaks
(p=0.73, t[39]=0.35). Addi tionally,
no significant difference was found
in trait anxiety between regular and
coloring mandala breaks (p=0.90,
t[39]= -0.12).
Mean pre- and post-STAI short-
term state anxiety scores for the col-
oring intervention break (c–=7.43,
SD=8.56, p=0.000002694) were de –
creased compared to short-term state
anxiety following the regular break
(c–=8.03, SD=9.3, p=0.000002915).
However, a comparison of mean pre-
and post-STAI scores in the trait anx-
iety normal break and the pre- and
post- scores in the trait anxiety color-
ing break found a significant
increase in trait anxiety following
the coloring break (c–=2.98, SD=5.99,
p=0.003) contrasted to trait anxiety
following the usual break (c–=2.83,
SD=5.78, p=0.003) (see Table 3).
Discussion
Findings from this study suggest
coloring mandalas during a break
increases HRV and decreases short-
term state anxiety. No significant
differences were found in short-term
state anxiety or trait anxiety
between coloring mandalas during a
break and the regular break. Data on
HRV support earlier studies using
HRV and pulse rates to examine
effects of coloring mandalas to
reduce anxiety. Data from the stud-
ies demonstrated HRV increased
after coloring mandalas, an indica-
tion of calming and recuperating
activities (Badke et al., 2018; Kim et
al., 2018; Wehrwein et al., 2016).
Evidence from earlier studies rein-
forces current study findings that
coloring mandalas decrease anxiety.
The short-term state anxiety and
trait anxiety scores decrease signifi-
cantly after the coloring mandala
intervention break.
Limitations
Because a small convenience
sample of nurses and nursing staff
on one medical-surgical unit was
used, results are not generalizable to
all nurses. The study did not collect
data on participants’ medical histo-
ries, so any preexisting anxiety dis-
orders were not identified. Addi –
tionally, all nurses in the study took
a pretest. However, taking a pretest
may bias participants in their
posttest responses. This study used a
self-report instrument to measure
anxiety. Although self-reports are
assumed to be truthful, they can be
flawed by bias. The study did not
evaluate if anxiety-reducing effects
from coloring mandalas continued
after the coloring activity ceased.
Recommendations for
Future Research
Future studies may focus on pos-
sible influence of the type of geo-
metric design selected for coloring
on anxiety of medical-surgical nurs-
es and nursing staff. Participants in
this study colored a pre-drawn man-
dala rather than creating an original
mandala. This has implications for
outcomes because a unique man-
dala is a personal choice of activity
in art therapy (Kaimal et al., 2017).
Future studies could examine possi-
Paired t-test for comparison of means
STAI = State-Trait Anxiety Inventory
TABLE 3.
Two-Tailed, Paired Samples t-Test for Mean Pre and Post Session Change in STAI Scores
Mean SD SE Mean
95% CI of Difference
t df
p Value
a = 0.05
Cohen’s d
Effect SizeUpper Lower
Short-Term State
Anxiety Normal
Break
8.025 9.297 1.469 10.998 5.051 5.459 39 0.000002915 0.863
Short-Term State
Anxiety Coloring
Break
7.425 8.563 1.359 10.163 4.686 5.483 39 0.000002694 0.867
Short-Term State
Anxiety: Normal
Break vs.
Coloring Break
0.6 10.746 1.699 4.036 -2.836 0.353 39 0.725 0.055
Trait Anxiety
Normal Break
2.825 5.781 0.914 4.674 0.975 3.090 39 0.003 .488
Trait Anxiety
Coloring Break
2.975 5.989 0.946 4.890 1.059 3.141 39 0.003 0.496
Trait Anxiety:
Normal Break vs.
Coloring Break
-0.15 7.731 1.222 2.322 -2.622 -0.122 39 0.902 -0.019
The Effect of Coloring Mandalas on the Anxiety of Medical-Surgical Nurses and Nursing Support Staff
May-June 2020 • Vol. 29/No. 3198
ble reduction of anxiety by creating
mandalas rather than coloring man-
dalas. Authors suggest coloring
mandalas is an appropriate therapy
for reducing stresses because the
activity involves selection and
manipulation of art materials and
individual decisions about color,
shape, patterns, and size. These deci-
sions evoke emotion and can create
a sense of accomplishment that can
reduce anxiety.
Nursing Implications
The increasing complexity of
nursing duties and the drive to con-
trol costs are producing considerable
pressure in nursing work environ-
ments (Roberts & Grubb, 2014).
This pressure can lead to excess and
prolonged anxiety, which may
result in illness and burnout and
affect nurses’ ability to provide qual-
ity care for their patients (Jordan et
al., 2016).
Significant relationship exists
between coloring mandalas and
medical-surgical nurse and nursing
support staff anxiety. Coloring man-
dalas can be used as a tool to combat
nursing fatigue and burnout, both
of which contribute to decreased
quality of patient care. Data from
this study provide the evidence to
recommend worksite wellness pro-
grams for nurses should focus equal-
ly on anxiety reduction, anxiety
management, and development of
healthy individualized coping skills.
Conclusion
Findings of this study suggest col-
oring pre-drawn mandalas is an
effective, individualized way to
lower anxiety in medical-surgical
nurses and nursing staff. Given the
health benefits of anxiety reduction,
mandala coloring could be used in
nursing practice as an evidence-
based intervention to decrease anxi-
ety for medical-surgical staff. Repli –
cation of this study and further
research are needed to determine
the duration of mandala coloring on
anxiety reduction.
REFERENCES
Abbing, A., Ponstein, A., van Hooren, S., de
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The Effect of Coloring Mandalas on the Anxiety of Medical-Surgical Nurses and Nursing Support Staff
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