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  1. Use the required  article to complete the work sheet. i
  2. This assignment contains:
    • Purpose of the Study:  Using information from the required article and your own words, summarize the purpose of the study.  Describe what the study is about. 
    • Research & Design:  Using information from the required article and your own words, summarize the description of the type of research and the design of the study.  Include how it supports the purpose (aim or intent) of the study.
    • Sample:  Using information from the required article and your own words, summarize the population (sample) for the study; include key characteristics, sample size, sampling technique.
    • Data Collection:  Using information from the required article and your own words, summarize one data that was collected and how the data was collected from the study.
    • Data Analysis:  Using information from the required article and your own words, summarize one of the data analysis/ tests performed or one method of data analysis from the study; include what you know/learned about the descriptive or statistical test or data analysis method.
    • Limitations:  Using information from the required article and your own words, summarize one limitation reported in the study.
    • Findings/Discussion:  Using information from the required article and your own words, summarize one of the authors’ findings/discussion reported in the study. Include one interesting detail you learned from reading the study.
    • Reading Research Literature:  Summarize why it is important for you to read and understand research literature.  Summarize what you learned from completing the reading research literature activity worksheet..

Scholarly Sources and Citations 

  • Use APA format in citations and references.

: Reading Research Literature Worksheet

Directions: Complete the following required worksheet using the required article for the current session.

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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).

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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

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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

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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.

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The Effect of Coloring Mandalas on the Anxiety of Medical-Surgical Nurses and Nursing Support Staff

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