The Role of Mandala Painting Before Surgery

Overview

Surgical interventions often cause significant anxiety and stress in patients during the preoperative period. In this study, it is aimed to determine the effect of mandala coloring, a non-pharmacological and art-based intervention, on reducing anxiety and stress levels in individuals scheduled for elective surgery. The universe of the study will consist of patients who will undergo elective surgery between June 2025 and June 2026 in the General Surgery Clinic of Istanbul Sultangazi Training and Research Hospital. Data will be collected using the Introductory Information Form, State Anxiety Inventory (STAI-S), Perceived Stress Scale (PSS), and Physiological Parameters Form (including blood pressure, pulse, respiration rate, and oxygen saturation). One day before surgery, patients who meet the inclusion criteria will be informed about the study and randomized into intervention and control groups using a random number table created with MS Excel software. Patients in the intervention group will perform a 20-minute mandala coloring activity in the preoperative waiting period. Before and after the application, participants' anxiety and stress levels will be evaluated with the STAI-S and PSS, and their physiological parameters will be recorded. Patients in the control group will receive standard preoperative care and will be evaluated at the same time points with the same tools, without any intervention. The study aims to provide evidence for the use of mandala coloring as a simple, low-cost, and effective nursing intervention to reduce preoperative anxiety and stress.

Surgical procedures, although often lifesaving and necessary, are known to trigger significant levels of psychological distress, particularly in the preoperative period. This phase, characterized by uncertainty, fear of anesthesia, and concerns about postoperative outcomes, commonly leads to increased levels of anxiety and stress. Preoperative anxiety is reported in up to 85% of surgical patients and is associated with adverse outcomes such as elevated pain perception, delayed recovery, higher analgesic needs, increased cardiac complications, and lower patient satisfaction. While pharmacological approaches are commonly used, there is growing interest in non-pharmacological and holistic strategies to manage preoperative anxiety and stress effectively. Among the emerging non-drug interventions, art-based therapeutic activities have gained attention due to their accessibility, affordability, and psychological benefits. One such method is mandala coloring, which involves filling in structured circular designs using colors of the participant's choice. The term "mandala" originates from Sanskrit, meaning "circle," and symbolizes wholeness and balance. According to Carl Jung, mandalas help individuals center themselves and connect with their inner states, offering a calming and integrative experience. Mandala coloring has been shown to reduce stress and anxiety by directing attention to the present moment, promoting mindfulness, and eliciting meditative-like states. Unlike traditional art therapy, mandala coloring does not require artistic skill and can be easily implemented across various age and educational levels. Studies suggest that coloring mandalas decreases cortisol levels, improves emotional regulation, and enhances psychological well-being in different populations. Despite its recognized benefits in mental health contexts, limited research exists on the use of mandala coloring specifically in surgical patients during the preoperative period. This study aims to fill this gap by evaluating the effect of a short, structured mandala coloring session on anxiety, stress, and selected physiological parameters among patients awaiting elective surgery. The study will be conducted between June 2025 and June 2026 at Istanbul Sultangazi Training and Research Hospital's General Surgery Clinic. A total of 60 adult patients who meet the inclusion criteria will be recruited and randomly assigned to either the Mandala Coloring Group (intervention) or the Standard Care Group (control) using a random number table created in MS Excel. On the day before surgery, participants will be informed about the study and will provide written informed consent. Baseline data will be collected using the Introductory Information Form, the State Anxiety Inventory (STAI-S), the Perceived Stress Scale (PSS), and a Physiological Parameters Form, which includes systolic and diastolic blood pressure, pulse rate, respiratory rate, and oxygen saturation. Patients in the intervention group will engage in a 20-minute mandala coloring activity using standardized coloring sets in a quiet, preoperative room. Those in the control group will receive routine preoperative care in the same setting, without any additional intervention. Following the intervention period, all participants will undergo the same post-test measurements using the aforementioned tools. By targeting both psychological and physiological indicators, this study aims to demonstrate that mandala coloring is a practical, low-cost, non-pharmacological approach that can be effectively integrated into routine preoperative nursing care. The findings are expected to contribute to evidence-based surgical nursing practices and support the inclusion of creative, holistic methods in the preparation of patients for surgery.