The Effects of Mandala Coloring Applied to Caregivers of Palliative Care Patients on Perceived Stress, Anxiety Level, and Quality of Life: A Cluster Randomized Controlled Trial

Abstract

Background: Caregivers of patients receiving palliative care frequently experience high levels of stress and anxiety, which may negatively affect their quality of life. Objectives: This study aimed to investigate the effects of mandala coloring on perceived stress, anxiety, and quality of life (primary outcomes) among caregivers of patients receiving palliative care. Methods: This cluster randomized controlled trial included 80 caregivers, allocated to an intervention group (n = 40) or a control group (n = 40). The intervention group participated in mandala coloring sessions 4 days per week for 4 weeks (16 sessions total), while the control group received no intervention. Data were collected using the Perceived Stress Scale (PSS), State Anxiety Scale, and Short Form-36 (SF-36) Health Survey. Postintervention outcomes were analyzed using analysis of covariance, controlling for baseline scores. The study was conducted and reported according to CONSORT cluster extension guidelines. Results: After adjustment for baseline scores, the intervention group showed significantly lower PSS (F = 133.29, p < 0.001, eta p(2) = 0.634) and state anxiety scores (F = 38.57, p < 0.001, eta p(2) = 0.334) compared with the control group. Postintervention SF-36 physical (F = 86.31, p < 0.001, eta p(2) = 0.529) and mental health scores (F = 112.05, p < 0.001, eta p(2) = 0.593) were significantly higher in the intervention group. In the control group, perceived stress and anxiety increased significantly, and quality of life scores decreased over the study period (p < 0.05). No adverse events, discomfort, or intervention-related withdrawals occurred, indicating that the intervention was safe and well-tolerated. Conclusion: Mandala coloring effectively reduced perceived stress and anxiety and improved the quality of life in caregivers of palliative care patients. Given its noninvasive, low-cost, and safe nature, it may be recommended as a supportive nurse-led intervention in palliative care settings. Relevance to Clinical Practice: Mandala coloring can be integrated into routine palliative care as a nurse-led nonpharmacological intervention to support caregiver well-being.