The effect of adult coloring (mandala pattern) on pain and anxiety associated with dressing changes in burn patients: A randomized controlled trial

Abstract

Introduction

The study investigated the effect of mandala coloring on pain and anxiety associated with dressing changes in burn patients.

Method

This clinical trial was conducted on 60 patients in two groups. At the beginning of the study [baseline (T1)], anxiety and pain were assessed using the BSPAS and VAS. A mandala pattern with colored pencils was provided to the patients in the intervention group. Each patient was given 30 min to color. Anxiety was measured at the 35th minute (T2). A dressing change was performed and 15 min later, the variables were measured again (T3). The control group received no intervention.

Results

The mean anxiety at the baseline (T1), 35th minute (T2), and 15 min after dressing changes (T3) in the intervention and control groups were 38.73  ±  5.55, 26.20  ±  6.08 and 28  ±  8.53, and 39.17  ±  4.17, 41.27  ±  3.68 and 41.63  ±  2.97, respectively. Anxiety at T1 was at the same for both groups. The anxiety in the intervention group decreased (P < 0.001) at T2 and T3 and increased in the control group. The mean pain intensity at the baseline (T1) and 15 min after dressing changes (T2) in the intervention group was 8.47  ±  1.432 and 5.9  ±  1.9, respectively, and in the control group was 8.33  ±  0.802 and 8.77  ±  0.626. Pain intensity at T1 was at the same level for both groups. The pain in the intervention group decreased at T2 (P < 0.001), whilst it increased in the control group.

Conclusion

Mandala coloring can reduce pain and anxiety during dressing changes in burn patients. It can be used as adjuvant treatment.

Lay Summary

Wound dressing in burn patients is accompanied by pain. This painful experience can lead to wound dressing anxiety in these patients. For this purpose, a study was conducted to check whether coloring before wound dressing can reduce the pain and anxiety of dressing in adults. Two groups of patients were included in the study; before the dressing, one group received a pre-prepared image of mandela designs along with colored pencils and colored the design to their taste. The other group did not receive any intervention. The intensity of pain and the level of anxiety of the two groups were measured before and after the dressing. The results showed that the coloring of the mandela design before dressing reduced the pain and anxiety related to the proceedure.

Introduction

Burn injuries, the most common soft tissue injuries, ¹ are an important cause of trauma worldwide. ² Burn injury is still a global public health problem. ³ Burns are the fourth most common trauma and every year more than 300,000 people die from them.^4–8 Burns and their related deaths are a big problem in low- and middle-income communities.^3–6

Burns greatly affect the quality of life and disturb the physical, mental,^1,9 social, and spiritual health of the patient. ⁹ Therefore, they are a threat to a person's health and life ¹⁰ meaning millions of people suffer from problems caused by burns ⁵ and can become disabled as a result. ¹¹

Pain and anxiety are significant problems for burn patients ¹² and they are related. ¹³ Pain is one of the most important complications of burns, and it is aggravated by wound care.^1,14

Although caring for a burn wound is associated with a lot of pain and anxiety, daily care is necessary for the proper healing of the wound. ¹ Pain and anxiety are part of the nature of burn dressing care.^1,13,15 The intensity of pain is high immediately after dressing changes. ¹³ Burn pain is severe, persistent, and distressing. ¹⁶

Severe pain while dressing changes can lead to many complications,^11,15 and there are many reports of inadequate pain control in burn patients. ¹⁴ Lack of effective control of acute pain increases the risk of chronic and neuropathic pain. Anxiety also causes unpleasant emotional reactions to pain. Increased anxiety in burn patients reduces the healing process of the wound as well as the patient’s quality of life and increases the duration of hospitalization. ¹ It has many harmful effects and damages the mind and body. ¹⁷ Pain raises anxiety, ¹ thus, pain^1,12 and anxiety management is essential during wound care ¹ and increases the quality of care. ¹²

Post-burn pain management is complex. Different parts of the nervous system are involved in the perception of pain and in responding to it. Realizing this allows us to recognize the need for multi-modal approaches to pain control. ¹⁴ Various medications are used to control pain^1,12 and anxiety in burn patients; but often, medications alone do not completely control pain and anxiety. ¹² On the other hand, long-term use of these drugs has side effects, which may negatively affect the care and quality of life of these patients.^1,12

Therefore, various non-pharmacological methods are used to control the pain of these patients such as, cognitive techniques (e.g., breathing exercise), distraction (e.g., music therapy), hypnosis,^1,12,16 virtual reality,^12,16,18 and transcutaneous electrical nerve stimulation (TENS). ¹⁶

Nowadays, drug side effects, financial burden, and incomplete disease treatment when using drugs have created a desire ¹⁹ to use complementary treatments.^19,20

Since nurses are an essential part of the care team for patients with burns, they must have the skills to care for these patients and reduce their pain during dressing. In addition to common treatments, they can use non-pharmacological methods to control the pain and anxiety of burn patients. ¹ Each patient should be offered a non-pharmacological method of pain control, at least as adjunctive therapy. ¹⁴

Art therapy is one non-pharmacological treatment, and it can be used as complementary and alternative medicine to restore balance and treat mental disorders.^21,22 Art therapy is a type of psychotherapy that uses art media as a way of expression and communication. The goal of this therapy for the client is to change and grow on an individual level using art materials in a safe and comfortable environment. ²¹ Visual arts (such as painting) are united with psychotherapy as a way of expression and developing coping skills. ²³

Mandala is a type of art therapy that is useful in various fields,^19,24 including medicine and nursing, to reduce anxiety (Figure 1).^24,25 In Sanskrit, mandala means circle,^19,23,26,27 which is a symbol of spirituality.^20,26,27 The purpose of the circle is to increase concentration ²³ as it makes people pay attention to their essence and be honest with themselves to achieve spiritual peace. ²⁸ In this way a mandala helps to maintain and promote mental health. ²⁴

Figure 1.

Example of a mandala color figure (can be viewed at special art-reference No. 25).

Engaging in an art therapy activity may induce a meditative state.^22,24 Recently, color therapy has been gaining attention, ²⁹ as color therapy combines elements of art therapy and meditation.^30,31 Colors help body homeostasis, ³¹ and the mandala coloring process uses states of mindfulness^17,24 and awareness to draw out emotions and reduce anxiety. ²⁴ While coloring, one's mind gets very involved in the coloring process and forgets to worry. ¹⁹ Mandala coloring does not require special skills or art training and can be used as a complementary treatment.^21,28

Despite the growing research on interventions related to pain control in burns, the available studies are insufficient to develop a standard. There is still a need for more research on different interventions to control burn pain ¹⁴ and pain and anxiety during dressing changes. ¹³ Since different people experience different anxieties, it is recommended to investigate the effect of coloring in clinical settings. Also, in addition to anxiety, other variables should be investigated. ²⁷ There is no study on the effect of mandala coloring on the pain and anxiety of burn patients; thus, the present study was designed with the hypothesis that patients who colored mandalas before dressing changes would experience less pain and anxiety. Therefore, this study aimed to explore the effect of coloring mandalas on pain and anxiety associated with dressing changes in burn patients.

Method

Participants, settings

This random clinical trial was conducted on 60 second-degree burns patients admitted to the burn ward of Hazrat Waliasr(A.S.) educational and medical center of Arak University of Medical Sciences. The mean age in the intervention and control groups was 41.43  ±  13.09 and 39.63  ±  12.6 years, respectively (16.7% were 18–25 years old, 25% patients were 26–35 years old, and 58.3% patients were 36–60 years old). Also, 78.3% of patients were married and 66.7% of patients were male. Most people (33.35%) had primary education. In 41.7% of cases, the cause of burns was fire.

The sample size was calculated based on Mehmoud Noor et al.'s study ²⁹ and using the following formula:

$$n={\displaystyle \frac{{(Z_{\alpha /2}+Z_{\beta })}^2\times 2{\sigma }^2}{{({\mu }_1-{\mu }_2)}^2}}$$

$${\displaystyle \frac{{(1.96+0.84)}^2\times 2{(10.205)}^2}{{(39.67-32.09)}^2}}$$

$${\displaystyle \frac{1632.946952}{57.4564}\approx 28.42}$$

Considering the difference between the mean scores before and after the intervention and the equal sample size in the intervention and control groups as well as taking into account the confidence coefficient of 95% (5% type I error) and the statistical power of 80% (20% Type II error), the sample size was determined to be 28 people in each group. But to prevent bias in the results and due to the possible loss of samples, 30 people were included in each group with a total sample size of 60 people. The samples were selected according to inclusion criteria using consecutive sampling. The sampling period was 62 days. The patients were then randomly assigned to an intervention group (A) and a control group (B) using a block randomization method (quadruple block). First, 15 blocks of four were prepared by the researcher and statistics expert as follows: AABB, ABAB, ABBA, BBAA, BABA, BAAB, etc  and people were assigned to two groups based on the list prepared in terms of A and B; this was continuously repeated until the sample volume was completed. The nature of the intervention (coloring) was such that the study was not blinded.

Inclusion/exclusion criteria

The inclusion criteria were having a second-degree burn diagnosed by the specialist, being hospitalized in the burn ward, between the ages of 18–60 years, patient's previous experience of dressing change (having at least one dressing experience for the current burn), the need to change dressing daily based on the physician prescription, the ability to color, no history of neurological diseases and use of psychotropic medications, no history of drug addiction, and no history of underlying medical conditions associated with pain or anxiety. The exclusion criteria were unwillingness to continue participating in the study and filling in the questionnaires incompletely.

Measures/materials and the procedure

After obtaining the code of ethics from the Arak University of Medical Sciences and coordinating with hospital officials, informed consent was obtained from the subjects. The researcher introduced the study to both groups and explained the intervention to those in the intervention group based on the informed consent approved by the ethics committee.

For data collection, in addition to filling in the demographic data form (age, gender, etc.) and burn information, the Visual Analog Scale (VAS) was used to assess pain intensity, and the abbreviated version of the Burn Specific Pain Anxiety Scale (BSPAS) was used to assess anxiety. The VAS is a numerical scale from 0–10, in which one selects a number that reflects patient pain intensity. Zero means no pain and ten means the worst pain. The use of VAS has been validated as a sensitive tool for pain assessment in burn patients. ³² The BSPAS is a validated tool for burn patients and assesses anxiety.^14,33 It consists of five items and respondents are asked to indicate their response to each item on a scale of visual-linear comparisons ranging from zero to ten: zero: not at all and ten: the worst imaginable situation or a lot. The average scores of five items and the scores specified on the linear visual scale determine the final score of pain anxiety. The minimum and maximum score of this scale is zero and 50, respectively. ³⁴

At the beginning of the study [baseline (T1)], the pain intensity in the intervention group (coloring) was measured using the VAS prior to providing the mandala coloring pattern to the patient. At the same time, the anxiety variable was also measured using the abbreviated version of BSPAS. Then, patients were given a pre-selected mandala pattern with a pack of 12 colored pencils for coloring as desired for 30 min. While making art, it is important to do the artwork rather than to finish it, because tactile and visual experiences during the activity are valuable. ²³ Therefore, the patients were told to just color them and that it is not important to finish them. In the burn ward, each patient has a separate room. The coloring and measurement of the variables were done in one’s private room and a quiet space. During coloring, the participants were alone. After coloring, they were given a 5-min break, and then, only the BSPAS questions were asked and the patient's response was recorded (T2). The patients were then directed to the dressing room to change their dressing and returned to their room. Fifteen minutes after the dressing change, the pain intensity (T2) and anxiety associated with dressing changes (T3) were measured and recorded again. Therefore, anxiety was measured at the baseline (T1), 35th minute (T2), 15 min after dressing (T3), and pain intensity was measured at the baseline (T1) and 15 min after dressing (T2).

All 30 patients participating in the study showed a great deal of interest in coloring and none of the 30 patients withdrew from the study due to the attractiveness of the intervention and continued coloring until the end. The control group received no intervention. The tools and time points for measuring the variables in the control group were similar to the intervention group. None of the 60 patients in the intervention and control groups withdrew from the study and accompanied us until the end of the study.

Statistical analysis

Finally, the obtained data were analyzed using SPSS 20 software. The collected data were analyzed using descriptive (mean and standard deviation) and inferential (paired t-test to compare the mean within groups, independent t-test to compare two means between groups, and repeated-measures analysis of variance (ANOVA) to compare the means of anxiety at three time points) statistics. The type I error (significance level /p-value) was considered equal to 5%.

Results

Based on the purpose of the study, we measured the independent variables of anxiety associated with dressing change anxiety and at the mentioned times, and the results are as follows.

According to Figure 2, the score of anxiety associated with dressing changes at T1 was 38.73  ±  5.55 and 39.17  ±  4.178 in the coloring and control groups, respectively. The results of the independent t-test showed no statistically significant difference in the mean score of anxiety at T1 between groups (p  =  0.734). These findings showed that anxiety decreased at T2 and T3 in the coloring group. The results of repeated-measure ANOVA showed that the observed differences were statistically significant (p < 0.001). Anxiety not only decreased in the control group during T2 and T3 but also increased.

Figure 2.

Comparison of the changes in mean anxiety scores associated with dressing changes at the baseline (T1), 35th minute (T2), and 15 min after dressing changes (T3) in the coloring and control groups.

As shown in Figure 3, the mean score of burn pain intensity before coloring was 8.47  ±  1.432 and 8.33  ±  0.802 in the intervention and control groups, respectively. The results of the independent t-test indicated no statistically significant difference between groups (p  =  0.658). The pain intensity in the intervention group significantly decreased at T2, (P < 0.001) whilst it increased in the control group. Pain intensity not only decreased in the control group during T2 but also increased.

Figure 3.

Comparison of the mean scores of pain intensity at the baseline (T1) and 15 min after dressing changes (T2) in the coloring and control groups.

Discussion

The present research was conducted to evaluate the effect of adult coloring (mandala pattern) on pain and anxiety associated with dressing changes in burn patients.

The participants of both groups were anxious at the beginning of the study (baseline). The observed difference between the groups at this time was not significant and they had the same conditions. In the 35th minute of the study, the anxiety of the control group decreased, but it increased in the control group. This anxiety difference was significant. To check the continuity of the short-term coloring effect, anxiety was checked again 15 min after the end of the dressing changes. The results showed that in the control group, although the anxiety score increased slightly compared to the previous measurement, the anxiety score was still low compared to the control group. This difference between the groups was significant, that is, the anxiety level was lower in the coloring group. According to the clinical experiences of the researchers, this reduction in the level of anxiety after coloring was significant not only statistically but also clinically.

Regarding pain, the results showed that the participants of both groups had high pain at the beginning of the study (baseline). The observed difference between the groups at baseline was not significant and they had the same conditions. Fifteen minutes after dressing changes, the pain intensity was checked again in both groups. Pain intensity was reduced in the coloring group and increased in the control group and this difference between the two groups was significant, that is, the pain intensity was lower in the coloring group. According to the clinical experiences of the researchers, this decrease in pain intensity after coloring was statistically and clinically significant and valuable.

The current findings are in line with other studies. Doing artistic work reduces the anxiety of cancer patients.^20,23 In addition, coloring books can reduce anxiety. ²⁷ Mandala coloring has also been able to reduce teenagers’ anxiety, ³⁵ students’ anxiety,^22,29 and students’ math anxiety. ²⁴ Children's pain and anxiety during needle sticks were also reduced with mandalas created on an iPad. ³⁶ Our findings are in line with studies using other non-pharmacological interventions (breathing exercise techniques and virtual reality) to reduce pain and anxiety in burn injury patients.^1,18

In art therapy, visual arts (such as drawing, painting, etc.) are united with psychotherapy as a means of facilitating emotional expression and developing coping skills. ²³ Art therapy makes a person understand the chaos of daily life and communicate without speaking and using words. Non-verbal therapies are great for people with anxiety because they do not require the self-consciousness that often accompanies talking. ³⁰

Coloring a mandala creates a positive cognitive and emotional feeling because of its ability to calm the “inner chaos” of people's emotional states. ²⁴ It connects the conscious and the unconscious and the reality and by revealing the unconscious, it brings healing. ²² When a person colors complex geometric shapes, an opportunity is provided to stop the internal dialogue. Concentration and deep mental engagement in this activity prevent the flow of negative thoughts ³⁰ and emotions in the mind and create a state similar to meditation.^29,30 Coloring relatively complex, symmetrical, and repetitive mandala patterns creates a state similar to meditation and reduces negative thoughts. ²⁹ According to Jung's theory, in coloring the mandala, the client's attention and focus on him/herself makes the therapist able to better formulate the goals and stages of the person's treatment. ¹⁹

The mandala has properties whose positive psychological effects do not reach humans from a distance. There is a mystery in the mandala patterns that makes one receive positive psychological effects after coloring them. ¹⁷

In this research, according to the features proposed for mandala coloring and the close relationship between pain and anxiety in burn patients, it can be said that mandala coloring with meditation and distraction was able to reduce pain and anxiety associated with dressing changes.

Clinical implications

The results of this research, in addition to teaching medical students, can be used in practice. Health professionals can offer mandala coloring as a non-pharmacological method of controlling pain and anxiety during dressing changes, at least as an adjunctive therapy. Considering the special conditions of burn patients who are prone to infection in addition to pain and anxiety, health centers should provide the setting and conditions to perform this attractive and easy artistic-therapeutic intervention.

Limitations

In this study, the frequency of measuring pain and anxiety was not the same. It would be better if both variables were measured at the same time points, which can be considered as one of the limitations of the study. It would be better to measure some physiological indicators, such as pulse, blood pressure, and respiration in addition to measuring pain and anxiety with the used tools.

Recommendations for future research

In this study, the intervention was done once before changing the dressing; it is suggested to investigate the cumulative effect of repeating the intervention. It is recommended to investigate this intervention in different groups and situations; for example, in children or before performing other painful procedures that are commonly used in burn treatment, such as excision and graft surgery. The coloring in our study was done individually, it would be beneficial to design studies that compare single and group coloring. Considering the conditions of the burned patients, the mandala design used in this study was simple and the same for all patients. It seems that study design with more complex or different designs is suitable. In this research, people were free to choose the colors and according to color theory, in mandala coloring, it is recommended to place warm colors in the central part and cold colors in the peripheral part of the mandala design to be more effective. As warm colors are reflected outside and cold colors are reflected inside, ¹⁹ it is better to investigate the effect of this coloring method in future studies. The comparison of the creation of the mandala with its coloring is also suggested for future studies.

Conclusion

Considering the complications that pharmacological treatments may pose to patients, finding alternative or complementary methods to treat the pain and anxiety during dressing changes seems necessary. Mandala coloring significantly reduced pain and anxiety experienced by burn injury patients during wound dressing changes. Therefore, it can be concluded that the use of the mandala coloring technique as one of the non-pharmacological methods and complementary can be effective in reducing pain and anxiety associated with dressing changes in burn patients. Mandala coloring is a safe, convenient, and accessible method with no need for special experience, skill, or art training. It can be used as a complementary treatment.^21,28

How to cite this article

Hamidreza S, Kobra R, Davood H and Siamak RI. The effect of adult coloring (mandala pattern) on pain and anxiety associated with dressing changes in burn patients: A randomized controlled trial. Scars, Burns & Healing, Volume 9, 2023. DOI: 10.1177/20595131231218062.