Effect of Twin Hearts Meditation and Mandala Coloring on Exam Anxiety in Nursing Students (Mandala)

March 10, 2026 updated by: Pouran Varvani Farahani, Near East University, Turkey

Comparison of Mandala Coloring and Twin Hearts Meditation on Practical Exam Anxiety: A Randomized Clinical Trial

This randomized clinical trial aimed to compare the effectiveness of Mandala coloring and Twin Hearts Meditation in reducing exam anxiety among undergraduate nursing students. Participants were randomly assigned to either the Mandala coloring group or the Twin Hearts Meditation group. Both interventions were administered before a practical examination. Anxiety levels were measured before and after the intervention using the State-Trait Anxiety Inventory (STAI). The study evaluated which complementary and non-pharmacological intervention was more effective in reducing exam-related anxiety among nursing students.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Study Purpose

The purpose of this study was to compare the effectiveness of Mandala coloring and Twin Hearts Meditation as complementary and non-pharmacological interventions for reducing exam anxiety among undergraduate nursing students.

Study Design

This study was designed as a randomized clinical trial conducted among undergraduate nursing students. Participants were randomly assigned to two intervention groups: Mandala coloring and Twin Hearts Meditation.

Sample Size

Out of 110 eligible nursing students, 100 who met the inclusion criteria were recruited. Based on previous research and a mean comparison formula with a significance level of 0.05 and a statistical power of 80%, the required sample size was calculated as 48 participants per group. Considering possible dropout, 50 participants were included in each group.

Data Collection Tools

Data were collected using:

  • A demographic questionnaire (age, gender, marital status, academic information)
  • The State-Trait Anxiety Inventory (STAI), a validated 40-item self-report instrument measuring state and trait anxiety.

Intervention

Participants were randomly assigned to one of two groups:

Twin Hearts Meditation Group:

Participants received a guided Twin Hearts Meditation session lasting 30 minutes under the supervision of the researcher.

Mandala Coloring Group:

Participants engaged in mandala coloring for 30 minutes using printed mandala designs and colored pencils under the supervision of the researcher.

Both interventions were conducted before a practical examination.

Outcome Assessment

Anxiety levels were measured before and after the intervention using the State-Trait Anxiety Inventory (STAI).

Ethical Considerations

The research received approval from the Cyprus International University Ethics Review Board (Approval No: EKK23-24/012/07). The study followed the ethical standards of the Council of Ethics and adhered to the principles of the Declaration of Helsinki (1964).

Statistical Analysis

Data were analyzed using SPSS software. Descriptive statistics, paired t-tests, independent t-tests, and chi-square tests were used. A P value < 0.05 was considered statistically significant.

Study Type

Interventional

Enrollment (Actual)

100

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Cyprus
    • North Cyprus
      • Nicosia, North Cyprus, Cyprus
        • KKTC (Turkish Republic Of Northern Cyprus)

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult
  • Older Adult

Accepts Healthy Volunteers

Yes

Description

Inclusion Criteria:

  1. All undergraduate nursing students in their first semester, male or female, enrolled in the English-language nursing program.
  2. Students not using other stress-reduction methods (e.g., progressive muscle relaxation, pharmacological therapy).
  3. Students who voluntarily agreed to participate and provided informed consent.

Exclusion Criteria:

  1. Unwilling to continue cooperation in the project.
  2. Using any psycho medicines (anti-depressants ...), mental health.
  3. Mourning, especially the death of loved ones or relatives in the 1st phase.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Supportive Care
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Twin Hearts Meditation
Behavioral: Twin Heart Meditation Participants in this group receive the Twin Heart Meditation intervention, a guided meditative technique based on the principles of loving-kindness and spiritual energy. The intervention is designed to reduce exam-related anxiety by promoting inner peace and emotional regulation.
Behavioral: Twin Heart Meditation

Participants in this group receive Twin Hearts Meditation, a guided meditation technique based on the principles of loving-kindness and spiritual energy. The intervention aims to reduce exam-related anxiety by promoting emotional balance and relaxation.

Intervention:

Behavioral: Twin Hearts Meditation

Participants practice guided meditation sessions lasting 30 minutes under the supervision of the researcher. The meditation protocol includes:

Physical warm-up exercises

Activation of the heart chakra

Activation of the crown chakra

Blessing the Earth with loving-kindness

Silent meditation using the phrase "Amen"

Expression of gratitude

Closing exercises

Sessions are conducted in a quiet room using audio guidance.

Behavioral: Mandala Coloring
Participants were provided with a printed mandala outline on A4 paper and six colored pencils (red, orange, yellow, green, blue, purple). They engaged in free, unstructured mandala coloring for 30 minutes
Experimental: Mandala Coloring
Participants in this group engage in mandala coloring, an art-based mindfulness activity designed to reduce exam anxiety and promote relaxation.
Behavioral: Twin Heart Meditation

Participants in this group receive Twin Hearts Meditation, a guided meditation technique based on the principles of loving-kindness and spiritual energy. The intervention aims to reduce exam-related anxiety by promoting emotional balance and relaxation.

Intervention:

Behavioral: Twin Hearts Meditation

Participants practice guided meditation sessions lasting 30 minutes under the supervision of the researcher. The meditation protocol includes:

Physical warm-up exercises

Activation of the heart chakra

Activation of the crown chakra

Blessing the Earth with loving-kindness

Silent meditation using the phrase "Amen"

Expression of gratitude

Closing exercises

Sessions are conducted in a quiet room using audio guidance.

Behavioral: Mandala Coloring
Participants were provided with a printed mandala outline on A4 paper and six colored pencils (red, orange, yellow, green, blue, purple). They engaged in free, unstructured mandala coloring for 30 minutes

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Exam Anxiety Levels
Time Frame: Anxiety levels are assessed at two time points: before the intervention (two hours prior to the OSCE) and immediately after the intervention prior to the examination.

The primary outcome measure evaluates changes in exam-related anxiety levels among nursing students following the Mandala coloring and Twin Hearts Meditation interventions. Anxiety is measured using the State-Trait Anxiety Inventory (STAI), a validated psychological instrument that assesses both state and trait anxiety. The STAI consists of two subscales with 20 items each, scored on a 4-point Likert scale. Higher scores indicate greater levels of anxiety.

Both groups completed the State-Trait Anxiety Inventory (STAI) two hours before the Objective Structured Clinical Examination (OSCE), immediately prior to the intervention, and again immediately after the intervention.
Anxiety levels are assessed at two time points: before the intervention (two hours prior to the OSCE) and immediately after the intervention prior to the examination.
Test Anxiety Levels
Time Frame: Anxiety levels are assessed at two time points: before the intervention (two hours prior to the OSCE) and immediately after the intervention prior to the examination.

The primary outcome measure evaluates changes in exam-related anxiety levels among nursing students following the Mandala coloring and Twin Hearts Meditation interventions. Anxiety is measured using the State-Trait Anxiety Inventory (STAI), a validated psychological instrument that assesses both state and trait anxiety. The STAI consists of two subscales with 20 items each, scored on a 4-point Likert scale. Higher scores indicate greater levels of anxiety.

Both groups completed the State-Trait Anxiety Inventory (STAI) two hours before the Objective Structured Clinical Examination (OSCE), immediately prior to the intervention, and again immediately after the intervention.
Anxiety levels are assessed at two time points: before the intervention (two hours prior to the OSCE) and immediately after the intervention prior to the examination.

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Near East University, Turkey

Investigators

  • Principal Investigator: Pouran Varvani Farahani, PhD, PhD in Pediatric Nursing, Department of Nursing, Faculty of Health Science, Cyprus International University

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

January 5, 2025

Primary Completion (Actual)

January 20, 2025

Study Completion (Actual)

January 20, 2025

Study Registration Dates

First Submitted

March 10, 2026

First Submitted That Met QC Criteria

March 10, 2026

First Posted (Actual)

March 13, 2026

Study Record Updates

Last Update Posted (Actual)

March 13, 2026

Last Update Submitted That Met QC Criteria

March 10, 2026

Last Verified

March 1, 2026

More Information

Terms related to this study

Keywords

Other Study ID Numbers

  • PVF2026Mandalamed

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

IPD Plan Description

There is no plan to make IPD available to other researchers

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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