Research| Volume 49, ISSUE 1, P62-74, January 2023

The Effect of Virtual Reality and Buzzy on First Insertion Success, Procedure-Related Fear, Anxiety, and Pain in Children during Intravenous Insertion in the Pediatric Emergency Unit: A Randomized Controlled Trial

Published:November 11, 2022DOI:



      Distraction methods such as virtual reality and cold vibration device are recommended during intravenous interventions. Few studies have focused on the impact of nonpharmacological interventions on intravenous insertion success.


      A randomized controlled study evaluated effect of virtual reality and cold vibration device application on first-attempt intravenous insertion success and procedure-related pain, fear, and anxiety during intravenous insertion in children. Children aged 4 to 10 years (N = 150) undergoing peripheral intravenous catheterization insertion in the pediatric emergency department were randomized to 1 of 3 groups: virtual reality, cold vibration (Buzzy), and control group. Distraction technique of talking and asking questions of children was used in control group. Primary outcome was first-attempt intravenous insertion success; secondary outcomes were procedure-related pain, fear, and anxiety. Study data were collected using Difficult Intravenous Access score, Emotional Appearance Scale for Children, Wong-Baker Faces Pain Rating Scale, Color Analog Scale, Children's Anxiety Meter-State, and Child Fear Scale. Data were analyzed using chi-square test, Fisher exact test, and Kruskal–Wallis test.


      There were no significant differences in first-attempt intravenous insertion success rates (virtual reality = 47.2%, Buzzy® = 50%, control = 46.9%), preprocedural emotional appearance scores, and procedure-related pain and anxiety scores. There was no difference between groups for vital signs before, during, and at fifth minute of procedure.


      Virtual reality and Buzzy may decrease procedure-related fear in children during intravenous insertion. This research has shown that pediatric emergency nurses can reduce pain and anxiety by talking to children, and simple distractions such as asking questions are as effective as more technological ones.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Srouji R.
        • Ratnapalan S.
        • Schneeweiss S.
        Pain in children: assessment and nonpharmacological management.
        Int J Pediatr. 2010; 2010474838
        • Düzkaya D.S.
        • Bozkurt G.
        • Ulupınar S.
        • Uysal G.
        • Uçar S.
        • Uysalol M.
        The effect of a cartoon and an information video about intravenous insertion on pain and fear in children aged 6 to 12 years in the pediatric emergency unit: a randomized controlled trial.
        J Emerg Nurs. 2021; 47: 76-87
        • Küçük Alemdar D.
        • Yaman Aktaş Y.
        The use of the buzzy, jet lidokaine, bubble-blowing and aromatherapy for reducing pediatric pain, stress and fear associated with phlebotomy.
        J Pediatr Nurs. 2019; 45: 64-72
        • Sivri Bilgen B.
        • Balcı S.
        The effect on pain of buzzy® and shotblocker® during the administration of intramuscular injections to children: a randomized controlled trial.
        J Korean Acad Nurs. 2019; 49: 486-494
        • İnal S.
        • Canbulat N.
        Using of distraction methods on procedural pain management of pediatric patients.
        Arch Health Sci Res. 2015; 2: 372-378
        • Özveren H.
        Non-pharmacological methods at pain management.
        Hacettepe Univ Fac Health Sci Nurs J. 2011; 18: 83-92
        • Bourdier S.
        • Khelif N.
        • Velasquez M.
        • et al.
        Cold vibration (Buzzy) versus anesthetic patch (EMLA) for pain prevention during cannulation in children: a randomized trial.
        Pediatr Emerg Care. 2021; 37: 86-91
        • Kearl Y.L.
        • Yanger S.
        • Montero S.
        • Morelo-Howard E.
        • Claudius I.
        Does combined use of the J-tip® and Buzzy® device decrease the pain of venipuncture in a pediatric population?.
        J Pediatr Nurs. 2015; 30: 829-833
        • Ballard A.
        • Khadra C.
        • Adler S.
        • et al.
        External cold and vibration for pain management of children undergoing needle-related procedures in the emergency department: a randomised controlled non-inferiority trial protocol.
        BMJ Open. 2019; 9e023214
        • Canbulat Şahiner N.
        • İnal S.
        • Sevim Akbay A.
        The effect of combined stimulation of external cold and vibration during immunization on pain and anxiety levels in children.
        J Perianesth Nurs. 2015; 30: 228-235
        • Ş Binay
        • Bilsin E.
        • Özalp Gerçeker G.
        • Kahraman A.
        • Bal Yılmaz H.
        Comparison of the effectiveness of two different methods of decreasing pain during phlebotomy in children: a randomized controlled trial.
        J Perianesth Nurs. 2019; 34: 749-756
        • Baxter A.L.
        • Cohen L.L.
        • McElvery H.L.
        • Lawson M.L.
        • von Baeyer C.L.
        An integration of vibration and cold relieves venipuncture pain in a pediatric emergency department.
        Pediatr Emerg Care. 2011; 27: 1151-1156
        • Bavelier D.
        • Green C.S.
        • Dye M.W.G.
        Children, wired: for better and for worse.
        Neuron. 2010; 67: 692-701
        • Dumoulin S.
        • Bouchard S.
        • Ellis J.
        • et al.
        A randomized controlled trial on the use of virtual reality for needle-related procedures in children and adolescents in the emergency department.
        Games Health J. 2019; 8: 285-293
        • Hua Y.
        • Qiu R.
        • Yao W.
        • Zhang Q.
        • Chen X.
        The effect of virtual reality distraction on pain relief during dressing changes in children with chronic wounds on lower limbs.
        Pain Manag Nurs. 2015; 16: 685-691
        • Özalp Gerçeker G.
        • Ayar D.
        • Özdemir E.Z.
        • Bektaş M.
        Effects of virtual reality on pain, fear and anxiety during blood draw in children aged 5-12 years old: a randomised controlled study.
        J Clin Nurs. 2020; 29: 1151-1161
        • Gerçeker G.Ö.
        • Ş Binay
        • Bilsin E.
        • Kahraman A.
        • Yılmaz H.B.
        Effects of virtual reality and external cold and vibration on pain in 7- to 12-year-old children during phlebotomy: a randomized controlled trial.
        J Perianesth Nurs. 2018; 33: 981-989
        • McCahill R.J.
        • Nagle C.
        • Clarke P.
        Use of virtual reality for minor procedures in the emergency department: a scoping review.
        Australas Emerg Care. 2020; 24: 174-178
        • Caruso T.J.
        • O’Connell C.
        • Qian J.J.
        • et al.
        Retrospective review of the safety and efficacy of virtual reality in a pediatric hospital.
        Pediatr Qual Saf. 2020; 5: e293
        • Schlechter A.K.
        • Whitaker W.
        • Iyer S.
        • Gabriele G.
        • Wilkinson M.
        Virtual reality distraction during pediatric intravenous line placement in the emergency department: a prospective randomized comparison study.
        Am J Emerg Med. 2021; 44: 296-299
        • Andersen R.D.
        • Langius-Eklöf A.
        • Nakstad B.
        • Bernklev T.
        • Jylli L.
        The measurement properties of pediatric observational pain scales: a systematic review of reviews.
        Int J Nurs Stud. 2017; 73: 93-101
        • Li H.C.W.
        • Lopez V.
        Children’s Emotional Manifestation Scale: development and testing.
        J Clin Nurs. 2005; 14: 223-229
        • Schulz K.F.
        • Altman D.G.
        • Moher D.
        • CONSORT Group
        CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials.
        BMJ. 2010; 340: c332
        • Canbulat N.
        • İnal S.
        • Sönmezer H.
        Efficacy of distraction methods on procedural pain and anxiety by applying distraction cards and kaleidoscope in children.
        Asian Nurs Res. 2014; 8: 23-28
        • Yen K.
        • Riegert A.
        • Gorelick M.H.
        Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access.
        Pediatr Emerg Care. 2008; 24: 143-147
        • Gerçeker G.Ö.
        • Yardimci F.
        • Erdoğdu M.
        • Eroğlu B.
        • İslamoğlu A.
        Psychometric properties of the Turkish version of the difficult intravenous access score for children.
        Dokuz Eylül Üniversitesi Hemşirelik Fakültesi Elektronik Dergisi. 2017; 10: 153-158
        • Mete İzci S.
        • Çetinkaya B.
        A Turkish Version of Children’s Emotional Manifestation Scale: reliability and validity assessment.
        J Pediatr Res. 2020; 7: 293-300
      1. Wong-Baker FACES Pain Rating Scale. Wong-Baker FACES Foundation.
        (Accessed October 11, 2020.)
        • Tsze D.S.
        • Hirschfeld G.
        • Dayan P.S.
        • Bulloch B.
        • von Baeyer C.L.
        Defining No Pain, Mild, Moderate, and Severe Pain Based on the Faces Pain Scale-Revised and Color Analog Scale in children with acute pain.
        Pediatr Emerg Care. 2018; 34: 537-544
        • McMurtry C.M.
        • Noel M.
        • Chambers C.T.
        • McGrath P.J.
        Children’s fear during procedural pain: preliminary investigation of the children’s fear scale.
        Health Psychol. 2011; 30: 780-788
        • Gerçeker G.Ö.
        • Ayar D.
        • Özdemir Z.
        • Bektaş M.
        Gaining of children’s state anxiety and children’s fear scale.
        E-Journal of Dokuz Eylul University Nursing Faculty. 2018; 11: 9-13
        • Kleiber C.
        • McCarthy A.M.
        Evaluating instruments for a study on children’s responses to a painful procedure when parents are distraction coaches.
        J Pediatr Nurs. 2006; 21: 99-107
        • Potts D.A.
        • Davis K.F.
        • Elci O.U.
        • Fein J.A.
        A vibrating cold device to reduce pain in the pediatric emergency department: a randomized clinical trial.
        Pediatr Emerg Care. 2019; 35: 419-425
        • Caprilli S.
        • Anastasi F.
        • Grotto R.P.L.
        • Scollo Abeti M.
        • Abeti M.S.
        • Messeri A.
        Interactive music as a treatment for pain and stress in children during venipuncture: a randomized prospective study.
        J Dev Behav Pediatr. 2007; 28: 399-403
        • Piskorz J.
        • Czub M.
        Effectiveness of a virtual reality intervention to minimize pediatric stress and pain intensity during venipuncture.
        J Spec Pediatr Nurs. 2018; 23e12201
        • Chen Y.J.
        • Cheng S.F.
        • Lee P.C.
        • Lai C.H.
        • Hou I.C.
        • Chen C.W.
        Distraction using virtual reality for children during intravenous injections in an emergency department: a randomised trial.
        J Clin Nurs. 2020; 29: 503-510
        • Althumairi A.
        • Sahwan M.
        • Alsaleh S.
        • Abduljabbar Z.
        • Aljabri D.
        Virtual reality: is it helping children cope with fear and pain during vaccination?.
        J Multidiscip Healthc. 2021; 14: 2625-2632
        • Lee H.N.
        • Bae W.
        • Park J.W.
        • et al.
        Virtual reality environment using a dome screen for procedural pain in young children during intravenous placement: a pilot randomized controlled trial.
        PLoS One. 2021; 16e0256489
        • Canbulat N.
        • Ayhan F.
        • Inal S.
        Effectiveness of external cold and vibration for procedural pain relief during peripheral intravenous cannulation in pediatric patients.
        Pain Manag Nurs. 2015; 16: 33-39
        • Lunoe M.M.
        • Drendel A.L.
        • Brousseau D.C.
        The use of the needle-free jet injection system with buffered lidocaine device does not change intravenous placement success in children in the emergency department.
        Acad Emerg Med. 2015; 22: 447-451
        • Shaukat H.
        • Neway B.
        • Breslin K.
        • et al.
        Utility of the DIVA score for experienced emergency department technicians.
        Br J Nurs. 2020; 29: S35-S40
        • Özalp Gerçeker G.
        • Ayar D.
        • Özdemir E.Z.
        • Bektaş M.
        The impact of the difficult vascular access, fear, and anxiety level in children on the success of first-time phlebotomy.
        J Vasc Access. 2018; 19: 620-625
        • Chad R.
        • Sulaiman E.
        • Jillian O.
        Effect of virtual reality headset for pediatric fear and pain distraction during immunization.
        Pain Manag. 2018; 8: 175-179
        • Tork H.M.M.
        Comparison of the effectiveness of Buzzy, distracting cards and balloon inflating on mitigating pain and anxiety during venipuncture in a pediatric emergency department.
        Am J Nurs Sci. 2017; 6: 26-32
        • Semerci R.
        • Kocaaslan E.N.
        • Akgün Kostak M.
        • Akın N.
        Reduction of pain during intravenous cannulation in children: Buzzy application. Article in Turkish.
        Agri. 2020; 32: 177-185
        • Eijlers R.
        • Utens E.M.W.J.
        • Staals L.M.
        • et al.
        Systematic review and meta-analysis of virtual reality in pediatrics: effects on pain and anxiety.
        Anesth Analg. 2019; 129: 1344-1353
        • Osmanlliu E.
        • Trottier E.D.
        • Bailey B.
        • et al.
        Distraction in the Emergency department using virtual reality for intravenous procedures in Children to Improve comfort (DEVINCI): a pilot pragmatic randomized controlled trial.
        CJEM. 2021; 23: 94-102
        • Knight K.
        • McClenaghan C.E.
        • Singh B.
        Virtual reality distraction from painful procedures in the paediatric emergency department.
        Arch Dis Child. 2019; 104: 204-205


      Büşra Güliz Yıldırım is a PhD student, Pediatric Nursing Department, Health Science Institute, Dokuz Eylul University, Izmir, Turkey. ORCID identifier:


      Gülçin Özalp Gerçeker is an Associate Professor, Pediatric Nursing Department, Dokuz Eylül University Faculty of Nursing, Izmir, Turkey. ORCID identifier: