Deltoid muscle intramuscular injection methods examining pain comfort satisfaction and fear in ShotBlocker helfer skin tap and standard techniques

Abstract

Background
Deltoid Muscle intramuscular (IM) injection is a standard nursing procedure that often causes discomfort and anxiety. Helfer Skin Tap (HST) and ShotBlocker have been introduced to reduce injection-related pain and improve patient experience.

Aim
This study compares the effects of the deltoid muscle intramuscular injection techniques Helfer Skin Tap, ShotBlocker, and Standard Technique on patients' pain, comfort, satisfaction, and fear levels.

Design
The study used a single-center, randomized, Controlled interventional study design in which three injection techniques were applied to one group.

Participants
Forty patients participated in the study.

Methods
A single-center randomized controlled interventional study was conducted with patients from the Emergency Department of Atatürk University Study Hospital. Data collection tools included forms for sociodemographic characteristics, pain assessment, comfort levels, satisfaction, and fear related to injections. The interventions were applied once daily for three days, and data were analyzed using appropriate statistical methods.

Results
Compared to the Helfer Skin Tap and Standard Technique, the ShotBlocker technique caused the most minor pain and fear and the highest levels of comfort and satisfaction among patients.

Conclusion
The findings suggest that the ShotBlocker technique is the most effective in reducing pain and fear while providing the highest comfort and satisfaction levels. This indicates its potential for widespread adoption in clinical practice to improve patient outcomes during deltoid muscle IM injections.

Trial registration
This research is a randomized controlled study. Therefore, a registration number was applied for at ClinicalTrials.gov. The registration number was obtained with the number “NCT05577832”. (First Posted 13/10/2022)

Conclusion and implications for nursing and/or Health policy
Due to its superior performance, the ShotBlocker technique should be integrated into nursing education and practice. This technique can improve the quality of patient care and enhance the patient experience during deltoid muscle IM injections.

Full text

Yildizand Çiftçi BMC Nursing (2025) 24:390
https://doi.org/10.1186/s12912-025-02901-8
RESEARCH Open Access
© The Author(s) 2025. Open Access This ar ticle is licensed under a Creative Commons Attribution-NonCommercial-NoD erivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or
parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To
view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by- nc- nd/4. 0/.
BMC Nursing
Deltoid muscle intramuscular injection
methods examining pain comfort satisfaction
andfear inShotBlocker helfer skin tap
andstandardtechniques
Güzel Nur Yildiz1 and Bahar Çiftçi2*
Abstract
Background Deltoid Muscle intramuscular (IM) injection is a standard nursing procedure that often causes dis-
comfort and anxiety. Helfer Skin Tap (HST) and ShotBlocker have been introduced to reduce injection-related pain
and improve patient experience.
Aim This study compares the effects of the deltoid muscle intramuscular injection techniques Helfer Skin Tap, Shot-
Blocker, and Standard Technique on patients’ pain, comfort, satisfaction, and fear levels.
Design The study used a single-center, randomized, Controlled interventional study design in which three injection
techniques were applied to one group.
Participants Forty patients participated in the study.
Methods A single-center randomized controlled interventional study was conducted with patients from the Emer-
gency Department of Atatürk University Study Hospital. Data collection tools included forms for sociodemographic
characteristics, pain assessment, comfort levels, satisfaction, and fear related to injections. The interventions were
applied once daily for three days, and data were analyzed using appropriate statistical methods.
Results Compared to the Helfer Skin Tap and Standard Technique, the ShotBlocker technique caused the most minor
pain and fear and the highest levels of comfort and satisfaction among patients.
Conclusion The findings suggest that the ShotBlocker technique is the most effective in reducing pain and fear
while providing the highest comfort and satisfaction levels. This indicates its potential for widespread adoption
in clinical practice to improve patient outcomes during deltoid muscle IM injections.
Trial registration This research is a randomized controlled study. Therefore, a registration number was applied
for at ClinicalTrials.gov. The registration number was obtained with the number “NCT05577832”. (First Posted
13/10/2022)
Conclusionand implications fornursing and/orHealth policy Due to its superior performance, the Shot-
Blocker technique should be integrated into nursing education and practice. This technique can improve the quality
of patient care and enhance the patient experience during deltoid muscle IM injections.
*Correspondence:
Bahar Çiftçi
bahar.ciftci@atauni.edu.tr
Full list of author information is available at the end of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 2 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
Keywords Fear, Deltoid muscle intramuscular injection, Nursing, Nursing practice, Pain, Patient comfort, Patient
satisfaction
Introduction
Nurses have cared for patients in society and hospitals
throughout history, and modern nursing began with
Florence Nightingale. Today, nursing is a healthcare dis-
cipline based on theoretical and scientific knowledge
and involves practical skills. Medication administration
is an essential nursing function requiring related exper-
tise and skills [1, 2]. In IM, the drug is administered into
deep muscle tissue. IM injection can be applied from 4
different regions: ventrolateral, femoral, patellofemoral,
and Deltoid. e nurse decides where to inject, consider-
ing the patient’s Body Mass Index, amount of medication,
muscle development, and muscle ratio [3].
e trauma caused by the needle when it enters the
tissue in injection procedures, not keeping the angle of
entry into the tissue constant, the patient’s previous expe-
riences, and psychological factors regarding the patient
may cause pain and affect the patient-nurse relationship,
patient care quality, and patient satisfaction [3, 4]. Nurses
can reduce the individual’s injection-related pain with
the correct injection technique [5]. In the literature, it
has been determined that methods such as ShotBlocker
[6] and Helfer Skin Tap (HST) [7] are used to reduce or
eliminate injection-related pain.
Background
During the deltoid muscle IM injection, the stimulus
given to the area temporarily blocks pain, closing the
doors to the central nervous system and reducing pain.
Less pain stimulus turns into electrical activity in the
transduction phase, the first stage of pain perception.
Pain is reduced in this way in the HST and ShotBlocker
Techniques, [2, 8].
Katharine Kolcaba [9, 10], who was the theorist of the
Comfort eory, defined comfort in nursing practices
as diagnosing the comfort needs of the individual/fam-
ily/society, planning nursing interventions for unmet
needs, and evaluating the basic comfort levels and the
post-application comfort levels. Increasing the comfort
of individuals is defined as a nursing initiative in nurs-
ing practices. For this reason, nurses are expected to take
precautions to improve the patient’s comfort levels in
nursing practices such as intramuscular injection appli-
cations [1, 10].
Fear of injection is a complication of injection and
describes anxiety about the syringe needle. A previ-
ous study reported that interventions reducing the fear
of injections are very important, as the fear of needles
is more common for patients requiring preventive care
and those receiving treatment [11]. In the literature,
HST and ShotBlocker are among the applications that
prevent complications in injection procedures [8]. Evi-
dence-based analyses by JBI indicate that physical stim-
ulation techniques are effective in reducing pain during
IM injections [11]. A systematic review has shown that
ShotBlocker and HST techniques play a significant role in
minimizing injection pain [12]. Furthermore, meta-anal-
ysis findings support the effectiveness of various pressure
and stimulation techniques in alleviating IM injection
pain [13].
In the literature, the effects of the HST technique on
pain were evaluated in general. It was found that previous
studies generally compared the HST technique with the
standard technique [7], and only one study compared it
with the shotlocker technique [14]. ere are few studies
in the literature that examine the effects of ShotBlocker
and HST use on pain levels in adults. Only one study
was detected in the literature regarding the comfort and
satisfaction of ShotBlocker and HST, and no study was
found on fear. In this context, the gaps in the literature
can be listed as follows; (1) e effects of ShotBlocker,
HST, and ST techniques on adults have not been fully
explained (ere are few studies in the literature on the
effects of ShotBlocker and HST on adults); (2) ere are
few studies on comfort and satisfaction (ere is only one
study on the effects of ShotBlocker and HST on com-
fort and satisfaction); (3) No research has been found
on the effects of injection techniques on fear of injection
in adults (Researching this topic could be an important
contribution to fill the gap in the literature). is indi-
cates that more studies are needed regarding using Shot-
Blocker indeltoid muscle intramuscular injections.
Aim ofthestudy
Equivalence of the experiment(s) and control groups is
essential in experimental studies. Also, to eliminate the
effects of external variables (e.g., pain threshold, pain
tolerance, comfort, satisfaction perception, etc.) in stud-
ies, applying all three techniques to the same individual
is valuable in emphasizing a study’s originality. [15]. e
last component of the Life Model, which was devel-
oped by Loper-Logan-Tierney and the most used nurs-
ing model on a global scale, is individuality in life, which
emphasizes that each individual reacts differently to the
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 3 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
same event, perceives it differently and develops differ-
ent coping mechanisms [16]. For this reason, in previous
studies found in the literature, the separation of patients
into experimental and control groups and the fact that in
this study, three different methods were used on the same
individuals by prioritizing individuality in life shows the
originality of the present study. e study aimed to inves-
tigate HST, ShotBlocker, and Standard Techniques in
terms of pain, comfort, satisfaction, and fear of injection
and to compare these parameters.
In addition, it was aimed to (1) compare the effects of
ShotBlocker, HST and standard injection techniques on
pain, fear, comfort and satisfaction during deltoid muscle
intramuscular injection, (2) fill the existing gaps in the liter-
ature by comparing the effects of injection techniques such
as ShotBlocker and HST on pain, fear, comfort and satis-
faction, (3) guide new studies using injection techniques on
pain, comfort, satisfaction and fear levels in injection appli-
cations, (4) prepare the ground for new methods other than
the conventional methods in the literature where the indi-
viduality of the patients is prioritized, (5) manage the pain,
comfort, satisfaction and fear process related to deltoid
muscle intramuscular injection with non-pharmacological
methods, (6) make a contribution to the literature both
clinically and theoretically by examining the effects of Shot-
Blocker and HST techniques on these parameters, consid-
ering the limited information in the literature on injection
fear, comfort and satisfaction levels.
Hypotheses
H1. Helfer Skin Tap, ShotBlocker, and intramuscu-
lar injections applied using standard methods affect
patients’ pain at different levels.
H2. Helfer Skin Tap, ShotBlocker, and intramuscu-
lar injections applied with standard methods affect
patients’ comfort at different levels.
H3. Helfer Skin Tap, ShotBlocker, and intramuscu-
lar injections applied with standard methods affect
patient satisfaction at different levels.
H4. Deltoid muscle intramuscular injections applied
with Helfer Skin Tap, ShotBlocker, and standard
methods affect patients’ injection-related fear at dif-
ferent levels.
Materials andmethods
Type ofthestudy
e study had a randomized-controlled design. For this
reason, a registration number, “NCT05577832,” was
received at ClinicalTrials.gov (First Posted 13/10/2022).
e design and conduct of the study followed the Con-
sort 2010 Guidelines.
Place andtime thestudy wasconducted
Cyanocobalamin injections are administered in the
country’s hospitals or Family Health Centers emergency
services. However, due to the risk of allergy, the first
dose is administered in hospitals’ emergency services.
e study was conducted with patients who came to
the Emergency Department of Atatürk University Study
Hospital in August 2023 to receive a Cyanocobalamin
injection.
Population andsample ofthestudy
The study population consisted of patients who
applied to the Emergency Department of Atatürk Uni-
versity Study Hospital in August 2023 to receive Cya-
nocobalamin injection. A priori power analysis was
performed in the GPOWER 3.1.9.7 Package Program
based on analysis of variance in repeated measure-
ments before determining the study sample [17]. It was
found that the number of samples required to exceed
90% of the power of the study with a 95% Confidence
Interval, α=0.05 and a medium effect size (0.25) was
36. When planning the research process, it was antici-
pated that there would be some losses. Therefore, the
researchers aimed to reach at least 36 people. Because
of the possible loss of data, the researchers decided
that 10% more individuals should be included in the
study. Thus, it was concluded that 40 participants
would be sufficient. A total of 86 patients applied to
the Emergency Department of Atatürk University
Study Hospital to receive Cyanocobalamin injection;
31 people were not included in the sample because
two patients were under 18 years of age, three patients
weighed less than 60 kilograms, four patients did not
reside in the city center, nine patients did not have the
first dose of Cyanocobalamin treatment, and 13 peo-
ple did not agree to participate in the study. A total of
55 people participated in the first stage of the study.
The study sample consisted of 40 people because 15
withdrew from the study (Figure1). The withdrawal of
15 patients from the study did not prevent randomi-
zation. The study continued with new patients instead
of those who withdrew from the study. For example,
patient number 15 was included in the study in the
order of BAC administration. However, the patient
who performed injections B and A did not participate
in injection C and withdrew from the study. In this
case, the patient who came to the clinic first and met
the inclusion criteria was included in the study instead
of patient number 15. The injection was performed in
the order of BAC administration. Additionally, patients
were informed about randomization after recruitment.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 4 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
Inclusion criteria ofthestudy
-Being over 18 years old
-Having at least three consecutive doses of IM Cya-
nocobalamin 1 ml amp injection treatment
-Being in the range of 60–120 kg
-Residing in Erzurum city center
-Just starting the first dose of Cyanocobalamin
treatment
- Having no scars, incisions, lipodystrophy, or
infections at the injection site
-Having no history of allergy to the drug
-Having no disease that prevents perception of
variables such as pain, fear, etc. (e.g., loss of vision,
hearing, sensation, cognitive impairment, stroke,
Diabetes Mellitus)
-Not using central or peripherally acting analgesics
or sedatives
-Having no missing limbs
-Being prescribed with Cyanocobalamin amp 1 ml
IM.
Exclusion criteria ofthestudy
-Not coming 3 times for injection application
-Administering another injection to the Deltoid
region
-Development of drug-related allergy or other com-
plications
-Withdrawal from the study
Data collection tools used inthestudy
e study’s data were collected using the Sociodemo-
graphic Characteristics Form, Visual Analogue Scale
(VAS), Comfort Scale for Injection (CSFI), Scale of Sat-
isfaction After Injection (CSAI), and Injection Fear Scale
(IFS).
Sociodemographic characteristics form
e form was prepared by using the researchers’ experi-
ences and literature data [4, 6, 7, 14, 18] and consisted of
questions on age, gender, marital status, presence of fear
of injection, level of fear of injection, severity of injection
pain, fear of injection pain.
Visual Analog Scale (VAS)
e VAS is a reliable measurement tool developed to
measure individuals’ pain levels using a simple, enjoy-
able, quick-to-fill-out, and easy-to-score scale. e Visual
Analog Scale was initially developed with the under-
standing that pain is a subjective experience and that it
is important to measure this experience quantitatively.
e VAS is usually presented as a 10 cm long line. Par-
ticipants indicate their current pain level by marking
it on this line. is marking allows the pain level to be
Fig 1. CONSORT Flow Diagram
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 5 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
expressed as a numerical value. In tests conducted, it has
been shown that the Turkish VAS version does not cre-
ate any linguistic and cultural problems and accurately
reflects the pain intensity. e VAS is a highly sensi-
tive tool for measuring the intensity of pain. Subjective
descriptive expressions are at both ends of a 10-cm ruler
(0: lowest pain level and 10: highest pain level) [19].
Comfort Scale forInjection (CSFI)
e scale was developed by Yıldız etal. to measure indi-
viduals’ comfort levels regarding injection and consists of
10 items. Yıldız etal (2024) developed the "Comfort Scale
for Injection" in Turkish society. ey collected data from
two state hospitals during the scale development pro-
cess. ey collected data from 102 participants in the
pilot application phase of the scale and 186 participants
in the main application phase. ey provided content
validity, structural validity (Exploratory Factor Analysis
and Confirmatory Factor Analysis), and criterion validity
during the scale development process. In addition, Yıldız
et al tested the scale’s reliability with Internal Consist-
ency (Cronbach’s Alpha) and Split-Half Reliability analy-
ses. As a result of the analyses, they determined that the
scale was valid and reliable. It was created in the 5-point
Likert design, from “1: I disagree” and “5: I totally agree”.
e scale is calculated based on the item score averages.
e lowest score that can be obtained from the scale is
one, and the highest score is 5. As the score increases, the
comfort level increases. e items of the CSFI evaluate
various aspects of comfort during injection, including the
patient’s posture, ability to expose the injection site, pri-
vacy, and pain perception. For instance, the scale includes
statements such as "I felt comfortable in the injection
position" and "e injection site was selected considering
my comfort." In their study, Yildiz etal. determined that
the Cronbach Alpha Value of the entire scale was 0.899
[20]. In this study, it was determined that the Cronbach
Alpha Value of the HST Technique was 0.85, the Cron-
bach Alpha Value of the ShotBlocker Technique was 0.81,
and the Cronbach Alpha Value of the Standard Tech-
nique was 0.81.
Scale ofSatisfaction After Injection (SSAI)
e scale was developed by Yıldız and Çiftçi (2023) to
determine patients’ satisfaction levels with the injection
procedure in the 5-point Likert design (“1-I am not at all
satisfied, 5-I am very satisfied”). Yıldız and Çiftçi (2023)
developed the "Scale of Satisfaction After Injection" in
Turkish society. ey collected data from 98 patients in
the pilot application phase of the scale and 389 patients
in the main application phase (189 for exploratory fac-
tor analysis, 200 for confirmatory factor analysis). ey
provided content validity, structural validity (Exploratory
Factor Analysis and Confirmatory Factor Analysis) and
Criterion validity during the development process of the
scale. In addition, Yıldız etal tested the reliability of the
scale with Internal Consistency (Cronbach’s Alpha) and
Split-Half Reliability analyses. As a result of the analyses,
they determined that the scale was valid and reliable. e
score is calculated based on the item score average. e
lowest score that can be obtained is one, and the high-
est score is 5. As the score obtained increases, the level
of satisfaction increases. SSAI consists of 9 items. e
items on the SSAI cover different aspects of patient sat-
isfaction, including pain management, communication
with the nurse, hygiene, and injection site privacy. Some
of the items include: "I was satisfied with the communica-
tion of the nurse during the injection" and "e injection
procedure was performed in a way that respected my
privacy." In the study conducted by Yıldız and Çiftçi, the
Cronbach Alpha Value of the entire scale was determined
to be 0.895 [21]. In this study, it was determined that the
Cronbach Alpha Value of the HST application was 0.85,
the Cronbach Alpha Value of the ShotBlocker Technique
was 0.73, and the Cronbach Alpha Value of the Standard
Technique application was 0.85.
Injection Fear Scale (IFS)
e scale was developed by Yıldız and Çiftçi (2023) to
determine individuals’ fear levels towards the injection
process and consists of 14 items in the 5-point Likert
design (“1- I am not afraid at all; 5- I am very afraid”).
Yıldız and Çiftçi (2023) developed the "Injection Fear
Scale" in Turkish society. ey collected data from 108
patients in the pilot application phase of the scale and
402 patients in the main application phase (196 for
exploratory factor analysis, 206 for confirmatory factor
analysis). ey provided content validity, structural valid-
ity (Exploratory Factor Analysis and Confirmatory Factor
Analysis) and Criterion validity during the development
process of the scale. In addition, Yıldız etal tested the
reliability of the scale with Internal Consistency (Cron-
bach’s Alpha) and Split-Half Reliability analyses. e
analysis results showed that the scale was valid and reli-
able. e score is calculated based on the item score aver-
age. e lowest score that can be obtained is one, and
the highest score is 5. As the score increases, the level of
fear increases. e scale items assess various fear factors
related to injection procedures, including anxiety about
pain, needle size, and potential complications. Example
items include: "I am afraid of seeing the needle before the
injection" and "I worry about developing an allergic reac-
tion after the injection." Yıldız and Çiftçi reported in their
study that the Cronbach Alpha Value of the entire scale
was 0.92 [22]. In this study, the Cronbach Alpha Value of
the HST application was found to be 0.90, the Cronbach
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 6 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
Alpha Value of the ShotBlocker Technique was 0.91, and
the Cronbach Alpha Value of the Standard Technique
application was 0.88.
Interventions
Application site
ere are several important reasons why the deltoid
region was chosen for intramuscular injection applica-
tions in this study. (1) e deltoid muscle provides an
ideal site for injection because it is an easily accessible
region and is generally not surrounded by large blood
vessels. is reduces the risk of complications during
injection. (2) e deltoid region has a thinner fat layer
than other muscles, allowing the injection to be per-
formed quickly and efficiently. us, the potential risk
of trauma can be reduced. (3) e deltoid region is less
uncomfortable and traumatic for patients. (4) Since the
deltoid muscle is a widely preferred region for intramus-
cular injections, it has the advantage of being a familiar
application for healthcare professionals and patients.
is creates the potential to increase the generalizability
of the study and the impact of the research results. In this
context, the selection of the deltoid region may play an
effective role in factors such as pain, comfort, fear, and
satisfaction, which allows for a better evaluation of the
effectiveness of different techniques in the study. e
deltoid muscle is generally used for vaccine preparations
and drug applications and has a low viscosity of 1 ml or
less. A horizontal line is drawn approximately 1 cm below
the upper arm’s acromion process towards the arm’s
outer side surfaces to determine the deltoid area. By join-
ing both ends of this imaginary line at the axillary line, an
inverted triangle is obtained, and the middle point of this
triangle creates the injection area [1, 3].
Methods tobe applied
For the validity and reliability of the research results,
injection applications were applied by a nurse expert in
the field of nursing principles. us, possible dichoto-
mies/biases regarding patient approach, patient dia-
logues, informed consent, informing the patient about
the research, patient position, and drug application
methods were eliminated. To ensure consistency between
applications, three injection applications were applied
to the patients at the same hours. To prevent interaction
between patients in the waiting room, cooperation was
made with the patients regarding the hours they would
arrive. us, patient interaction was prevented and bias
was reduced. During the data collection phase, coopera-
tion was made with the nurse working in the clinic. e
nurse in the clinic informed the researcher about the
application to be made according to the randomization
order. After the application, data were collected by the
nurse in the clinic in order to prevent bias.
e patient is tapped twice on the lower part of the
injection site in HST and the lower part of the del-
toid muscle without touching the injection site. Dur-
ing the third tapping process, the needle is entered into
the detected area in synchronization with the tapping.
By holding the plunger with the active hand, the drug is
injected at a rate of 10 seconds/ml. e nurse waits 10
seconds before withdrawing the needle. With the fourth
stroke, the needle is withdrawn straight and steadily at
the angle at which it entered the tissue [23].
ShotBlocker has a non-pointed, short, approximately
2 mm thick surface with blunt protrusions touching the
skin. e protruding surface is placed on the area to be
applied before the injection. A hole in the middle of the
vehicle allows injections to be made easily. e injec-
tion is used through this hole. e ShotBlocker device is
placed on the Deltoid area, and gentle pressure is applied
in this method. e needle sheath is removed, and the
syringe is held between the thumb and index finger of the
active hand. e needle is inserted rapidly into the tissue
from the middle of the ShotBlocker device at an angle of
72–90 degrees. Once the needle is in, the nurse grasps
the lower end of the syringe using the thumb and index
finger of the passive hand. e drug is injected at a rate of
10 seconds/ml by holding the piston with the active hand.
e nurse waits 10 seconds before withdrawing the nee-
dle. e needle is withdrawn straight and steady at the
angle at which the tissue was entered. e ShotBlocker
device on the Deltoid region is removed [24].
Randomization andreducing bias
e study consisted of a single sample. It was very impor-
tant to reduce bias in the research process. erefore,
some precautions were taken to prevent bias in the study;
(1) e most important precaution was to randomize the
research methods during the application. (2) Participants
did not know in which order the application would be
made. us, one-way blinding was provided. (3) More
than one patient was prevented from being in the wait-
ing room during the data collection process. In this way,
interaction between participants was prevented. (4) In
addition, participants cooperated in not communicat-
ing with other participants. us, interaction between
participants was minimized and participants were pre-
vented from acting biased consciously or unconsciously.
(5) It was ensured that the measurement tools used in the
study were valid, reliable and in line with the hypothesis
of the study. Otherwise, bias could have been caused in
the study. (6) Appropriate statistical analyses were used
in reporting the research results and Bonferroni analysis
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 7 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
was used in comparisons. (Bonferroni analysis is used to
reduce the frequency of false positive results.)
Based on the power analysis, 40 people were planned to
be included in the present study. To avoid bias, the order
of the methods to be applied to the patients was ran-
domly classified as A, B, and C. ree different applica-
tions would be evaluated once a day for three days in the
study. To determine which methods A, B, and C would
be, the researcher wrote the names of the methods on
three pieces of paper and drew them in order.
Method A was HST, Method B was Standard Tech-
nique, and Method C was ShotBlocker Technique. Since
three methods were used in the research, there were 6
combinations regarding the order of the methods used
(3!=3*2*1*=6; ACB, BAC, BCA, CAB, and CBA). A, B,
and C methods were classified as ABC, ACB, BAC, BCA,
CAB, and CBA, respectively. Similarly, the researcher
wrote these methods on six pieces of paper and drew
them individually. is way, the sequence of methods to
be applied to the patient group was determined. ACB,
BAC, CAB, BCA, CBA, and ABC rankings were drawn.
e order of the methods for the patients to be included
in the study was planned in this way. e patients were
divided into two groups according to the order of their
admission to the hospital. Each patient was assigned to
the groups according to the order of their arrival. In this
way, bias was prevented in terms of which groups the
patients would be assigned to. In addition, the order of
the application techniques was ensured to be equally
organized (Table1).
Collection ofdata
Before starting the study, patients were informed about
its purpose and method and their rights and responsi-
bilities. e patients who agreed to participate in the
study completed the “Sociodemographic Characteris-
tics Form.” ree different methods were applied to the
patients once every day. After each application, the “Vis-
ual Analog Scale,” “Comfort Scale for Injection,” “Scale of
Satisfaction After Injection,” and “Injection Fear Scale”
were filled out.
During the study, patients were waited for half an hour
after the injection and kept under observation to provide
early intervention for IM injection complications. e
data were collected within half an hour while the patient
was under observation, and no complications developed
in any patient.
Statistical analysis
e data were evaluated in the SPSS package program.
e statistical significance value was accepted as 0.05
when assessing the data. Type 1 error was kept at 5%,
and evaluation was made with a 95% Confidence Inter-
val. Cronbach’s Alpha Value was examined to determine
the reliability of the measurement tools. Skewness and
Kurtosis values were analyzed to determine whether the
measurements showed a normal distribution. e fact
that Skewness and Kurtosis values were between +3 and
−3 indicated that the measurements had a normal distri-
bution. e ANOVA Test for Repeated Measurements
was used to determine the difference in repeated meas-
urements. e t-test was used for independent groups
to determine which measurements caused the differ-
ence. Post-hoc analysis was performed with Bonferroni
analysis to reduce the risk of false positives. e relation-
ship between the two measurements was examined with
Pearson correlation analysis. e “Partial Eta Square"
value was used for the "Repeated Measures ANOVA"
test to determine the effect sizes. Cohen’s d value was
used for the "Dependent Groups t-Test.” Even if a result
is statistically significant, it may not be clinically signifi-
cant. erefore, it is recommended that the effect size be
considered. An eta squared value of 0.01 is defined as a
small effect size, 0.06 as a medium effect size, and 0.14
and above as a large effect size. Cohen’s d of 0.2 is defined
as small, 0.2-0-6 as medium, and 0.6 and above as large
effect size. erefore, this study evaluated clinical signifi-
cance according to effect sizes.
Ethical approval andconsent toparticipate
Ethical permission was obtained from the Atatürk Uni-
versity Faculty of Medicine Clinical Study Ethics Com-
mittee (B.30.2.ATA.0.01.00/596 and date 29.09.2022).
Table 1 Order of Injection Methods Applied According to the Order of the Patients
Patient Number Order of
Methods Patient Number Order of
Methods Patient Number Order of
Methods Patient Number Order of
Methods
1–2 ACB 11–12 ABC 21–22 CBA 31–32 BCA
3–4 BAC 13–14 ACB 23–24 ABC 33–34 CBA
5–6 CAB 15–16 BAC 25–26 ACB 35–36 ABC
7–8 BCA 17–18 CAB 27–28 BAC 37–38 ACB
9–10 CBA 19–20 BCA 29–30 CAB 39–40 BAC
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 8 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
Institutional permission was obtained from the hospital
where the study would be conducted, and the number
was E-42190979-500.07.03.2300082408. Informed con-
sent was obtained from the participants who agreed to
participate in the study. e relevant ethical principles
of “Informed Consent,” “Volunteering,” and “Protection
of Confidentiality” were followed because data obtained
from human beings were used in the study. All experi-
ments were conducted according to the Declaration of
Helsinki and relevant ethical guidelines and regulations.
Patients were monitored with a form for any harm or
complications, and no complications developed during
the study.
Results
Results ofparticipants
A total of 37.5% of the patients were between the ages of
18–30, 50% were women, 60% were married, 62.5% had
a BMI value of 25 and above, 35% had an arm circum-
ference between 30–34 cm, 82.5% had a BMI value of 25
and above, 82.5% had experience with injections in the
Deltoid region, 52.5% of the patients had a fear of injec-
tion, and 37.5% had an injection fear level between 0 and
29 (0 being the lowest - 100 being the highest). It was also
found that 52.5% of the patients thought the injection
pain was moderate, 60% of them were afraid of injection
pain, and 45% of the patients had a slight fear of injection
pain (Table2).
Implications forimplementation
Whether the difference between the three measurements
was statistically significant was tested with the "Repeated
Measures Anova test". Post-hoc analysis was performed
to determine which groups caused the difference. Post-
hoc analysis was performed with the Bonferroni analysis
to reduce the risk of false positives. e mean pain score
of the deltoid muscle intramuscular injection applied
with HST was higher than the intramuscular injection
applied with ShotBlocker. is difference had a moderate
clinical impact (p<0.05, d=0.353) (Tables3-4). e effect
sizes observed in this study, particularly the moderate
Cohen’s d values, suggest that ShotBlocker provides a
clinically meaningful reduction in injection-related pain.
In addition, the partial eta square results indicate that the
choice of injection technique has a substantial impact on
patient-reported pain, comfort, and satisfaction, rein-
forcing the importance of technique selection in clini-
cal practice. Future studies should further evaluate these
effect sizes in diverse patient populations to strengthen
their generalizability.
e average comfort score of the deltoid muscle intra-
muscular injection applied with HST was lower than
that used with ShotBlocker. is difference had a mod-
erate clinical impact (p<0.05, d=0.380) (Tables3-4).
e mean satisfaction score of the deltoid muscle
intramuscular injection applied with HST was lower
than that used with ShotBlocker. is difference had a
moderate clinical impact (p<0.05, d=0.478) (Tables3-
4). e mean satisfaction score of the deltoid muscle
intramuscular injection applied with HST was lower
than that of the standard technique. is difference
had a moderate clinical impact (p<0.05, d=0.486)
(Tables3-4).
e mean fear score of the injection application with
the ShotBlocker was lower than that of the injection
application with the HST. is difference had a moderate
clinical impact (p<0.05, d=0.372) (Tables3-4). e mean
fear score of the injection application with the Shot-
Blocker was lower than that of the injection application
with the Standard Technique. is difference had a mod-
erate clinical impact (p<0.05, d=0.320) (Tables3-4).
Table 2 Sociodemographic Characteristics of Patients (n=40)
* (0=Not at all, 100=Very much)
Characteristics Variables N %
Age 18–30 years old 15 37.5
31–40 years old 14 35
41 years and above 11 27.5
Gender Female 20 50
Male 20 50
Marital status Married 24 60
Single 16 40
BMI Between 18.5–24.9 15 37.5
25 and over 25 62.5
Arm circumference 25-29cm 13 32.5
30-34cm 14 35
35 and over 13 32.5
Experience of having previous injections
in the deltoid region Yes 33 82.5
No 7 17.5
Fear of injection Yes 21 52.5
No 19 47.5
Injection fear level* 0–29 15 37.5
30–60 15 37.5
61 and over 10 25
Severity of injection pain No 2 5
A little 17 42.5
Moderate 21 52.5
Fear of injection pain Yes 24 60
No 16 40
How severe is the fear of injection pain? No 4 10
A little 18 45
Moderate 16 40
A lot 2 5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 9 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
In Table 4, injection applications were compared in
terms of VAS, CSFI, SSAI, and IFS. In addition, the
relationship between VAS, CSFI, SSAI, and IFS scores
of injection applications was examined. When VAS
scores were examined, it was determined that there
was a positive relationship between the applications of
"Helfer Skin Tap- Standard technique" (p<0.05). How-
ever, when VAS scores were examined, it was found
that there was no relationship between the applica-
tion pairs of "Helfer Skin Tap-ShotBlocker" and "Shot-
blocker- Standard technique" (p>0.05) (Table4).
When the CSFI scores were examined, it was deter-
mined that there was a positive relationship between
these application pairs; "Helfer Skin Tap-ShotBlocker",
"Shotblocker- Standard technique" and "Helfer Skin
Tap- Standard technique" (p<0.05). When the SSAI
scores were examined, it was determined that there
was a positive relationship between these application
pairs; "Helfer Skin Tap-ShotBlocker", "Shotblocker-
Standard technique" and "Helfer Skin Tap- Standard
technique" (p<0.05). When the IFS scores were exam-
ined, it was determined that there was a positive rela-
tionship between these application pairs; "Helfer Skin
Tap-ShotBlocker", "Shotblocker- Standard technique"
and "Helfer Skin Tap- Standard technique" (p<0.05)
(Table 4). is shows the consistency of the measure-
ments (Table4).
When the results of the "t test analysis in dependent
groups" were examined, it was determined that the same
results were obtained as the Bonferroni analysis and that
there was a statistically significant difference between the
same application pairs. is indicates that the risk of false
positives or false significance is low. (Tables3 - 4).
Discussion
e pain during intramuscular injection may affect the
patient’s comfort level and satisfaction level and increase
the level of fear [1, 2]. Nurses can reduce injection-
related pain by using the correct injection technique [5].
Reducing injection-related pain becomes very important
because pain during IM injection will affect the nurse-
patient relationship, care satisfaction, patient comfort,
and quality of care. It was detected in the literature that
some studies were conducted on reducing patients’
pain levels during intramuscular injections. However, it
seems that studies conducted on the effects of injection
techniques on patients’ comfort and satisfaction lev-
els in IM injection are limited, and there are no studies
on its effects on fear of injection. e present study dis-
cussed the impact of 3 different techniques on patients’
pain, comfort, satisfaction, and fear levels during deltoid
muscle intramuscular injection in line with the literature
data.
It was found in the present study that all injection tech-
niques affected pain at different levels (Tables3-4). e
lowest pain level was in the IM injection application
applied with a ShotBlocker, and the highest was in the IM
injection application applied with HST (Tables3-4). Con-
sidering the findings, it is recommended that clinicians
incorporate ShotBlocker and HST techniques into stand-
ard deltoid IM injection protocols to enhance patient
comfort and minimize procedural pain. Training pro-
grams should emphasize the correct application of these
techniques to ensure consistency and effectiveness in
clinical practice. e literature found that HST with IM
injection applied to adults is less painful than the Stand-
ard Technique [25, 26]. ere are studies in the literature
Table 3 Comparison of the Effects of Intramuscular Injection Techniques on Patients’ Pain, Comfort, Satisfaction, and Fear (n=40)
a: Visual Analog Scale, b: Comfort Scale for Injection c: Scale of Satisfaction After Injection d: Injection Fear Scale, ηp2:Partial Eta Square,
* Bonferroni analysis (Post-hoc test)
Parameters Applications Skewness/Kurtosis X ±SS Test and p
VASaHelfer Skin Tap10.435/1.065 3.20±2.70 F=3.313
p=0.042
1>2*
ηp2=0.078
Shotblocker20.538/0.850 2.05±2.30
Standard technique30.403/0.893 2.68±1.50
CSFIbHelfer Skin Tap1−0.719/−0.477 4.31±0.58 F=3.559
p=0.033
1<2*
ηp2=0.084
Shotblocker2−1.106/0.414 4.53±0.44
Standard technique3−0.669/−0.456 4.42±0.48
SSAIcHelfer Skin Tap1−0.032/−0.314 4.29±0.54 F=6.974
p=0.002
1<2, 1<3*
ηp2=0.152
Shotblocker2−0.523/−0.811 4.53±0.38
Standard technique3−0.437/−0.758 4.50±0.39
IFSdHelfer Skin Tap1−0.70/−1.290 2.36±0.82 F=3.177
p=0.047
1>2, 3>2*
ηp2=0.075
Shotblocker20.620/−0.458 2.11±0.85
Standard technique30.147/−0.876 2.30±0.76
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 10 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
reporting that IM injection applied with a ShotBlocker is
less painful [6] and more painful [18] than the Standard
Technique. In the study of Karabey and Karagözoğlu, it
was found that the least pain was experienced in the use
of ShotBlocker, followed by HST, and the most pain in
the Standard Technique application among the intramus-
cular injection techniques applied to the deltoid region
[14]. ese findings suggest that selecting an appropri-
ate injection technique plays a critical role in pain man-
agement and overall patient experience, particularly in
clinical settings where procedural discomfort can impact
treatment adherence. Considering the findings, it is rec-
ommended that clinicians incorporate ShotBlocker and
HST techniques into standard deltoid IM injection proto-
cols to enhance patient comfort and minimize procedural
pain. Training programs should emphasize the correct
application of these techniques to ensure consistency
and effectiveness in clinical practice. In the present study,
it is considered that ShotBlocker was most effective in
reducing pain because of Gate Control eory (GCT).
e most commonly used theory to explain the occur-
rence of pain is the CCT. Using HST and ShotBlocker, a
painless stimulus is given at the injection site before the
painful stimulus is presented, reducing the effect of tiny,
pain-carrying fibers. It is argued that the pressure applied
to the skin by the ShotBlocker reduces the mechani-
cal stimulation of large-diameter muscle fibers and the
effect of tiny, pain-bearing fibers in HST [8]. In using
ShotBlocker, the stimulus and pressure occur closer to
the injection site, while the area around the injection site
is hit in HST. Although muscle relaxation is achieved
by giving only a stimulus in the HST Technique, in the
ShotBlocker Technique, giving both pressure and stimu-
lus before and during the injection application, as well
Table 4 “Test for Dependent Groups” and “Correlation Values” between the measurements
a: Visual Analog Scale, b: Comfort Scale for Injection c: Scale of Satisfaction After Injection d: Injection Fear Scale, d:Eect Size/Cohen’s d
*Pearson correlation analysis
Parameters Applications Mean Dierence Standard Error t and p value Correlation and p*
VASaHelfer Skin Tap-ShotBlocker 1.15 0.515 t=2.235
p=0.031
d=0.353
r=0.160
p=0.326
Shotblocker- Standard technique −0.625 0.417 t=−1.499
p=0.142
d=0.237
r=0.099
p=0.544
Helfer Skin Tap- Standard technique 0.525 0.402 t=1.306
p=0.199
d=0.207
r=0.385
p=0.014
CSFIbHelfer Skin Tap-ShotBlocker −0.220 0.092 t=−2.402
p=0.021
d=0.380
r=0.387
p=0.014
Shotblocker- Standard technique 0.103 0.083 t=1.234
p=0.225
d=0.195
r=0.354
p=0.025
Helfer Skin Tap- Standard technique −0.118 0.072 t=−1.639
p=0.109
d=0.259
r=0.650
p=0.001
SSAIcHelfer Skin Tap-ShotBlocker −0.236 0.494 t=−3.020
p=0.004
d=0.478
r=0.470
p=0.002
Shotblocker- Standard technique 0.025 0.060 t=0.414
p=0.681
ES=0.065
r=0.514
p=0.001
Helfer Skin Tap- Standard technique −0.211 0.068 t=−3.075
p=0.004
d=0.486
r=0.606
p=0.001
IFSdHelfer Skin Tap-ShotBlocker 0.248 0.106 t=2.351
p=0.024
d=0.372
r=0.682
p=0.001
Shotblocker- Standard technique −0.191 −0.094 t=−2.026
p=0.050
d=0.320
r=0.732
p=0.001
Helfer Skin Tap- Standard technique 0.058 0.109 t=0.524
p=0.603
d=0.083
r=0.622
p=0.001
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 11 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
as giving this stimulus closer to the injection point, sug-
gests that it is effective in reducing pain in parallel with
GCT. e clinical relevance of these results highlights
the need for evidence-based pain management strate-
gies in nursing practice. For instance, Şahan and Yildiz
(2023) conducted a systematic review emphasizing the
efficacy of ShotBlocker and HST techniques in minimiz-
ing IM injection pain, supporting their clinical relevance
in pain management [12]. Additionally, Cmc etal. (2023)
highlighted in a JBI review that physical stimulation tech-
niques, including ShotBlocker, effectively reduce proce-
dural pain in intramuscular injections [11]. Furthermore,
meta-analysis findings from Ayinde etal. (2021) reinforce
the role of various pressure-based and sensory modula-
tion methods in pain reduction during IM injections [13].
ShotBlocker’s ability to interfere with pain perception
through simultaneous pressure and sensory stimulation
suggests its potential for broader clinical applications.
On the other hand, the HST technique, while theoreti-
cally effective, may require additional patient education
and adaptation to optimize its benefits. Future studies
should focus on evaluating patient preferences and psy-
chological responses to different injection techniques to
develop more patient-centered pain management proto-
cols. In the present study, it was also found that the HST
Technique was the most painful method. is may have
occurred because the HST procedure requires tapping,
the patients are not accustomed to this method, and the
patients have pain expectations regarding the injection
application because the HST Technique requires tapping.
All applications affected the comfort level of patients at
different levels. It was determined in the study that the
average comfort score in IM injection was highest in the
ShotBlocker technique and lowest in the HST application
(Tables3-4). Studies conducted on comfort in intramus-
cular injection are limited in the literature, and there are
studies on using HST [27] to increase the comfort level
in intramuscular injection. Only one study that examined
the effects of ShotBlocker use in IV injection applica-
tion was found in the literature [28]. However, no study
has been conducted to explore the impact of using HST
and ShotBlocker on comfort in intramuscular injections
in adults. is suggests that the effect of injection tech-
niques on the comfort level of patients in deltoid muscle
intramuscular injection was ignored. Studies examining
the impact of comfort during injections found that the
HST and ShotBlocker Technique effectively increased
the patient’s comfort compared to the Standard Tech-
nique [27, 28]. Juntilla etal. conducted a study compar-
ing HST and the Standard Technique for intramuscular
injection in infants and reported that HST effectively
increased comfort levels [27]. While HST has been
shown to improve comfort in infants, its effectiveness
in adults may be influenced by factors such as patient
familiarity with the technique and psychological expecta-
tions of pain. Pain may affect the patient’s comfort level
during interventional applications such as intramuscu-
lar injection [1, 2]. Previous studies reported that as the
level of pain caused by the injection technique decreases,
the comfort level increases [27, 28]. ese findings high-
light the importance of integrating sensory modulation
techniques into routine nursing practice to optimize
patient comfort. We believe that the fact that the average
comfort scores of the patients in the present study were
from high to low in ShotBlocker, Standard Technique,
and HST, respectively, occurred because the least pain-
ful injection technique, the ShotBlocker Technique, fol-
lowed by the Standard Technique and HST applications,
respectively (Tables3-4). Also, the fact that HST Tech-
nique requires hitting may have caused a decrease in the
comfort levels of the patients. Additionally, the discom-
fort associated with the HST technique may stem from
the tapping motion, which could induce anxiety or dis-
comfort in patients unfamiliar with this approach. Future
research should explore how patient education and prior
exposure to injection techniques influence comfort per-
ceptions. Investigating psychological and cultural fac-
tors that shape patient responses to different techniques
could provide valuable insights into optimizing patient-
centered care strategies.
It was found in the present study that each injection
technique affected the patients’ satisfaction levels at dif-
ferent levels (Tables3-4). In this study, it was determined
that the method that the patients were most satisfied
with was the ShotBlocker Technique, followed by the
Standard Technique and HST, respectively (Tables3-4).
Studies conducted on satisfaction with intramuscular
injection are pretty limited in the literature. It is pos-
sible to come across studies in the literature reporting
that ShotBlocker, Acupressure, and Vibration Stimula-
tion increase satisfaction levels in intramuscular injec-
tion compared to Standard Technique [4, 29, 30]. In the
study conducted by İnangil and Şendir, which compared
cold application, the use of ShotBlocker and Stand-
ard Technique in subcutaneous injection in terms of
pain and satisfaction, it was found that the use of Shot-
Blocker caused more satisfaction than cold application
and Standard Technique [30]. ese findings suggest that
patient satisfaction is closely linked to the level of pain
experienced during medical procedures. Non-pharmaco-
logical pain management strategies, such as ShotBlocker
and Acupressure, may play an essential role in improv-
ing the overall patient experience, particularly in settings
where repeated injections are necessary. Previous studies
report that the level of satisfaction increases as the level
of pain caused by the injection technique used decreases
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 12 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
[4, 29, 30]. is emphasizes the importance of integrat-
ing effective pain-reducing techniques into routine nurs-
ing practice to enhance both procedural outcomes and
patient adherence to treatment plans. e study results
are parallel to the literature data in this respect. e dif-
ference in satisfaction may be because the least painful
injection application of the patients was the ShotBlocker
Technique, followed by the Standard Technique and
HST, respectively (Tables3-4). Additionally, patient unfa-
miliarity with the HST technique, which involves a tap-
ping motion, may have contributed to lower satisfaction
scores. e lack of prior exposure to this method could
have influenced patient expectations, reinforcing the
need for pre-procedural education when implementing
alternative injection techniques.
In the study, it was also determined that all applica-
tions affected patients’ fear of injection at different lev-
els (Tables 3-4). e lowest level of fear was in using
ShotBlocker, followed by the Standard Technique and
HST application, respectively (Tables3-4). It is possible
to come across previous studies conducted on injection
fear in the literature [31, 32]. However, it was found that
interventional studies on fear of injection were limited in
the literature [31, 33]. No study was detected in the lit-
erature investigating the effects of injection techniques
on patients’ injection fear levels. Mason et al. (2022)
reported that eight sessions of group-based Cognitive
Behavioral erapy caused a decrease in fear reactions
such as fear, disgust, and fainting in individuals with
blood injection and injury fear [31]. In their study con-
ducted on blood-injection fear, Lilliecreutz etal. reported
that Cognitive Behavioral Group erapy applied to
pregnant women for two sessions reduced the anxi-
ety and fear levels of pregnant women and was effective
for at least three months after birth [33]. ese findings
suggest that psychological interventions may be benefi-
cial in reducing injection-related fear; however, there is
a need to explore non-pharmacological and procedural
techniques that can be implemented during routine
clinical practice. While Cognitive Behavioral erapy
has been shown to reduce fear responses in controlled
settings, sensory modulation techniques like Shot-
Blocker may provide a practical, immediate solution for
minimizing procedural anxiety in real-world healthcare
environments.
In the literature, studies conducted on reducing the
injection fear levels of individuals are limited, and there
are no new studies aimed at reducing the fear of injec-
tion; it was reported in relevant studies that future
studies should be conducted in this respect [32]. ese
factors highlight the importance of tailoring injection
techniques to individual patient needs, considering
prior experiences and anxiety levels to optimize the
overall patient experience. Nir etal. reported that nee-
dle size, previous injection experiences, fear of pain,
and clinical comfort affect the fear of injection [32].
is may be because this study’s least painful injection
application was the ShotBlocker Technique, followed
by the Standard Technique and HST applications,
respectively (Tables 3-4). Additionally, patient unfa-
miliarity with the HST technique’s tapping motion may
have contributed to increased anxiety, as unexpected
stimuli can sometimes amplify procedural fear rather
than alleviate it. Also, the fact that the HST Technique
requires hitting might have affected the fear levels of
the patients.
Limitations andgeneralizability ofthestudy
Some of the study’s limitations were that only individu-
als who met the study criteria were included, the study
was conducted in a short period, and the procedures
were performed only on the deltoid region, which may
limit the applicability of the findings to other patient
populations, such as pediatric or elderly individu-
als who may have different pain responses and com-
fort levels. Additionally, this study was conducted in a
single-center setting with an adult population, which
may limit the generalizability of the findings to broader
populations, particularly pediatric and elderly patients
who may require different injection techniques based
on muscle structure and pain perception.
e sample consisted of patients presenting to the
emergency department, which may not fully represent
individuals receiving intramuscular injections in other
healthcare settings, such as primary care clinics, inpa-
tient hospital units, or long-term care facilities, where
age-related factors and chronic conditions may influ-
ence pain perception and response to injection tech-
niques. Moreover, variations in patient characteristics,
including age, pain tolerance, and previous injection
experiences, could influence the observed outcomes.
Given these limitations, future multi-center stud-
ies with pediatric and elderly populations are recom-
mended to enhance the external validity of the findings
and determine whether the observed pain reduction
and comfort-enhancing effects of ShotBlocker and HST
techniques are applicable across different age groups.
Expanding the study to include different anatomical
injection sites and prolonged follow-up periods may
also provide deeper insights into the long-term effects
of these injection techniques. e results obtained in
the present study can be generalized to patients who
applied to the emergency department on the specified
dates.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 13 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
Conclusion
e present study found that the ShotBlocker Technique
was the most effective method for reducing pain and
fear. It also determined that the technique provided the
highest level of comfort and satisfaction for the patients.
e study results highlight the importance of adopting
ShotBlocker in clinical and educational settings. In clin-
ical settings, incorporating this technique into routine
injection procedures by healthcare professionals may
increase patient engagement in the treatment process
and reduce negative psychological effects of treatment.
In educational settings, effectively teaching the use of
ShotBlocker to healthcare professionals will enable the
widespread use of this technique. Future research may
further investigate the effectiveness of ShotBlocker in
different patient groups and in various clinical scenar-
ios, contributing to the development of general practice
guidelines. Additionally, studies investigating the long-
term effects of ShotBlocker and its comparative effec-
tiveness with other pain management techniques will
support the wider adoption of this technique.
Recommendations forclinical practice
It is recommended to introduce ShotBlocker in nursing
education, to provide training on the use of ShotBlocker,
and to turn ShotBlocker use into a psychomotor skill. In
the nursing profession, it may be recommended to take
the necessary precautions to reduce the level of pain
and fear, increase the level of comfort and satisfaction
in deltoid muscle intramuscular injection applications,
and popularize the use of novel methods and techniques
such as ShotBlocker. In nursing practice, it may also be
recommended to support using ShotBlocker to reduce
patients’ pain and fear levels and increase their comfort
and satisfaction levels during deltoid muscle intramus-
cular injections. It may also be recommended that novel
methods and techniques in nursing management be sup-
ported and introduced to affect nursing practices posi-
tively and that the materials required for teaching and
implementing these methods and techniques be sup-
plied. In nursing studies, it is recommended that future
studies be planned to determine patients’ comfort, sat-
isfaction, and fear levels regarding injection, as well as
conduct studies to reduce patients’ pain and fear levels
and increase their comfort and satisfaction levels.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12912- 025- 02901-8.
Additional file 1
Acknowledgments
We thank the patients for taking part in the study. We thank the Scientific and
Technological Research Council of Turkey for their financial contributions
Authors’ contributions
GNY: Conceptualization, Resources, Data, Formal Analysis, Supervision, Visuali-
zation, Investigation, Writing – original draft, Methodology, Writing – review
& editing, Project administration BÇ: Conceptualization, Resources, Software,
Supervision, Funding acquisition, Investigation, Writing – original draft, Meth-
odology, Project administration Note: The author(s) affirm that the methods
used in the data analyses are suitably applied to their data within their study
design and context, and the statistical findings have been implemented and
interpreted correctly.
Funding
This research was supported by the Scientific and Technological Research
Council of Turkey with project number 123S001.
Data availability
Datasets used and/or analyzed during the current study are available from the
corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Ethical permission was obtained from the Atatürk University Faculty of
Medicine Clinical Study Ethics Committee (B.30.2.ATA.0.01.00/596 and
date 29.09.2022). Institutional permission was obtained from the hospital
where the study would be conducted, and the number was E-42190979-
500.07.03.2300082408. Informed consent was obtained from the participants
who agreed to participate in the study. The relevant ethical principles of
“Informed Consent,” “Volunteering,” and “Protection of Confidentiality” were
followed because data obtained from human beings were used in the study.
All experiments were conducted according to the Declaration of Helsinki and
relevant ethical guidelines and regulations. Patients were monitored with a
form for any harm or complications, and no complications developed during
the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1 Department of Dialysis, Vocational School of Health Services, Department
of Dialysis, Mus Alparslan University, Mus, Turkey. 2 Department of Fundamen-
tal of Nursing, Atatürk University, Erzurum, Turkey.
Received: 10 December 2024 Accepted: 26 February 2025
References
1. Potter PA, et al. Fundamentals of nursing-e-book. 11 ed. Canada: Elsevier
health sciences; 2021. ISBN: 9780443124068.
2. Kozier BJ, et al. Kozier And Erb’s Fundamentals of nursing: Concepts,
process, and practice. 11 ed, ed. Berman A, Snyder S, Frandsen G. London:
Pearson Canada; 2020. ISBN 9780135428733.
3. Taylor C, Lynn P, Bartlett J. Fundamentals of nursing: The art and science
of person-centered care. Wolters Kluwer. 2018;9. ISBN 1496391004,
9781496391001.
4. Savcı C, et al. Effectiveness of Two Different Methods on the Perceived
Pain and Satisfaction During Intramuscular Antibiotic Injection: Shot-
Blocker and Local Vibration. Clinical Nursing Research. 2022;31(5):812–9.
5. Al Awaidy, S., S. Bawikar, and P. Duclos, Safe injection practices in a
primary health care setting in Oman. EMHJ-Eastern Mediterranean Health
Journal, 12 (Supp. 2), S207-S216, 2006, 2006.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 14 of 14
Yildizand Çiftçi BMC Nursing (2025) 24:390
6. Aydın E, Avşar G. Examining the effect of "Shotblocker" in relieving pain
associated with intramuscular injection. Complement Ther Med. 2019;47.
https:// doi. org/ 10. 1016/j. ctim. 2019. 09. 001.
7. Shah S, Narayanan A. Effect of Helfer Rhythmic skin tap technique on pro-
cedural pain among patients receiving intramuscular injection. Manipal
Journal of Nursing and Health Sciences. 2016;2(1):3–9.
8. Zeyrek Şanlıalp A. Methods and physical interventions used to reduce
pain during intramuscular injection in adults. In: Güler S, editor. Health
and Science 2022: Nursing-1. İstanbul: Efe Academic Publishing; 2022. p.
61–74.
9. Krinsky R, Murillo I, Johnson J. A practical application of Katharine
Kolcaba’s comfort theory to cardiac patients. Applied Nursing Research.
2014;27(2):147–50.
10. Kolcaba KY. A theory of holistic comfort for nursing. Journal of advanced
nursing. 1994;19(6):1178–84.
11. Cmc S, et al. Effectiveness of physical stimulation for reducing injection
pain in adults receiving intramuscular injections: a systematic review and
meta-analysis. JBI Evidence Synthesis. 2023;21(2):373–400.
12. Şahan S, Yildiz A. The effect of shotblocker application on intramuscu-
lar injection pain in adults: a meta-analysis. Clinical Nursing Research.
2022;31(5):820–5.
13. Ayinde O, Hayward RS, Ross JD. The effect of intramuscular injection
technique on injection associated pain; a systematic review and meta-
analysis. PloS one. 2021;16(5):e0250883.
14. Karabey T, Karagözoğlu Ş. The Effect of Helfer Skin Tap Technique and
ShotBlocker Application on Pain in Deltoid Muscle Injection. Clinical and
Experimental Health Sciences. 2021;11(4):721–6.
15. Yılmaz Ö, Tuncer M. The ımportance of pılot study ın an experımental
research: the effect of teachıng on academıc success accordıng to
dale’s cone of experıence. Electronic Journal of Education Sciences.
2020;9(17):89–96.
16. Holland K, Jenkins J. Applying the Roper-Logan-Tierney Model in
Practice-E-Book. Elsevier Health Sciences. 2019. ISBN, 0702061220,
9780702061226.
17. Faul F, et al. G* Power 3: A flexible statistical power analysis program for
the social, behavioral, and biomedical sciences. Behavior research meth-
ods. 2007;39(2):175–91.
18. Tuğrul E, Nese C, Leyla K. Effects of ShotBlocker on relief of pain due to
Hepatitis B vaccine injection into deltoid muscle. International Journal of
Caring Sciences. 2017;10(3):1669–75.
19. Aslan FE. Health assessment and clinical decision making. Akademisyen
Tıp Bookstore. 2017;3. ISBN 9786059354363.
20. Yildiz GN, Şirin Gök M, Çiftçi B. Development and psychometric validation
of the comfort scale for injection. BMC nursing. 2024;23(1):903.
21. Yıldız, G.N. and B. Çiftçi, Development of the scale of satisfaction after
injection, in 1. International Uludağ Scientific Research Cangress, İ.Ç.
Barutçu, Editor. 2023, International Sciance and Art Research Center:
Bursa. p. 102-110.
22. Yıldız, G.N. and B. Çiftçi, Development of the injection fear scale, in 1.
International Uludağ Scientific Research Cangress, İ.Ç. Barutçu, Editor.
2023, International Science and Art Research Center: Bursa, Türkiye. p.
93-101.
23. Helfer JK. Painless injections: Helfer skin tap technique. Journal of Surgery
and Surgical Research. 2021;7(1):17–9.
24. Bonix. ShotBlocker. 2022 [cited 2022 9.9.22]; Available from: https:// bionix.
com/ catal ogsea rch/ resul t/?q= shotb locker.
25. Hassnein AA, Soliman HMM. Efficacy of Helfer skin tapping technique on
pain intensity as perceived by the patients receiving intramuscular injec-
tion. International Journal of Nursing Didactics. 2016;6(2):12–22.
26. Neupane U, Thomas P, Thakur R. A study to assess the effectiveness of
Helfer skin tap technique on the level of pain during intramuscular injec-
tion among adults in a selected hospital, Bangalore. International Journal
of Health Sciences and Research. 2019;9(1):95–103.
27. Juntilla NA, Nacar KM, Velez Y TJ. Effects of Helfer skin tap technique on
the level of pain experienced by infants during intramuscular injection.
[Bachelor’s thesis, De La Salle Medical and Health Sciences Institute].
GreenPrints. 2018. https:// green prints. dlshsi. edu. ph/ bsn/ 298/.
28. Karabey T, Karagözoğlu Ş. The effect of new device on pain and comfort
levels in individuals undergoing peripheral intravenous cannula inser-
tion. J Vasc Access Devices. 2022. https:// doi. org/ 10. 1177/ 11297 29822
11136 85.
29. Inangil D, Inangil G. The effect of acupressure (GB30) on intramuscular
injection pain and satisfaction: Single-blind, randomised controlled study.
Journal of Clinical Nursing. 2020;29(7–8):1094–101.
30. Inangil D, Şendir M. Effectiveness of mechano-analgesia and cold applica-
tion on ecchymosis, pain, and patient satisfaction associated with subcu-
taneous heparin injection. Journal of Vascular Nursing. 2020;38(2):76–82.
31. Mason EC, et al. A comprehensive group-based cognitive behav-
ioural treatment for blood-injection-injury phobia. Br J Clin Psychol.
2022;61(2):494–509.
32. Nir Y, et al. Fear of injections in young adults: prevalence and associations.
The American journal of tropical medicine and hygiene. 2003;68(3):341–4.
33. Lilliecreutz C, Josefsson A, Sydsjö G. An open trial with cognitive behavio-
ral therapy for blood- and injection phobia in pregnant women-a group
intervention program. Arch Womens Ment Health. 2010;13(3):259–65.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com