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Running head: DISTRACTION IN PEDIATRICS

Distraction Techniques During Invasive Procedures in Pediatric Patients

Kirstee Novak

Azusa Pacific University

GNRS 507 Scientific Writing

Professor Diana Amaya Rodriguez, PhD, MS, CNS, RN

March 10, 2015

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DISTRACTION IN PEDIATRICS

Distraction Techniques During Invasive Procedures in Pediatrics

The following essay reviews literature about the effectiveness of distraction techniques

on levels of pain, distress, and fear in pediatric patients during painful invasive procedures. The

themes that will be discussed are the ways distraction interventions are defined, the diversity of

samples that participated in the studies, and the role of the nurses in the intervention.

Background

Children who undergo procedures involving needles often experience fear, distress,

anxiety and undermanaged pain (McCarthy et al., 2010). Intravenous (IV) catheter insertion and

venipuncture are often the procedures most painful and feared by pediatric patients. Procedural

pain in pediatrics differs from acute or chronic pain for its association with anticipatory anxiety;

however, the predictive nature presents an opportunity to minimize a child’s distress and pain

through non-pharmacological techniques. According to an article hosted by the National Institute

of Health and written by The Royal Australasian College of Physicians (RACP; 2005),

distraction is highly encouraged for procedures such as IV insertion, venipuncture,

immunizations and central venous port access. Research demonstrates distraction as a versatile,

effective, safe, and inexpensive method to decrease undermanaged pain in pediatrics. Often

when children undergo an IV insertion, the anxiety and distress can lead to increased failed

attempts, thus leading to more attempts and an increase in stress experienced by children. Not to

mention, failed IV attempts cost hospitals with at least 200-299 beds an average of $630,672 per

year (Vuetek Scientific, 2012). As hospitalized children commonly experience pain and distress

related to needle procedures and hospitals are charged high rates for failed IV attempts, there is

an increased need to utilize distraction strategies into IV and needle procedures.

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Themes Existing in Research

Definition of Intervention

Existing research has investigated the effects of parental-distraction on fear, distress, and

pain. However, throughout the articles, distraction strategies varied in definition, manner of

parental involvement and the materials or toys that were used. Tüfekci, Çelebioglu, &

Küçükoglu (2009) defined distraction as the use of a toy to redirect a child’s attention. Prior to

the procedure, children were given a kaleidoscope and were asked to use the toy while parents

accompanied the child during the venipuncture. Findings showed that pain was decreased in

school-aged children who used the kaleidoscope during venipuncture when compared to children

who did not use the kaleidoscope (Tüfekci et al., 2009). Perhaps the children were more able to

maintain focus on the toy than their parent, thus providing more concentration, allowing the child

to forget the anticipated pain. The redirection of a child’s attention by using a gender-neutral toy

is likely to have contributed to the effectiveness of the intervention rather than using a gender-

specific toy, such as a female doll or action figure.

Rennick et al. (2011) investigated the effect of a parent-guided distraction approach

called “Touch & Talk Intervention” in decreasing pain in children during procedures. Mothers

who had a child in the Pediatric Intensive Care Unit (PICU) were asked to be the primary

distraction for children undergoing a needle procedure; mothers soothed their child using a

method of their choice (Rennick et al., 2011). The freedom mothers were given to capture their

child’s attention in the way they chose may have increased effectiveness of the intervention. The

PICU setting is typically a stressful and procedural heavy environment, therefore, the children

could have had increased responsiveness to their mothers’ distraction in ways that other children

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who do not have the stress of the PICU might. At least 73% of the mothers felt their child’s

distress was decreased and their pain experience was improved (Rennick et al., 2011). Children

view a parent or guardian as a protector, which was potentially the reason Rennick et al. chose to

use the mother as a distractor during the procedure.

McCarthy et al. (2010) emphasized parental-guided distraction and coaching in their

intervention. Parents were given a 15-minute training on distraction techniques, and the parent

and child selected a distractor item together such as a book, video game, or toy (McCarthy et al.,

2010). Findings portrayed that children who experienced the intervention had significantly lower

levels of distress, but not as significant decreases in their level of pain. Children who received

higher levels of parental distraction reported lower scores on the Observational Scale of

Behavioral Distress-Revised (OSBD-R) compared to the control group (McCarthy et al., 2010).

Perhaps the combination of a distractor item and a coach decreased distress levels in children

rather than simply using one or the other. Also, parents were prepared with proper training on

how to coach the child, which potentially increased efficacy of the entire intervention.

Diversity of Participants

Testing the effectiveness of distraction in pediatrics is a global concern, and procedural

effectiveness has been investigated in children of many cultures, developmental levels, and with

a variety of diagnoses. Tüfekci et al., (2009) examined the intervention effectiveness in 206

Turkish children 7-11 years old with no developmental problems or disabilities that would

impair communication of pain scores. Outcomes indicated the average pain score for children on

the Wong-Baker FACES Pain Rating Scale (WBFPRS) in the intervention group were 4.64 in

comparison to the average pain score of the control group, which was 5.14 (Tüfekci et al., 2009).

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Two factors that potentially effected interpretation of pain were age and culture. Children of

school age, which these children were, often have a higher pain tolerance than toddlers or pre-

school aged children. Interpretation of pain is likely to vary amongst cultures. Particularly in

Middle Eastern cultures, personal strength and pleasing others is of importance; therefore,

outward expression of pain is seen as a sign of weakness (Carteret, 2011). Research has

portrayed effectiveness of distraction in Turkish children and supports versatility of the

intervention to children in other countries.

Participants in another study were not pediatric patients, but the mothers of patients aged

0-3 years. In Rennick et al. (2011), 65 English or French speaking mothers participated who had

a child in the PICU and whose prognosis was expected to survive. The mothers were recruited

from Canadian pediatric hospitals, thus showing that distraction interventions are applicable to

many different cultures. This article adds diversity to the collection of articles reviewed because

it is the only study in which mothers were the participants rather than the children, and it

provided insight on the experience from a mother’s point of view.

One study specifically tested pediatric participants with cancer. Windich-Biermeier,

Sjoberg, Dale, Eshelman, & Guzzetta (2007) examined distraction intervention effectiveness in

50 children and adolescents with cancer, of multiple ethnicities, and who were 5-18 years of age.

Subjects were required to understand and speak English, to be able to see and hear, and to have

been receiving chemotherapy for a diagnosis of cancer. There is little being done to study the

effectiveness of distraction as pain management in children with cancer, making this a valuable

addition to the diversity of this review. Perhaps the reason for lack of research is the reality that

children with cancer undergo copious amounts of needle procedures and might become

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acclimated; therefore, the intervention would not be as effective and would not be applicable to

the majority of children. The variety of participants expands the criteria for children given that

distraction techniques have been confirmed by researched in various ethnicities, ages, and

illnesses. The common outcome of reduced pain, fear, and distress during painful invasive

procedures within the multiple studies, confirm the interventions better than one individual study

could.

Nurses’ Role in the Intervention

The topic of pain management and distraction techniques often involves nurses for the

reason nurses are knowledgeable in pain control. Many studies focus on the actual

implementation and effectiveness of distraction, but one by Olmstead, Scott, Mayan, Koop, &

Reid (2014) evaluated the contributing factors in a nurses’ decision to use distraction in painful

procedures (Olmstead et al., 2014). Three themes were discovered from this study that nurses

likely base their decision on whether or not to use distraction: knowledge, clinical experience,

and relational capacity. Nurses provided a variety of opinions about their experience with

distraction and their evaluation of its effectiveness. An ethical aspect that was addressed by

nurses was whether or not it would benefit the child more or prolong the procedure and cause

more harm. Nurses revealed that pediatric procedural pain is undermanaged and highlighted the

raw strengths and weaknesses of using distraction strategies as non-pharmacologic pain

management.

Pediatric oncology nurses in the study by Windich-Biermeier et al. (2007) participated

either as the nurse involved in the venipuncture/port access or as coaches for parents (Windich-

Biermeier et al., 2007, p. 9). Nurses guided the parents in distracting their child, which

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potentially increased the effectiveness of the procedure. There was no indication of how nurses

were trained to assist in coaching parents, but with clinical experience in the field of pediatrics,

the nurses could have enhanced the distraction more than if parents had distracted independently.

Overall, the role of nurses was to encourage and support parents in their distraction activities in

order to manage procedural pain. Experienced nurses may have decreased parental anxiety by

assisting them in the strategies, thus decreasing the children’s anxiety as well.

In the study by Sadeghi et al. (2013), nurses were active as the venipuncture nurse and

also as the child’s coach. The nurses were the distraction coach and measured the child’s pain

after the procedure using the Wong-Baker FACES Pain Rating Scale. A significant difference for

self-reported pain was found between the intervention group and the control group, with a lower

average pain score in the intervention group. Although the two studies used nurses as coaches for

both the parents and the children, both had positive effects in decreasing pain and distress during

venipuncture, port access, and IV insertion.

Discussion

With great amount of existing research surrounding this topic, it is important to

acknowledge gaps in the literature, limitations of the reviewed studies, and important findings of

each. Gaps in existing studies include lack of research surrounding parent vs. guardian or sibling

participation in the intervention, as well as whether it is more effective to have the same sex

parent as the child or opposite sex. There has been specific research done with mothers as

distraction coaches, but there has not been research focused solely on fathers. A comparison

study should be done to see if the intervention is more or less effective than those using mothers

as distraction coaches.

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Limitations of the studies reviewed included a small sample size of 50 patients in one

study, limiting its validity in applying to large groups of children (Windich-Biermeier, 2007).

Some studies were conducted in naturally stressful environments such as the PICU or pre-

operative departments, which can contribute to high levels of distress in children even prior to

the IV insertion or venipuncture. Although the limitations and gaps in research exist, important

key findings should not go unnoticed. Distraction strategies proved effective in decreasing pain

and distress in patients with cancer, even though these patients typically endure many painful

needle procedures. Also, mothers who participated in the Touch & Talk Intervention study

reported that their children had decreased distress and fear, which demonstrated that there is a

noticeable decrease in stress with distraction. Lastly, one study reported there was no outcome

documented that was worsened with the implementation of distraction (Olmstead et al., 2014).

These findings, limitations, and gaps in research demonstrate an increased need to alleviate

undermanaged procedural pain in pediatrics by using distraction strategies.

Conclusion

The variety of ways in which distraction interventions were defined throughout the studies, the

diversity of the subjects who participated, and the role of the nurses were major aspects of

research. These aspects demonstrate why distraction techniques are effective in decreasing pain

and distress during invasive procedures. Distraction strategies have proved to be effective in

many settings and populations, giving authenticity to the further implementation of the

intervention in hospitals in order to improve procedural pain in children.

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Clinical Implications

Research demonstrates that distraction is an effective non-pharmacologic method to

decrease pain in children who undergo painful procedures. Nurses’ play a crucial role in pain

management and have an obligation to address the needs of patients through pharmacologic and

non-pharmacologic approaches. Existing research has been evaluated to answer the following

PICOT question: “In school-aged hospitalized patients, does the use of parental-guided

distraction during painful invasive procedures (versus no use of distraction techniques) result in

reduction of pain and behavioral distress during the duration of the procedure?” This section will

explore the existing data and the clinical implications as they apply to implementing these

suggestions into clinical use.

Key Findings

Distraction strategies have proven to be an effective, versatile, safe, and inexpensive

method of non-pharmacologic decrease of pain and distress in children of various ethnicities,

cultures, diagnoses, and ages. Distraction was effective in procedures such as IV insertion,

venipuncture, immunizations, and central venous port access (Sadeghi et al., 2013; Rennick et

al., 2011; Tüfekci, 2009; McCarthy et al., 2010; Windich-Biermeier et al., 2007). Approaches

such as parental-coaching, distraction with an item or toy, and a combination of both all had

results of reduced pain or distress (Sadeghi et al., 2013; Rennick et al., 2011; Tüfekci, 2009;

McCarthy et al., 2010; Windich-Biermeier et al., 2007). Studies found that distraction strategies

were effective in hospitalized children from the PICU, pre-operative surgical wards, and in

patients from outpatient clinics (Sadeghi et al., 2013; Rennick et al., 2011; Tüfekci, 2009;

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McCarthy et al., 2010; Windich-Biermeier et al., 2007). These key findings impact

implementation in the clinical setting.

Strategies for Change

Distraction strategies will be implemented in a pediatric medical department to decrease

pain and distress in hospitalized patients receiving IV insertions. McCarthy et al. (2010)

demonstrated efficacy using the combination of a parent as a coach and a distractor item of the

child’s choice in school-aged hospitalized patients. Therefore, the same combination will be used

in school-aged hospitalized patients on a medical floor. Although it has not yet been tested on a

medical floor, significant effects have been shown in other hospital departments. Patients may

use any distractor item of their choice provided by the department or one of their own personal

toys or items. Tüfekci et al. (2009) had positive results with the use of a toy, which supports the

use of a distractor item of the child’s choice in this intervention. The combination of parental

coaching and a distractor item will be used due to effectiveness shown in previous research.

Prior to using the intervention in the clinical setting, a three-month period without

distraction interventions will be used to measure baseline pain and distress levels in patients

during IV insertions. During this time, nurses will be trained in distraction strategies and how to

coach parents in distraction (McCarthy et al., 2010). After three months, nurses will incorporate

distraction during IV insertions for all school-aged children by allowing them to pick a distractor

item and training the parents in distraction coaching (McCarthy et al., 2010; Tüfekci et al.,

2009). Parents will play an active role in coaching their child while the child uses the distraction

item as he or she wishes. Patients and/or parents must always have the right to refuse the use of

distraction for the procedure. In order to determine effectiveness, the intervention will be used

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for three months and results of pain and distress scores will be compared to baseline scores

received during the three-month span without the intervention. If either pain or distress scores

are lower than the group who did not receive the intervention, the distraction strategies will be

continued for the next three months.

Data Measurements and Grading of Studies

In the study by Tomlinson, von Baeyer, Stinson, and Sung (2010), The Wong-Baker

FACES Pain Rating Scale showed to be most effective in measuring pain responses in children;

therefore, it will be used to measure pain after the procedure is complete. As demonstrated in the

studies by McCarthy et al. (2010) and Windich-Biermeier et al. (2007), the Observational Scale

of Behavioral Distress-Revised was effective in measuring distress; therefore, the nurse will use

this scale to evaluate distress after the procedure. Scores on the Wong-Baker FACES Pain Rating

Scale closer to zero and scores closer to 8 on the Observational Scale are desired, as it would

indicate lower levels of pain and distress.

McCarthy et al. (2010), Sadeghi et al. (2013), and Windich-Biermeier et al. (2007) were

all classified as Grade II and Tüfekci et al. (2013) was classified as grade III on the Fineout-

Overholt grading system (2010). Therefore, significant strength and support is provided to the

outcomes and effectiveness of the intervention from these studies. Tomlinson et al. (2010) was a

grade V study (Fineout-Overholt, 2010), which demonstrated evidence of various scales used in

children and the efficacy of each one.

Ethical, Cultural, and Spiritual Considerations

All patients have the right to controlled and properly managed pain regardless of its

cause. The ethical considerations related to the need for pain control are beneficence and non-

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maleficence. Beneficence is a moral obligation to act in the best interest and for the benefit of the

patient, which the intervention aims to do by reducing pain and distress. To act with non-

maleficence is to prevent harm. Uncontrolled pain can be physically and psychologically harmful

in pediatric patients. Beneficence and non-maleficence are ethical considerations that support the

need for procedural pain management in pediatric patients.

Cultural aspects were acknowledged as the intervention was studied and shown to be

effective in various cultures and ethnicities. Efficacy of the intervention was shown in children

from Turkey (Tüfekci et al., 2013), Canada (Rennick et al., 2013) and Iran (Sadeghi et al., 2013).

Distraction was also proven effective in children throughout the United States (McCarthy et al.,

2010; Windich-Biermeier et al., 2007). This intervention is unlikely to interfere with cultural

aspects as it has been proven effective in various cultures.

Pain can have detrimental psychological effects on children, which can impact a patient’s

spirituality as well. This intervention respects the spiritual implications of a patient by attempting

to decrease pain and distress. Comfort, coping, and happiness are of importance in patient

treatment and the intervention aims to enhance these factors through distraction. Nurses often

walk among the hurting in an attempt to heal and comfort patients in hopes of alleviating any

suffering and conveying hope and love (O’Brien, 2014, p. 100). Through this intervention nurses

will have the opportunity to alleviate pain and distress while bestowing hope and love in

pediatric patients.

Barriers & Facilitators

The barriers that are involved with this intervention include obtaining funding to provide

toys, books, and other distractor items. Patients who do not want their parents in the room,

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parents who do not want to participate, nurses who are unable to attend training, or nurses who

have no interest in participating are also barriers in the implementation of this intervention.

Facilitators in the study should be nurses who desire to participate in the intervention in hopes of

decreasing pain and distress, as well as training parents to coach their child through the

procedure.

Gaps in Literature

Gaps in existing literature demonstrate a lack of research involving guardian or sibling

participation as a distraction coach, as well as effectiveness comparing the same sex parent or

opposite sex. Research has been done with parents either active in distraction or present during

the procedure without a role, but research has not been done without the parent present at all.

More research should be done in using distraction techniques with nurses or health care

providers if parents are unable to be present.

Conclusion

After evaluation of research revealed efficacy of distraction strategies as a method of

non-pharmacologic pain management, as well as had impacts on distress, there is significant

evidence to support the further implementation of the intervention in the clinical setting. Nurses

play a crucial role in the management of pain in patients and will have the opportunity to

decrease distress and pain during procedures through distraction techniques. As this intervention

has shown effective in a diversity of school-aged hospitalized children, it has the potential to

improve anticipatory procedural pain and distress in pediatric hospitalized patients throughout

the world.

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References

Carteret, M. (2011). Health Care for Middle Eastern Patients & Families. In Dimensions of

Culture. Retrieved March 13, 2015, from

http://www.dimensionsofculture.com/2010/10/health-care-for-middle-eastern-patients-

families/

Fineout-Overholt, E., Melnyk, B.M., Stillwell, S.B., Williamson, K.M. (2010). Critical appraisal

of the evidence: Part I. AJN, 110(7). 47 – 52.

Kleiber, C., & McCarthy, A. (2006). Evaluating instruments for a study on children's responses

to a painful procedure when parents are distraction coaches. Journal Of Pediatric

Nursing, 21(2), 99-107.

McCarthy, A., Kleiber, C., Hanrahan, K., Zimmerman, M., Westhus, N., & Allen, S. (2010).

Impact of parent-provided distraction on child responses to an IV insertion. Children's

Health Care, 39(2), 125-141. doi:10.1080/02739611003679915

O'Brien, M. E. (2014). Spirituality in Nursing Standing on Holy Ground (fifth ed., pp. 96-100).

Burlington, MA: Jones & Bartlett Learning.

Olmstead, D. L., Scott, S. D., Mayan, M., Koop, P. M., & Reid, K. (2014). Influences shaping

nurses' use of distraction for children's procedural pain. Journal for Specialists in

Pediatric Nursing, 19(2), 162-171. doi:10.1111/jspn.12067

Rennick, J. E., Lambert, S., Childerhose, J., Campbell-Yeo, M., Filion, F., & Johnston, C. C.

(2011). Mothers’ experiences of a Touch and Talk nursing intervention to optimize pain

management in the PICU: A qualitative descriptive study. Intensive & Critical Care

Nursing, 27(3), 151-157. doi:10.1016/j.iccn.2011.03.005

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http://www.dimensionsofculture.com/2010/10/health-care-for-middle-eastern-patients-families/

http://www.dimensionsofculture.com/2010/10/health-care-for-middle-eastern-patients-families/


Sadeghi, T., Mohammadi, N., Shamshiri, M., Bagherzadeh, R., & Hossinkhani, N. (2013). Effect

of distraction on children's pain during intravenous catheter insertion. Journal For

Specialists In Pediatric Nursing, 18(2), 109-114. doi:10.1111/jspn.12018

Tomlinson, D., von Baeyer, C., Stinson, J., & Lillian, S. (2010). A Systematic Review of Faces

Scales for the Self-report of Pain Intensity in Children. Pediatrics, 126(5), 999.

Tüfekci, F., Çelebioglu, A., & Küçükoglu, S. (2009). Turkish children loved distraction: using

kaleidoscope to reduce perceived pain during venipuncture. Journal Of Clinical Nursing,

18(15), 2180-2186. doi:10.1111/j.1365-2702.2008.02775.x

Windich-Biermeier, A., Sjoberg, I., Dale, J., Eshelman, D., & Guzzetta, C. (2007). Effects of

distraction on pain, fear, and distress during venous port access and venipuncture in

children and adolescents with cancer. Journal Of Pediatric Oncology Nursing, 24(1), 8-

19.

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Clinical Implications Rubric

Clinical Project: Clinical Implications Paper = 20% of grade (100 points)A. Purpose/Objective of this assignment: To identify a PICOT question, recommend

changes to practice based on the literature and grading of the evidence, assess potential barriers to using the a change in practice, and develop an evaluation plan.

B. Assignment Requirements: Write a 3 – 5 page section, to be added to the literature review, applying the key findings for recommendations in changes to nursing practice, with proper citations, to answer the PICOT question.

Develop a logical transition paragraph from the Literature Review to this section, including the PICOT question.

Identify the key findings (about 1 or 2 paragraphs) about the clinical problem as applicable to nursing practice. (Do not repeat your literature review discussion.)

Briefly discuss the clinical implications. Support recommendations for practice change with clear arguments, using rationale/support for the changes based on the literature review findings.

Provide a brief statement of grading criteria and outcomes, cite the criteria used. DEVELOP A PLAN for making the change in practice in a clinical setting. Include

potential policy changes, nurse education, patient education, what the new intervention is. Cite the sources from where recommendations come from.

Include a plan for how will evaluate and measure outcomes, with a time frame.

Discuss relevant barriers/facilitators related to successful implementation of the evidence-based change.

Identify any relevant ethical considerations (about 1 paragraph) related to the clinical problem, the research reviewed (methodology, participants’ human rights, etc.), and the implementation of the change (e.g. apply utility and justice frameworks as appropriate, etc.).

Include cultural and spiritual considerations (2 paragraphs), Briefly discuss gaps in the literature (1 paragraph) regarding the clinical

problem and make recommendations for further research. UTILIZE ALL APPROPRIATE APA GUIDELINES FOR CITATIONS,

REFERENCES, DOCUMENT ORGANIZATION, FORMATTING, ACADEMIC LANGUAGE, CONCLUSION AND GRAMMAR.

Grading Rubric for Clinical Project: Clinical Implications Paper:

Category Exemplary Meets Requirements Needs Improvement

Points

Transition Section

Maximum10 points

Problem clearly identified.Thesis statement and focus of the paper clear to reader.Significance to nursing discussed.PICOT question included

Problem identified.Thesis statement clear to readerSignificance to nursing identified.PICOT question included

Problem unclear.Thesis statement unclear or missing.Significance to nursing not addressed.PICOT question not included

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Body – Plan for change

Maximum35 points

Appropriate findings from your literature review identified and discussed.Uses inference and reason to draw logical conclusions about implications and consequences.Identifies a strategy and potential problems.Provides support for change or innovation.Transitions link sections and paragraphs well.Content vocabulary appropriate, used well.Evaluation outcome clearly discussed and supportedClear plan developed to implement change in practice.

Literature review incorporated adequately.Draws logical conclusions.Identifies a strategy and potential problems.Proposed change is understandable and has support in literature.Evaluation outcomes included.Minor problems with transition and order of paragraphs or sections.Content vocabulary generally accurate.Plan developed to implement change in practice, but not clear.

Literature review not incorporated adequately.Findings unclear.Strategies unclear or not logical.No support for proposed changes.No evaluation outcome or evaluation outcome not clearly supported.Many or significant problems with transition and order of paragraphs or sections.Significant errors in content vocabulary.Plan unclear for change in practice

Grading of Evidence,Barriers/Facilitators to change, spiritual/cultural and ethical considerations15 points

Barriers/Facilitators to change identified and addressed, considered possible ethical implications, demonstrates insight and depth in discussion. Cultural/Spiritual Considerations included.Summary statement of grading of evidence with citation.

Minimal discussion of possible barriers/facilitators, minimal insight and/or depth.Ethical, spiritual or cultural considerations not all included.Summary statement of grading of evidence with citation.

No discussion of possible barriers/facilitators, no ethical considerations, no spiritual/cultural considerations, no insight/depth demonstrated.No summary statement of grading of evidence with citation.

ConclusionMaximum15 points

Clear, thorough summary.Relevance to nursing clearly stated.Recommendations clear and supported.

Problem and findings summarized.Relevance to nursing appropriate.Recommendations supported.

Summary inadequate.Relevance to nursing unclear or missing.Recommendations unclear or unconnected.

AssignmentMax. 5 points

Addresses all required elements of assignment & expands them.

Addresses all required elements of assignment.

Fails to address all required elements of assignment

Grammar & SpellingMax. 10 points

No grammar or spelling errors.

1-2 minor errors per page.

3 or more errors per page.

APA Format for Citations include all No more than two minor More than two

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Citations

Max. 5 points

elements of APA formatting, according examples in APA 7.01.

errors in APA style formatting in all citations. Follows examples in APA 7.01.

minor errors or one significant error in formatting in all citations. Does not follow examples in APA 7.01.

*Formatting

Max.5 points

Follows all APA formatting guidelines; uses Word functions appropriately, introduction and conclusion included

Follows all formatting guidelines; minor problems with Word functions.

Formatting errors; page length incorrect; poor use of Word functions.

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