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6 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com
THE Centers for Medicare and Medicaid Serv-
ices report that pressure injuries (PIs) affect
millions of patients each year, with incidence
rates ranging from 2.2% to 23.9% in long-term
care organizations. PIs occur as a result of in-
tense or prolonged pressure in combination
with shear and are affected by excessive heat
and moisture, poor nutrition and blood circu-
lation, chronic illness, and soft-tissue condi-
tions (for example, an abrasion or sprain).
For 3 years, PI prevalence increased at a
Texas long-term continuing care retirement com-
munity that provides independent living, assisted
living, memory care, and skilled nursing. The or-
ganization faced several challenges, including
the lack of a nurse educator and inconsistent
continuing education for nursing staff.
To address these challenges, a PI quality
improvement team, consisting of the director
of nurses, an assistant director of nurses, an
RN, a licensed practical nurse (LPN) and a
certified nurse assistant (CNA), was created to
develop an evidence-based practice (EBP)
project of educational interventions and
strategies for consistent PI prevention. The
project was part of the author’s doctor of
nursing practice (DNP) program.
First steps
The QI team started the project by using the
PICOT (Patient, population, problem; Inter-
vention; Comparison, control; Outcome, ob-
jective; Timeframe) mnemonic to develop
this question:
P: In LPNs caring for older adult residents in
nursing homes,
I: how will the implementation of a formal PI
prevention program
Pressure injury
prevention in
long-term care
Follow the
evidence to
improve
outcomes.
By Melissa De Los Santos, DNP, RN
L E A R N I N G O B J E C T I V E S
1. Describe strategies for preventing pressure injuries (PIs) in long-term care (LTC).
2. Discuss how to implement a project designed to prevent PIs in LTC.
The author and planners of this
CNE
activity have disclosed no relevant financial relationships
with any commercial companies pertaining to this activity. See the last page of the article to
learn how to earn CNE credit.
Expiration: 7/1/24
CNE
1.6 contact
hours
MyAmericanNurse.com July 2021 American Nurse Journal 7
C: compared to no formal program
O: affect PI incidence
T: over a 5-month period?
A systematic literature search was then
completed across three databases (PubMed,
CINAHL, and Cochrane Library). The search
initially yielded more than 65,000 articles, but
applying subject headings when possible and
reviewing journal titles and abstracts nar-
rowed the results to 51 articles. The inclusion
criteria for those articles consisted of partici-
pants 18 years of age and older, articles pub-
lished within 10 years, and those written or
translated in English. Exclusion criteria includ-
ed treatment options such as redistribution de-
vices, wound care products, non-English items,
and articles published before 2008. Applying
these criteria and removing duplicate articles
reduced the number to 20 studies: four Level
I studies, four Level IV studies, two Level V
studies, seven Level VI studies, and three Lev-
el VII studies from around the world. (See Hi-
erarchy of evidence.)
On the basis of a study analysis, the team
found a body of evidence indicating that for-
mal PI programs with consistent PI preven-
tion education, interdisciplinary techniques,
standardized PI risk assessments, increased
communication, consistent documentation,
and ongoing monitoring can help decrease PI
incidence.
Building the project
Building the formal PI program required de-
termining the stakeholders and establishing a
timeline.
Stakeholders
Project stakeholders were the facility residents
and their families, CNAs, staff RNs and LPNs,
nursing administrators, and the organization’s
leaders. The EBP project included all residents
who were at risk for PIs, and all received pre-
vention strategies.
Timeline
Preliminary discussions began in the fall of 2018
and concluded in the spring of 2019, when the
project received approval by the university, the
DNP program, and the long-term care organiza-
tion (the project didn’t require institutional re-
view board approval). By the end of 2019, QI
team meetings were planned and support and
resources were finalized.
A timeline with evidence-based interventions
and outcomes organized, captured, and docu-
mented three project implementation phases:
educational intervention, implementation, and
sustainment and dissemination. Health informa-
tion collected as part of the project was de-
identified.
I used a logic model as the framework for
my project. (See Logic model in action.)
Launching the project
The EBP project launched on July 1, 2019, with
self-paced online PI education, risk assess-
ments (weekly and Braden Scale assessments),
interdisciplinary teamwork strategies, PI pre-
vention strategy communication, and docu-
mentation using PI identification communica-
tion tools and repositioning charts to increase
reporting and encourage ongoing monitoring.
I led four staff development sessions on all
shifts to introduce the EBP project to nursing
staff. Participants completed a pretest (to
gauge current PI knowledge) before the on-
line education program and a post-test after.
Phase 1: Educational intervention
Phase one consisted of implementing three
online, self-paced PI education modules from
an outside vendor and developing the quality
improvement team. The team’s responsibilities
included increasing PI prevention communica-
tion, promoting an effective multidisciplinary
team, discussing goals in staff meetings, mon-
itoring progress, assisting with accurate docu-
mentation of PI prevention strategies, and pro-
moting sustainability.
The 20-week nursing staff educational pro-
gram focused on consistent use of PI risk assess-
ment methods, effective interdisciplinary strate-
gies, increased communication, and accurate
documentation of PI prevention strategies. Inte-
grated checklists served as reminders to consis-
Hierarchy of evidence
Different types of studies provide different levels of evidence.
• Level I—Systematic review or meta-analysis of all relevant random-
ized controlled trials (RCTs)
• Level II—Well-designed RCTs
• Level III—Well-designed controlled trials without randomization
• Level IV—Well-designed case control and cohort studies
• Level V—Systematic reviews of descriptive and qualitative studies
• Level VI—Single descriptive or qualitative study
• Level VII—Opinions of authorities, reports of expert committees
Source Mazurek Melnyk B, Fineout-Overholt E. Evidence-based Practice in Nursing & Health-
care: A Guide to Best Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2018.
8 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com
tently implement the change based on current
protocols. For example, RNs completed monthly
comprehensive skin assessments; LPNs complet-
ed quarterly and as-needed Braden Scale assess-
ments; RNs and LPNs completed weekly skin as-
sessments; and CNAs, restorative aids, and
medication aids completed daily skin assess-
ments during routine care.
Flyers posted in the breakroom, next to the
time clock, and behind both nurses’ stations
outlined the importance of implementing and
documenting PI prevention. (See Promoting
PI prevention.)
Phase 2: Implementation
Phase two focused on PI prevention strategies,
consistent use of the Braden Scale, and weekly
skin assessments. Two project implementation
forms (a PI identification communication tool
and a repositioning chart) previously used
within the organization were resurrected for
this project. Daily skin checks were document-
ed on the PI identification communication
tool, and PI prevention strategies, such as turn-
ing residents on a schedule, were documented
on repositioning charts.
Phase 3: Sustainment
Phase three consisted of sustaining the pre-
vention strategies, conducting team meetings,
developing a skin algorithm, and incorporat-
ing project implementation forms into the
electronic health record.
Analyzing outcomes
Outcome analysis included educational inter-
Logic model in action
A logic model is a graphic tool for planning, describing, managing, communicating, and evaluating a program or intervention. It
consists of two main sections: process (inputs, activities, and outputs) and outcomes (short-, medium-, and long-term goals). Fre-
quently, assumptions and contextual or external factors also are included.
The author used the body of evidence and recommendations in the literature to create the model for the project described in the
article. The process section helped guide implementation, and project outcomes were planned, outlined, and appraised through-
out. External factors included the time it would take to complete training, and underlying assumptions included awareness of pre-
vention strategies that will decrease PI risk.
CNAs = certified nursing assistants, ID = identification, LPNs = licensed practical nurse, MAs = medication aids, PI = pressure injury, PIP = pressure injury prevention, RAs = restorative aids
Learn more about logic models at cdc.gov/dhdsp/docs/logic_model .
• Staff members
(RNs, LPNs,
CNAs, MAs,
RAs)
• PIP online edu-
cation on Braden
Scale, PI ID
Communica-
tion Tool, and
Repositioning
Chart
• Access to resi-
dent electronic
charts and
meeting rooms
Inputs
• By month 5,
there will be
a reduction
of PI rates
and costs
associated
with treat-
ment in resi-
dents
Outcomes
• Conduct training
sessions for accurate
implementation and
documentation of
Braden Scale
Activities
• Inservices or work-
shops for staff lead-
ing to better docu-
mentation and
increased reporting
of skin alterations
and PIs will occur
• PIP education will be
completed during
the first month of
implementation and
available online for
reinforcement for
future use
Outputs
• By the first
month after
training,
there will be
an increase of
knowledge of
PI risk factors
as evidenced
by consistent
use of Braden
Scale, PI ID
Communica-
tion Tool, and
Repositioning
Chart
• By month 3, there
will be an increased
proportion of staff
implementing
strategies to de-
crease the risk of
PIs as evidenced
by consistent use
of Braden Scale,
PI ID Communica-
tion Tool, and
Repositioning
Chart and de-
creased incidence
of PIs in residents
Long-term goalShort-term goal Medium-term goal
• Time to complete
training
• Paid or unpaid train-
ing
• Other protocols cur-
rently being imple-
mented
External factors
• Improve health
outcomes by
eliminating PIs
Impact
• Awareness of PIP strategies will decrease risk of PIs.
• Consistent and accurate use of PIP risk assessments will decrease risk of PIs.
• Increased understanding of PIP will decrease costs and improve health
outcomes.
• Empowering staff will influence behaviors to improve health outcomes.
Assumptions
MyAmericanNurse.com July 2021 American Nurse Journal 9
vention, PI prevention strategies, PI rates, and
cost savings.
Educational intervention
The educational intervention yielded a 57% nurs-
ing staff completion rate. Knowledge change
was calculated by analyzing staff pretest and
post-test scores. In the pretest, 61.5% of nursing
staff scored 80 on the PI assessments and 42%
scored 100. In the post-test, 13% of staff scored
80 and 87% scored 100 (a more than 50% in-
crease in 100 scores).
PI prevention strategies
In two-thirds of cases where CNAs had docu-
mented abnormal skin concerns on the PI
identification communication tool, RNs and
LPNs responded by completing multiple Braden
Scale assessments, even though there was no
formal protocol requiring them to do so. The
results confirmed the value of the tool.
Results also indicated the benefits of im-
plementing multicomponent PI prevention
initiatives, such as turning, repositioning, and
mobilizing frequently, along with other inter-
ventions (such as completing the Braden
Scale, skin assessments, special mattresses,
topical products, heel protectors, pillows, nu-
tritional assessments and interventions, hy-
dration, PI reporting, and communication).
Analysis of Braden Scale score averages and
repositioning frequency percentages showed
that patients with a high-risk Braden Scale
score (between 10 and 12) had a 71% reposi-
tioning average; moderate risk (13 to 14) had
a 59% repositioning average; at risk (15 to 18)
had a 66% repositioning average. Inconsistent
documentation affected the results, but repo-
sitioning averages were at or above 59% con-
sistently.
PI rates
For 3 years, PI incidence rates at the organiza-
tion had been rising steadly, from 0.67% in
2016 to 2.3% in 2017 and 5.3% in 2018. The
national average was 7.2% to 7.3%. The EBP
project achieved anticipated decreased PI
rates. Between July and December 2019, four
Stage II PIs were reported during the interven-
tion (4% PI incidence rate in 2019), resulting
in a 25% decrease in PI rates. Based on analy-
sis, more consistent use of the PI identifiction
communication tool with appropriate follow-
up may have prevented more PIs.
Cost savings
According to the Agency for Healthcare Re-
search and Quality, PIs in the United States
cost between $9.1 and $11.6 billion per year.
Costs associated with legal action resulting
from facility-acquired PIs add to the econom-
ic burden. Based on the evidence, the EBP
Promoting PI prevention
As part of the quality improvement team’s efforts to educate nursing staff
about pressure injury (PI) prevention, they created a flyer to post through-
out the organization. The flyer promoted staff empowerment through edu-
cation and encouraged the use of a repositioning/skin inspection chart and
a PI identification communication tool. At the end of each shift, completed
charts and tools are submitted to the assistant director of nursing, who
promptly reviews them to identify any new skin issues.
Repositioning/skin inspection chart
When developing the care plan, consider comorbid conditions, such as
frailty and dementia.
• Change the patient’s position at least every 2 hours.
• Reposition patients sitting in chairs every hour.
• Inspect skin during activities of daily living.
• Document the patient’s position and skin inspection every shift.
(View a repositioning chart at myamericannurse.com/?p=258423.)
PI identification communication tool
• Complete on all residents daily during routine care every shift.
• If the skin inspection reveals an area of concern, note it on the tool below.
PI identification communication tool
Date: Check all that apply:
Resident’s name:
n No skin problem noted
Reporter’s name:
n Bruise n Skin tear
n Reddened area
Place an “X” on the area of the body where you see a concern.
Reporter’s signature ________________
______________________________
Nurse’s signature (if reporter is not a nurse) __________________________
10 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com
project was expected to reduce PI prevalence
by at least 62%. This long-term care organiza-
tion’s financial policies prohibited the discov-
ery of direct costs, but because PI prevalence
decreased by 25% between July and Decem-
ber of 2019, it’s safe to assume some savings
occurred. In addition, it’s reasonable to con-
clude that decreased PI prevalence rates are
viewed as desirable by potential residents,
which could increase revenue from patient
recruitment.
Sustaining the intervention
To support sustainability and continued use of
evidence for data-driven changes, the QI team
developed a skin integrity algorithm. (See
Skin integrity algorithm.) The team also rec-
ommended to nursing leadership that the or-
ganization continue to use Braden Scale and
weekly skin assessments. The EBP project
prompted a culture change within the organi-
zation, enhancing PI awareness and contin-
ued use of the implementation forms by nurs-
ing staff after the EBP project ended.
Closing the gap
This EBP project used evidence to close the
gap between knowledge and action. Contin-
ued efforts include integrating implementation
forms and the skin integrity algorithm into
electronic formats for permanent use. Other
recommendations are incorporating increased
EBP into long-term care facilities for better
outcomes and to increase the quality of care
for all residents. AN
Access references at myamericannurse.com/?p=258423.
Melissa De Los Santos is a professor in the vocational nursing
program at Austin Community College, Eastview Campus in
Austin, Texas.
Skin integrity algorithm
To ensure the pressure injury (PI) prevention evidence-based practice was sustained, the quality improvement team developed a skin
integrity algorithm.
Weekly skin assessment
Abnormal findingNo abnormal finding
Continue Braden Scale assessments per protocol Nurse follow-up assessment and complete a Braden Scale assessment
Braden Scale risk scores*
Mild-risk scores (15 to 18)
Encourage mobilization, turning, and repositioning; document on
repositioning chart every shift.
Assist with peri-care and ADLs as needed.
Maintain hydration and nutrition.
Assist with mobilization, turning, and repositioning; document on
repositioning chart every shift.
Assist with peri-care and ADLs every shift.
Implement consultations with physician, wound team, and
dietician as needed.
Assist with mobilization, turning, and repositioning; document on
repositioning chart every shift.
Assist with peri-care and ADLs every shift.
Consult with physician, wound team, and dietician for additional
interventions.
Inspect, report, and document skin concerns on PI identification
communication tool every shift.
Inspect, report, and document skin concerns on PI identification
communication tool every shift.
Assist with hydration and nutrition every shift.
Inspect, report, and document skin concerns on PI identification
communication tool every shift.
Assist with hydration, nutrition, and offer supplements every shift.
Moderate-risk scores (13 to 14)
High-risk scores (12 or below)
ADLs = activities of daily living, PI = pressure injury
*For this project, the Braden Scale Score for very high risk (9 or below) was incorporated into the high-risk score.
MyAmericanNurse.com July 2021 American Nurse Journal 11
Please mark the correct answer
online.
1. Harold*, your 88-year-old patient,
enjoys sitting in his chair for the en-
tire morning. How often should you
reposition him?
a. Every 30 minutes
b. Every 45 minutes
c. Every 60 minutes
d. Every 90 minutes
2. You should document your inspec-
tion of Harold’s skin every
a. hour.
b. shift.
c. day.
d. week.
3. Joan, a 78-year-old resident in a
long-term care (LTC) facility, has a
Braden Scale score of 16. You know
that all of the following actions are
appropriate except:
a. assisting with mobilization, turn-
ing, and repositioning.
b. assisting with peri-care every
shift.
c. assisting with activities of daily
living every shift.
d. requesting a consultation with the
wound care team and dietician.
4. Which of the following statements
about PICOT is incorrect?
a. P = patient, population, problem
b. I = intervention
c. C = contrast, contractual
d. O = outcome, objective
5. You’re asked to spearhead a team
to reduce PIs in the LTC setting where
you work. The team is analyzing the
results of a literature search, and
some team members aren’t familiar
with the levels of evidence used to
guide the analysis. You explain that al-
though the precise levels can vary,
Level I typically includes
a. case control and cohort studies.
b. systematic review or meta-analy-
sis of all relevant randomized
controlled trials.
c. opinions of authorities and re-
ports of expert committees.
d. a single descriptive or qualitative
study.
6. Level VII typically includes
a. case control and cohort studies.
b. systematic review or meta-analy-
sis of all relevant randomized
controlled trials.
c. opinions of authorities and re-
ports of expert committees.
d. a single descriptive or qualitative
study.
7. Which of the following statements
about logic models is correct?
a. It’s a graphic tool for planning,
describing, managing, communi-
cating, and evaluating a program
or intervention.
b. It’s a written tool for planning,
describing, managing, communi-
cating, and researching a pro-
gram or intervention.
c. It includes outcomes in the form
of long-term goals.
d. The process section includes
medium-term goals.
8. You’re assembling a team for a
project to reduce PIs in your LTC set-
ting. Whom would you include on the
team?
______________________________
______________________________
______________________________
9. What would you anticipate the
team would identify as activities that
would help reduce PIs?
______________________________
______________________________
______________________________
10. What would be reasonable short-,
medium-, and long-term goals for this
project?
______________________________
______________________________
______________________________
*Names are fictitious.
POST-TEST • Pressure injury prevention in long-term care
Earn contact hour credit online at myamericannurse.com/pressure-injury-prevention
Provider accreditation
The American Nurses Association is accredited as a provider
of nursing continuing professional development by the
American Nurses Credentialing Center’s Commission on
Accreditation.
Contact hours: 1.6
ANA is approved by the California Board of Registered Nurs-
ing, Provider Number CEP17219.
Post-test passing score is 80%.
Expiration: 7/1/24
CNE: 1.6 contact hours
CNE
Concise Guide, 7th Edition
Student Paper Checklist
Use this checklist while writing your paper to make sure it is consistent with seventh edition APA Style. This checklist
corresponds to the writing and formatting guidelines described in full in the Concise Guide to APA Style (7th ed.).
Refer to the following chapters for specific information:
• paper elements and format in Chapter 1
• writing style and grammar in Chapter
2
• bias-free language in Chapter
3
• punctuation, lists, and italics in Chapter
4
• spelling, capitalization, and abbreviations in Chapter
5
• numbers and statistics in Chapter
6
• tables and figures in Chapter 7
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Chapters 9 and 10
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Write the title in title case: Capitalize the first
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Introduction (Section 1.11): Repeat the paper
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2
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Eliminate wordiness, redundancy, evasiveness,
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both short, simple sentences and long, involved
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Use verbs that agree in number (i.e., singular or
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Pronouns (Sections 2.16–2.21): Use first-
person pronouns to describe your work and
your personal reactions (e.g., “I examined,”
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Use other pronouns correctly.
Bias-Free Language (Chapter 5)
Eliminate biased language from your writing.
Avoid perpetuating prejudicial beliefs or
demeaning attitudes. Instead, use bias-free
language to describe all people and their
personal characteristics with inclusivity and
respect, including
° age
° disability
° gender
° participation in research
° racial and ethnic identity
° sexual orientation
° socioeconomic status
° intersectionality
For guidelines on writing about people without
bias and examples of bias-free language, see
the Bias-Free Language pages.
Punctuation, Italics, and Lists
Punctuation (Sections 4.1–4.6, 4.8–4.10): Use
punctuation marks correctly (periods, commas,
semicolons, colons, dashes, parentheses,
brackets, slashes), including in reference list
entries. Use varied punctuation marks in your
paper. Avoid having multiple punctuation
marks in the same sentence; instead, split the
sentence into multiple shorter sentences. Use
one space after a period or other punctuation
mark at the end of a sentence. Use a serial
comma before the final element in lists of three
or more items. Use parentheses to set off
in-text citations.
Quotation Marks (Sections 4.7): Use quotation
marks correctly. Place commas and periods
inside closing quotation marks; place other
punctuation marks (e.g., colons, semicolons,
ellipses) outside closing quotation marks. Use
quotation marks around direct quotations.
Italics (Sections 4.15–4.16): Use italics correctly
to draw attention to text. Use italics for the first
use of key terms or phrases accompanied by a
definition. Do not use italics for emphasis.
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https://apastyle.apa.org/style-grammar-guidelines/grammar/logical-comparisons
https://apastyle.apa.org/style-grammar-guidelines/grammar/verb-tense
https://apastyle.apa.org/style-grammar-guidelines/grammar/active-passive-voice
https://apastyle.apa.org/style-grammar-guidelines/grammar/first-person-pronouns
https://apastyle.apa.org/style-grammar-guidelines/grammar/first-person-pronouns
https://apastyle.apa.org/style-grammar-guidelines/grammar/singular-they
https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/age
https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/disability
https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/gender
https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/research-participation
https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/racial-ethnic-minorities
https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/sexual-orientation
https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/socioeconomic-status
https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/intersectionality
https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/
https://apastyle.apa.org/style-grammar-guidelines/punctuation/space-after-period
https://apastyle.apa.org/style-grammar-guidelines/punctuation/serial-comma
https://apastyle.apa.org/style-grammar-guidelines/punctuation/serial-comma
https://apastyle.apa.org/style-grammar-guidelines/italics-quotations/quotation-marks
https://apastyle.apa.org/style-grammar-guidelines/italics-quotations/italics
Lists (Sections 4.11–4.14): Ensure items in lists
are parallel. Use commas to separate items
in simple lists. Use semicolons to separate
items when any items in the list already contain
commas.
For more information, including how to create
lettered, numbered, and bulleted lists, see the
Lists pages.
Spelling, Capitalization,
and Abbreviations
Spelling and Hyphenation (Sections 5.1–5.2):
Spelling and hyphenation should match the
Merriam-Webster.com Dictionary or the APA
Dictionary of Psychology. Write words with
prefixes and suffixes without a hyphen.
For more information, including the spelling of
common technology terms, see the Spelling
and Hyphenation pages.
Capitalization (Sections 5.3–5.11): Use title
case and sentence case capitalization correctly.
Capitalize proper nouns, including names of
racial and ethnic groups. Do not capitalize
names of diseases, disorders, therapies,
treatments, theories, concepts, hypotheses,
principles, models, and statistical procedures,
unless personal names appear within these
terms.
For more information, including capitalization
to use for specific paper elements, see the
Capitalization pages.
Abbreviations (Section 5.12–5.18): Use
abbreviations sparingly and usually when
they are familiar to readers, save considerable
space, and appear at least three times in
the paper. Define abbreviations, including
abbreviations for group authors, on first use.
Do not use periods in abbreviations. Use Latin
abbreviations only in parentheses, and use
the full Latin term in the text. Do not define
abbreviations listed as terms in the dictionary
(e.g., AIDS, IQ) and abbreviations for units of
measurement, time, Latin terms, and common
statistical terms and symbols.
For more information, including abbreviations
that do not need to be defined, see the
Abbreviations pages.
Numbers and Statistics
Numbers (Sections 6.1–6.8): Use words to
express numbers zero through nine in the
text. Use numerals to express numbers 10 and
above in the text. In all cases, use numerals in
statistical or mathematical functions, with units
of measurement, and for fractions, decimals,
ratios, percentages and percentiles, times,
dates, ages, scores and points on a scale, sums
of money, and numbers in a series (e.g., Year 1,
Grade 11, Chapter 2, Level 13, Table 4).
For more information and exceptions, see the
Numbers pages.
Statistics (Sections 6.9–6.12): Include enough
information to allow readers to fully understand
any analyses conducted. Space mathematical
copy the same as words, with spaces between
signs. Use statistical terms in narrative text: “the
means were,“ not “the Ms were.” Use statistical
symbols or abbreviations with mathematical
operators: “(M = 6.62),” not “(mean = 6.62).”
Tables and Figures
General Guidelines (Sections 7.1–7.7): Include
tables and/or figures if required for your paper
or assignment. When possible, use a standard,
or canonical, form for a table or figure. Do not
use shading or other decorative flourishes.
In the text, refer to each table or figure by its
number. Explain what to look for in that table
or figure by calling out the table or figure in the
text (e.g., “Table 1 lists…” “As shown in Figure
1…”).
Either embed each table or figure in the
text after it is first mentioned or place it on
a separate page after the reference list. If
embedded, place the table or figure at either
the top or the bottom of the page with an extra
double-spaced line between the table or the
figure and any text.
Tables (Sections 7.8–7.21): Use the tables
feature of your word-processing program to
create tables. Number tables in the order they
are mentioned in the text. Include borders only
at the top and the bottom of the table, beneath
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https://apastyle.apa.org/style-grammar-guidelines/spelling-hyphenation/spelling
https://apastyle.apa.org/style-grammar-guidelines/spelling-hyphenation/hyphenation
https://www.merriam-webster.com/
https://dictionary.apa.org/
https://dictionary.apa.org/
https://apastyle.apa.org/style-grammar-guidelines/spelling-hyphenation/
https://apastyle.apa.org/style-grammar-guidelines/spelling-hyphenation/
https://apastyle.apa.org/style-grammar-guidelines/capitalization/title-case
https://apastyle.apa.org/style-grammar-guidelines/capitalization/title-case
https://apastyle.apa.org/style-grammar-guidelines/capitalization/sentence-case
https://apastyle.apa.org/style-grammar-guidelines/capitalization/proper-nouns
https://apastyle.apa.org/style-grammar-guidelines/capitalization
https://apastyle.apa.org/style-grammar-guidelines/abbreviations/definition
https://apastyle.apa.org/style-grammar-guidelines/abbreviations/latin
https://apastyle.apa.org/style-grammar-guidelines/abbreviations/latin
https://apastyle.apa.org/style-grammar-guidelines/abbreviations
https://apastyle.apa.org/style-grammar-guidelines/abbreviations
https://apastyle.apa.org/style-grammar-guidelines/numbers
column headings, and above column spanners.
Do not use vertical borders or borders around
every cell in the table.
All tables include four basic components:
number, title, column headings, and body.
Write the table number above the table title
and body and in bold. Write the table title one
double-spaced line below the table number
and in italic title case. Label all columns. Center
column headings, and capitalize them in
sentence case. Include notes beneath the table
if needed to describe the contents. Start each
type of note (general, specific, and probability)
on its own line, and double-space it.
See sample tables on the APA Style website.
Figures (Sections 7.22–7.32): Use a program
appropriate for creating figures (e.g., Word,
Excel, Photoshop, Inkscape, SPSS). Number
figures in the order they are mentioned in the
text. Within figures, check that images are clear,
lines are smooth and sharp, and font is legible
and simple. Provide units of measurement.
Clearly label or explain axes and other figure
elements.
All figures include three basic components:
number, title, and image. Write the figure
number above the figure title and image and
in bold. Write the figure title one double-
spaced line below the figure number and in
italic title case. Write text in the figure image
in a sans serif font between 8 and 14 points.
Include a figure legend if needed to explain
any symbols in the image. Position the legend
within the borders of the figure, and capitalize
it in title case. Include notes beneath the figure
if needed to describe the contents. Start each
type of note (general, specific, and probability)
on its own line, and double-space it.
See sample figures on the APA Style website.
In-Text Citations (Chapter 8)
Cite only works you read and ideas you
incorporated into your paper.
Include all sources cited in the text in the
reference list (exception: personal
communications are cited in the text only).
Make sure the spelling of author names and the
publication dates in the in-text citations match
those of the corresponding reference
list entries.
Paraphrase sources in your own words
whenever possible.
For guidance on how to paraphrase sources,
see the Paraphrasing pages.
Cite appropriately to avoid plagiarism, but do
not repeat the same citation in every sentence
when the source and topic do not change.
For guidance on appropriate citation, see the
Appropriate Level of Citation page.
Write author–date citations according to
seventh edition guidelines: Include the author
(or title if no author) and year. For paraphrases,
it is optional to include a specific page
number(s), paragraph number(s), or other
location (e.g., section name) if the source work
being paraphrased is long or complex.
° One author: Use the author surname in all in-
text citations.
° Two authors: Use both author surnames in all
in-text citations.
° Three or more authors: Use only the first
author surname and then “et al.” in all
in-text citations.
For more information, including exceptions
to basic in-text citation styles, see the Basic
Principles of Citation pages.
Use either the narrative or the parenthetical
citation format for in-text citations.
° Parenthetical citation: Place the author name
and publication year in parentheses.
° Narrative citation: Incorporate the author
name into the text as part of the sentence and
then follow with the year in parentheses.
For works with two authors,
° use an ampersand (&) in parenthetical in-text
citations: (Guirrez & Castillo, 2020)
° use the word “and” in narrative in-text
citations: Guirrez and Castillo (2020)
For more information, see the Parenthetical and
Narrative Citations page.
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https://apastyle.apa.org/style-grammar-guidelines/citations/paraphrasing
https://apastyle.apa.org/style-grammar-guidelines/citations/appropriate-citation
https://apastyle.apa.org/style-grammar-guidelines/citations/basic-principles/
https://apastyle.apa.org/style-grammar-guidelines/citations/basic-principles/
https://apastyle.apa.org/style-grammar-guidelines/citations/basic-principles/parenthetical-versus-narrative
https://apastyle.apa.org/style-grammar-guidelines/citations/basic-principles/parenthetical-versus-narrative
When citing multiple works in parentheses,
place the citations in alphabetical order. When
multiple parenthetical citations have the same
author(s), order the years chronologically and
separate them with commas (e.g., Coutlee,
2019, 2020). When the authors are different,
separate the parenthetical citations with
semicolons (e.g., Coutlee, 2019, 2020; Ngwane,
2020; Oishi, 2019).
For more examples, see the Citation of Multiple
Works page.
Limit the use of direct quotations. Include the
author (or title if no author), year, and specific
part of the work (page number(s), paragraph
number(s), section name) in the citation.
° Short quotation (less than 40 words): Use
double quotation marks around the quotation.
° Block quotation (40 words or more): Use the
block format: Indent the entire quotation 0.5
in. from the left margin and double-space it.
For more information, see the Quotations page.
References (Chapters 9 and 10)
Start the reference list on a new page after
the text.
Center and bold the section label “References”
at the top of the page.
Double-space the entire reference list, both
within and between entries.
Use a hanging indent for each reference
entry: First line of the reference is flush left,
and subsequent lines are indented by 0.5 in.
Apply the hanging indent using the paragraph-
formatting function of your word-processing
program.
All reference entries should have a
corresponding in-text citation. The beginning
of the reference entry (usually the first
author’s surname) and year should match the
corresponding in-text citation.
List references in alphabetical order according
to seventh edition guidelines.
Create the appropriate reference entry for
the type of work being cited, as described in
Chapter 9 and shown in Chapter 10 and on the
Reference Examples pages.
Do not create reference entries for personal
communications and secondary sources.
For a list of works to include and exclude from a
reference list, see the Works Included page.
Each reference entry includes four elements:
author, date, title, and source.
See exceptions for references with missing
information on the Missing Information page.
Use punctuation to group information and
separate reference elements.
For more information, see the Basic Principles
of References page.
List authors in the same order as the original
source. Use initials for authors’ first and middle
names. Put a comma after the surname and a
period and a space after each initial (e.g. Lewis,
C. S.). Put a comma after each author (even two
authors). Use an ampersand before the last
author.
For more information, including what to do
when a work has more than 20 authors, see the
Reference Elements page.
Capitalize titles in sentence case: Capitalize only
the first word of the title, the subtitle, and any
proper nouns. Format titles according to the
type of work.
° Works that stand alone: Italicize the title
(e.g., authored books, reports, data sets,
dissertations and theses, films, TV series,
albums, podcasts, social media, websites).
° Works that are part of a greater whole: Do
not italicize or use quotation marks around
the title (e.g., periodical articles, edited book
chapters, TV and podcast episodes, songs).
Write the title of the greater whole (e.g., journal
or edited book) in italics in the source element.
For more information, including when to
include bracketed descriptions for titles, see the
References Elements page.
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https://apastyle.apa.org/style-grammar-guidelines/citations/quotations/
https://apastyle.apa.org/style-grammar-guidelines/references/examples
https://apastyle.apa.org/style-grammar-guidelines/citations/personal-communications
https://apastyle.apa.org/style-grammar-guidelines/citations/personal-communications
https://apastyle.apa.org/style-grammar-guidelines/citations/secondary-sources
https://apastyle.apa.org/style-grammar-guidelines/references/works-included
https://apastyle.apa.org/style-grammar-guidelines/references/elements-list-entry#author
https://apastyle.apa.org/style-grammar-guidelines/references/elements-list-entry#date
https://apastyle.apa.org/style-grammar-guidelines/references/elements-list-entry#title
https://apastyle.apa.org/style-grammar-guidelines/references/elements-list-entry#source
https://apastyle.apa.org/style-grammar-guidelines/references/missing-information
https://apastyle.apa.org/style-grammar-guidelines/references/basic-principles
https://apastyle.apa.org/style-grammar-guidelines/references/basic-principles
https://apastyle.apa.org/style-grammar-guidelines/references/elements-list-entry#author
https://apastyle.apa.org/style-grammar-guidelines/references/elements-list-entry#title
Do not include database information for
works retrieved from academic research
databases. Do include database information
for works retrieved from databases with
original, proprietary content or works of limited
circulation (e.g., UpToDate).
For more information, see the Database
Information page.
Include a DOI or URL for any work that has one.
If there is no DOI, include a URL if the work
is retrieved online (but not from a database).
Present DOIs and URLs as hyperlinks (beginning
with “http:” or “https:”). Copy and paste DOIs
and URLs directly from your web browser. Do
not write “Retrieved from” or “Accessed from”
before a DOI or URL. Do not add a period after
a DOI or URL.
For more information, see the DOIs and URLs
page.
© 2021
Last updated March 10, 2021
More information on APA Style can be found in the Publication Manual of the
American Psychological Association (7th ed.) and the Concise Guide to APA
Style (7th ed.).
CITE THIS HANDOUT:
American Psychological Association. (2021). Concise
Guide, 7th edition student paper checklist.
https://apastyle.apa.org/instructional-aids/
concise-guide-formatting-checklist
We thank Miriam Bowers-Abbott, of Mount Carmel College
of Nursing, for providing the inspiration for this content.
https://apastyle.apa.org/style-grammar-guidelines/references/database-information
https://apastyle.apa.org/style-grammar-guidelines/references/database-information
https://apastyle.apa.org/style-grammar-guidelines/references/dois-urls
https://apastyle.apa.org/instructional-aids/concise-guide-formatting-checklist
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- In-Text Citations Cite Appropriately to Avoid Plagiarism: Off
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- In-Text Citations Use Narrative or Parenthetical Citation Format: Off
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- References Center and Bold Section Label: Off
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- References Use a Hanging Indent for References: Off
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- References Create Appropriate Reference for Each Work: Off
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