To the Graduate Committee:
The thesis submitted herein was written by Amanda Barnett-McLean and is entitled Broad-Spectrum Antibiotics: Treatment of Sepsis Versus Growing Resistance. I have examined the final copy of this thesis for form and content and recommend, along with this thesis committee, that it be accepted in partial fulfillment of the requirements for the degree of the Master of Science in Nursing.
We have read this thesis and recommend its acceptance:
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Graduate Studies in Nursing
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A Thesis Presented for the Master of Science Nursing – Family Nurse Practitioner Program, Carson Newman University
Amanda Barnett-McLean
Spring 2021
This paper is being submitted on April 29th, 2021, for Angela Wood’s Research Methods and Design in Nursing class, NURS – 516 – AOL. Correspondence concerning this article should be addressed to Amanda Barnett-McLean. I have no known conflict of interest to disclose.
Email: [email protected]
In presenting the thesis in partial fulfillment of the requirements for a Master’s Degree at Carson-Newman University, I agree that the library shall make it available to borrowers under rules of the Library. Brief quotations from this thesis are allowable with special permission, provided that accurate acknowledgement of the source is made. Permission for extensive quotation from or reproduction of this thesis may be granted by my major professor, or in his/her absence (pick one), by the Chair of the Graduate Studies Department when, in the opinion of either, the proposed use of the material is for scholarly purpose. Any copying or use of the material in this thesis for financial gain shall not be allowed without my written permission.
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This thesis is dedicated to my father, Thomas Mark Barnett. It sadly was not until his passing that I was able to return to school and fulfill my dream of becoming a registered nurse. It is due to his faith and love however, that I have had the confidence to continue on and pursue my goal of becoming a nurse practitioner.
Acknowledgements
I would like to thank those who have helped in the process of obtaining my graduate degree. This includes my family for all of the support they have given during school, my coworkers for their understanding and constant question answering, and my preceptors that worked closely with me to guide me on my path to knowledge. Permission to use copyrighted material is listed here, as well as any acknowledgements to grants or funding utilized in completing the research.
Abstract
Each thesis must include an abstract. An abstract is a brief and concise explanation detailing the contents of the thesis. The word limit on the abstract is 350 words. The abstract shall be double spaced.
Table of Contents
Thesis Approval Sheet……………………………………………………………………………………………
Title Page……………………………………………………………………………………………………………. i
Statement of Permission to Use………………………………………………………………………………
Dedication………………………………………………………………………………………………………… ii
Acknowledgement………………………………………………………………………………………………..iii
Abstract………………………………………………………………………………………………………………iv
Table of Contents………………………………………………………………………………………………….v
List of Tables………………………………………………………………………………………………………vi
…………………………………………………………………………………Appendix
List of Figures…………………………………………………………………………………………………….vii
Sepsis Severity Scoring Tool………………………………………………………….Appendix 1
Changes in Septic Parameters…………………………………………………………Appendix 2
Roy’s Adaption Theory…………………………………………………………………Appendix 3
CHAPTER I………………………………………………………………………………………………………….1
Introduction…………………………………………………………………………………………………………..1
Problem Statement…………………………………………………………………………………………………1
Hypothesis…………………………………………………………………………………………………………….2
Significance…………………………………………………………………………………………………………..3
Research Design…………………………………………………………………………………………………….3
Theoretical Framework…………………………………………………………………………………………..4
Roy’s Physiological Adaption Model…………………………………………………………….4
Definition of Terms………………………………………………………………………………………………..5
Limitations……………………………………………………………………………………………………………7
Summary………………………………………………………………………………………………………………7
CHAPTER TWO …………………………………………………………………………………………………..8
Literature Review…………………………………………………………………………………………………..8
Text ……………………………………………………………………………………………………………………. 6
Chapters ………………………………………………………………………………………………………. 6
Chapter Contents. ………………………………………………………………………………………….. 6
Types of Studies ……………………………………………………………………………………………. 7
Quantitative Study Content …………………………………………………………………………….. 8
Qualitative Study Content. ……………………………………………………………………………… 9
Subdivisions/Headings …………………………………………………………………………………. 11
References ………………………………………………………………………………………………….. 11
Tables and Figures ……………………………………………………………………………………………… 11
Tables ………………………………………………………………………………………………………… 11
Figures……………………………………………………………………………………………………….. 12
Appendix ……………………………………………………………………………………………………….. 13
Vita ……………………………………………………………………………………………………………….. 13
CHAPTER III ……………………………………………………………………………………………………. 14
Formatting and Technical Pointers ……………………………………………………………………. 14
Typeface or font ………………………………………………………………………………………….. 14
Spacing ………………………………………………………………………………………………………. 14
Margins ……………………………………………………………………………………………………… 14
Pagination ………………………………………………………………………………………………….. 14
Paper and Duplication ………………………………………………………………………………….. 14
Guidelines for choosing the Thesis option: ……………………………………………………………. 15
Guidelines for choosing the Collaborative research project: …………………………………….. 15
Re: Grading Rubric for Graduate Projects/Thesis: ………………………………………………….. 16
ADVANCED PRACTICE PROJECT PREPARATION …………………………………………. 17
Advanced Practice Project …………………………………………………………………………………… 18
Definition ………………………………………………………………………………………………………. 18
Guidelines for the Advanced Practice Project …………………………………………………….. 18
Article format …………………………………………………………………………………………………. 18
Guidelines for choosing the Advanced practice project option: ………………………………… 19
Re: Grading Rubric for Graduate Projects/Thesis: ………………………………………………….. 20
PRESENTATION PREPARATION …………………………………………………………………….. 21
PRESENTATIONS…………………………………………………………………………………………….. 22
Poster guidelines for thesis ………………………………………………………………………………. 22
Poster guidelines for advanced practice projects …………………………………………………. 22
Oral presentation guidelines for thesis ……………………………………………………………….. 23
Oral presentation guidelines for advanced practice projects …………………………………. 23
REFERENCES ………………………………………………………………………………………………….. 24
References ……………………………………………………………………………………………………… 25
APPENDICES …………………………………………………………………………………………………… 26
Chapter 1: Introduction
Sepsis is a known health crisis across the United States. It kills 270,000 Americans each year alone (The Sepsis Alliance Institute, 2021). Sepsis is more common among men than women and has a higher incidence in the nonwhite population over the white population in America (Martin et al., 2003). There are different severity levels of sepsis including severe sepsis and septic shock (The Sepsis Alliance Institute, 2021). Sepsis is often treated with multiple strong antibiotics, antivirals, or antifungals depending on the type of suspected infection (The Sepsis Alliance Institute, 2021a). It is the timing and particularly the rush of this treatment that is of question in the following study.
Problem Statement
Many studies on the subject of sepsis have been completed to lower the rate of incidence and mortality. For many years, the research has pushed for faster diagnosis and treatment as a combatant force to the devastating reaches of sepsis’s power. This view toward faster treatment has led to guidelines suggesting that antibiotics be given within a specific time frame of identifying levels of the differing condition. Survival rate was found to decrease an average of 7.6% for each hour antibiotics were delayed post hypotension is septic patients (Patterson, MBBS, 2019). However, for patients that had not yet reached this critical level, a less dynamic effect or no important difference was seen is survival rate when comparing administration start times of antibiotics (Patterson, MBBS, 2019). The Sepsis Severity Score tool is used when diagnosing the septic level and is considered the “gold Standard” for determining treatment progression (Balk, Dr., 2021). The aim of this study is to determine the importance of antibiotic timing in relation to severity and mortality of patients diagnosed with sepsis. The intent is to determine whether rapid disbursement of broad-spectrum antibiotics is necessary, harmful, or beneficial to patients that are diagnosed with Systemic Inflammatory Response Syndrome (SIRS), Septic Shock, or Severe Septic Shock.
Hypothesis
Delaying broad-spectrum antibiotics until infection source is confirmed in patients diagnosed with sepsis but not yet in fluid refractory hypotension, will cause little or no increase in severity or mortality, but will have a significant impact on decreasing antibiotic resistance, side effects, or allergies in these patients.
Significance
The concern for importance of this study is seeded in the possible overuse of broad-spectrum antibiotics, leading to superbugs, additional allergies or side effects, and resistance. In fact, according to the World Health Organization (WHO), antibiotic resistance is leading to increased medical costs, higher mortality rates, longer inpatient stays, and is one of the largest threats to health globally (Antibiotic Resistance, 2020)! While many studies have been conducted to verify the validity and importance of antibiotics being started within a crucial timeframe (such as the first hour of diagnosis), few have been done to see if this rush to medicate is causing a massive overuse on our available broad-spectrum antibiotics. This study will evaluate if there is a significant amount of harm and health risk involved in the current sepsis protocol and if it warrants a review of the process in which treatment of this illness is presently managed.
Research Design
This study will be set up in causal-comparative/quasiexperimental research design (WSSU, n.d.). It will attempt to prove a cause-and-effect relationship between the mass usage in broad-spectrum antibiotic use for patients who have 2 or more SIRS criteria and the increasing antibiotic resistance problems. This study will not in any way change how a physician chooses to medicate a patient based on the current sepsis protocol. It will simply follow the patients identified as septic, determine based on cultures and other factors if the broad-spectrum antibiotics were actually an appropriate treatment option, and if so, was the source of infection susceptible to the chosen broad-spectrum drug. Independent variables will not be manipulated, and groups will be naturally occurring and not assigned by this researcher (WSSU, n.d.).
Theoretical Framework
The nursing theory that is most strongly associated with the hypothesis is Roy’s Physiological Adaption Model. To arrive at this point, one must first understand Sister Callista Roy’s Adaption Model (RAM) as a whole (Petiprin, 2020). This nursing model includes four modes of functioning: person, environment, nursing, and health. These translate into the metaparadigms: physiological, self-concept, role function, and interdependence. The theory addresses that health is a continuum that one must deal with all their life and that they will always be in a constantly changing state of health vs. illness (Petiprin, 2020). It also reminds that the human in a “bio-psycho-social being” and that the environment is ever changing; it could be said to be improving or declining (Petiprin, 2020, para. 5). The mode that this research will be focusing on will be physiological or basic bodily health.
Roy’s Physiological Adaption Model
The physiologic portion of this model has to do with basic bodily functions. This can be broken all the way down to the cellular level which is exactly what is being affected when someone is ill with sepsis. This physical portion of the RAM theory involves oxygenation, activity, rest, fluid and electrolytes, elimination, neurologic function, endocrine function, and protection (Gonzalo, BSN, RN, 2014, para. 23). When studying illness such as sepsis and medical treatments involving systemic fluid restoration and antimicrobials, it is important to assess how these treatments will affect the patient as a whole (Gonzalo, BSN, RN, 2014). The RAM will assist in the analysis of patient adaptation and coping methods through their illness and recovery and any possible adjustments it requires them to make to their daily lifestyle (Gonzalo, BSN, RN, 2014).
Roy’s Principles and Assumptions
Roy’s model has philosophical, scientific, and cultural assumptions built into its depths. While the philosophical matters play very little role in the diagnosis or treatment of sepsis, the cultural and specifically the scientific principles of this nursing theory can be seen with almost every case (Jennings, 2017). People must come to terms with their own mortality, faith, or cultural comforts anytime they are faced with illness and asked to make choices regarding their healthcare.
Definition of Terms
Limitations
This study is foreseeably limited by the length of time it will take follow treated patients and see if antibiotic resistance or allergies may have evolved to the broad-spectrum antibiotics that are given during their septic episode. This study may have to be further narrowed to only include certain medications, as it may yield to wide of a range of results to track. This study will be conducted solely out of one emergency room in a single location and the lack of cultural or ethnic variance may be skewed from that of broader results.
Summary
The main goal of this author’s research is not to modify the treatment of sepsis as a whole or to discourage the use of broad-spectrum antibiotics. This project rather is to investigate if there may be some leeway in the timing with which those antibiotics are given in order to investigate a patient’s underlying condition or microbial source further, so that more accurate treatment may be applied. This research than hopes in turn that evidence will show proof of a marginal reduction in antibiotic resistance, side effects, and allergic reactions.
Chapter 2: Literature Review
Defining Sepsis and Mortality Risks
Sepsis is a “systemic illness caused by (a) microbial invasion of normally sterile parts of the body… [the term] serves to differentiate an illness of microbial origin from an identical clinical syndrome that can arise in several non-microbial conditions” (National Institute of Health, 2007, para 2). While sepsis can be caused by bacterial, viral, or fungal microbes, the primary defining characteristic of sepsis is systemic organ failure. Severe sepsis and septic shock are a major cause of emergency department and intensive care unit admissions and are associated with significant mortality rates and health care costs (Sterling et al, 2015). Sepsis currently causes 270,000 deaths in the US annually and according to the Sepsis Alliance affects 49 million people yearly (The Sepsis Alliance Institute, 2021). It disproportionately affects children, the elderly, those with compromised immune systems, and those in lower socioeconomic brackets (The Sepsis Alliance Institute, 2021). Sepsis is often overly and inaccurately diagnosed, as frequently the symptoms of sepsis can be explained by multiple other conditions, many of which require alternate treatments than those for sepsis. However, in a push to combat the high mortality rates associated with sepsis, the guidelines for treating sepsis require that Emergency Departments triage potential septic cases higher and administer broad-spectrum antibiotics as quickly as possible. All of this started based on a 2006 study, which found a 7.6% decrease in survival rates for patients who were severely septic for each hour that antibiotics were delayed (Kumar et al, 2006). Emergency departments now follow the Sepsis Alliance guidelines and time expectations therein (Kumar et al, 2006). Subsequent studies, however, have failed to demonstrate such a large decrease, with some studies reporting no increase in mortality regardless of antibiotic administration concerning either shock recognition or triage time (Sterling et al, 2015).
Misdiagnosis
Currently, there is little information on the rates of the misdiagnoses of sepsis. More specifically, it is unknown how many patients are diagnosed and treated for sepsis while not actually being septic. These patients are those who because their symptoms first met the SIRS and/or the quick Sequential Organ Failure Assessment score (qSOFA) criteria for diagnosis when they were triaged but were administered treatment unnecessarily as other sources for their inappropriate vital signs were discovered, and they were later discharged. This literature review aims to provide a background for the potential harm caused by over-diagnosis of sepsis in Emergency Departments, specifically focusing on the financial harm caused by the expense of treatment, the long term documented negative health effects associated with the administration of broad-spectrum antibiotics, and the additional financial, emotional, and psychological burden associated with sepsis readmission, a frequent occurrence for patients treated for sepsis (Kempker & Martin, 2018).
The Cost of Sepsis
A 2020 analysis by the U.S. Department of Health and Human Services found that the cost of sepsis treatment for Medicare beneficiaries alone reached the staggering cost of $41.5 billion in 2018, with an estimate to spend over $60 billion by 2021. (U.S. Department of Health and Human Services, 2020). The average cost of treatment for sepsis per patient per incident is $21,000 (Kempker & Martin, 2018). The average cost of sepsis treatment ranges, depending on patient location, hospital network, and severity of sepsis; the one commonality, however, is the massive expense of sepsis treatment. For comparison, the average cost of a new compact SUV in 2018 was $28,000, a mere $7,000 more than the cost of being treated for sepsis. (Kelley Blue Book | New and Used Car Price Values, Expert Car Reviews, 2018). For further analysis, the average individual income in 2018 was $35,000 (US Census Bureau, 2019). Sepsis treatment for the average American in 2018 cost 60% of their income, and the cost of healthcare has steadily increased since then (National Institute of Health, 2020). Obviously, this is an incredible financial burden on patients, insurance companies, and hospital systems.
Kempker and Martin’s 2018 analysis of 20% of the hospitals in the Premier Alliance Network found that, on average, a diagnosis of sepsis increased the length of hospital stay, which in turn increases the cost of the stay and treatment (Kempker & Martin, 2018). As it is illegal in the United States to discharge a patient with sepsis, any diagnosis of sepsis is a guaranteed additional expense for the patient, which in turn is potentially an increased expense on the hospital network and the taxpayers. Marik and Taeb’s 2017 article “SIRS, qSOFA and New Sepsis Definitions” in the Journal of Thoracic Disease notes that at the time of admission, 15% of patients meet the criteria for a diagnosis of sepsis, and 47% of patients meet the SIRS criteria at least once (but often more than once) during hospitalization, regardless of their actual septic status (Marik & Taeb, 2017). Given the number of documented sepsis cases in the U.S., this is a potentially huge number of misdiagnosed sepsis cases, and while the heightened precautions concerning sepsis may be warranted, given the previously noted high mortality rate, this illustrates one of the largest problems with both the way sepsis is diagnosed and with how quickly broad-spectrum antibiotics are being administered. The SIRS criteria, the standard for diagnosis, has a potential false-positive rate of up to nearly 50% while patients are hospitalized (Seckel, 2020). The question stands: how much time should be taken before administering potentially harmful and certainly expensive sepsis treatment, given the level of uncertainty associated with a positive diagnosis?
From a financial perspective, the answer seems clear – more time should be allowed between diagnosis and administration, at least until a majority of SIRS criteria are met, or until a more sensitive diagnosis system has been created. For more information on proposed new sepsis diagnosis criteria, see Usman, Usman, and Ward’s 2019 “Comparison of SIRS, qSOFA, and NEWS for the Early Identification of Sepsis in the Emergency Department” in the American Journal of Emergency Medicine, available on the National Institute of Health’s website. (Usman et al, 2019).
Gut Dysbiosis and The Long-Term Effects of Broad-Spectrum Antibiotics
Perhaps the most concerning aspect of sepsis misdiagnosis and the accompanying aggressive treatment plans is the near-certainty of gut dysbiosis from the administration of broad-spectrum antibiotics. There is a growing body of evidence that suggests that dysbiosis of gut microbiota is associated with the pathogenesis of both intestinal and extra-intestinal disorders.
What is Gut Dysbiosis?
Gut dysbiosis is a “persistent imbalance of [the] gut’s microbial community, [which] relates to inflammatory bowel diseases (IBD), irritable bowel syndrome (IBS), diabetes, cancer, cardiovascular and central nervous system disorders.” (Belizario and Faintuch, 2018, para. 1). The National Institute of Health further identifies gut dysbiosis as being directly correlated to other illnesses, such as allergies, celiac disease, obesity, asthma, and metabolic syndrome. (Carding et al, 2015). Gut microbiota “functions in tandem with the host’s defenses and the immune system to protect against pathogen colonization and invasion. It also performs an essential metabolic function, acting as a source of essential nutrients and vitamins and aiding in the extraction of energy and nutrients, such as short-chain fatty acids (SCFA) and amino acids, from food.” (Carding et al, 2015, para. 2).
A single dose of clindamycin, a broad-spectrum antibiotic commonly used in the treatment of sepsis, has effects lasting a minimum of 28 days and results in a 90% loss of normal microbial taxa. (Buffie et al, 2012). Clindamycin also predisposes patients to C. difficile colitis (more commonly denoted as CDIFF), an intestinal pathogen that is known to cause colitis and diarrhea in patients (Buffie et al., 2011). In this same study, it was found that mice exposed to CDIFF who were then treated with clindamycin rapidly developed both diarrhea and colitis, which was followed by a 4 -5day period of rapid weight loss and a 40-50% mortality rate (Buffie et al., 2011). The surviving mice had severely restricted microbiota and remained highly susceptible to CDIFF infections for at least 10 days following their exposure to clindamycin treatment. While this outcome requires further testing, both on rodent subjects and human ones, the picture it paints is not encouraging. Considering that sepsis disproportionately affects children, the elderly, and people in lower socioeconomic brackets (thus people who possibly do not have access to clean, running water at all times, a necessary staple to survive a virulent bout of diarrhea), the prevalence of CDIFF after clindamycin administration is particularly concerning, as these groups are also particularly susceptible to suffering severe dehydration and death because of diarrhea. (National Institute of Health, 2017).
Other Complications
Diarrhea is not the worst of the possibilities to result from the administration of broad-spectrum antibiotics. According to Carding et al, “data suggest that CNS-related co-morbidities frequently associated with GI disease may originate in the intestine as a result of microbial dysbiosis (Carding et al, 2015, para 2)”, which is to say that a host of diseases and disorders are now being linked definitively to gut dysbiosis as a primary cause (Belizario and Faintuch, 2018). Ribeiro et al’s 2020 analysis “Effects of Antibiotic Treatment on Gut Microbiota and How to Overcome Its Negative Impacts on Human Health” published by the American Chemical Society delves further into this issue, noting an “alarming” impact of antibiotics on gut microbiota (Ribeiro et al., 2020). Ribeiro et al’s study does note that while antibiotics are a significant factor in negatively impacting gut microbiota, other key factors do play a part, such as duration of antibiotic treatment, number of doses, antibiotic class, host age, genetic susceptibility, and lifestyle (Ribeiro et al., 2020). It is important to reiterate that the most susceptible populations for sepsis are also the most likely populations to suffer higher mortality rates from CDIFF infections, due to the severity of symptoms associated with diarrhea for those groups. (National Institute of Health, 2020).
Beyond CDIFF, it is notable that morbidity rates increase for patients treated for sepsis. In a 2016 analysis titled “Sepsis-induced long-term immune paralysis – results of a descriptive, explorative study,” Arens et al found a direct correlation between people who had undergone treatment for sepsis and increased mortality rates spanning years after treatment (Arens et al., 2016). Patients who are given broad-spectrum antibiotics develop long-lasting impairment of their immune systems. The study noted “comprehensively impaired” cytokine secretion as a reaction to different activators of the immune system and calls for further research into mortality rates of patients treated for sepsis multiple years after treatment (Arens et al., 2016).
Time Delays: The Difference of An Hour
Current diagnostic methods for sepsis center largely around SIRS criteria, with a lesser but still notable reliance on qSOFA and/or eSOFA. This diagnostic criterion is largely based on the 2016 Kumar study that relates a 7.6% decrease in survivability per hour that Emergency Departments fail to administer broad-spectrum antibiotics to patients diagnosed with sepsis (Patterson, MBBS, 2019). Emergency Departments currently triage patients and are typically required to administer antibiotics within 1 hour of a sepsis diagnosis, as well as fluids, have blood cultures obtained, and have a lactic reported (Patterson, MBBS, 2019). Based on the Kumar study, this should have a significant impact on survival rates for sepsis – there should be a direct correlation between administration and mortality based solely on time, or “the Golden Hour” as some call it (Kumar et al., 2006). However, a meta-analysis performed in 2015 by Sterling et al reveals a much different picture (Kumar et al., 2006). (While a meta-analysis may be considered a secondary source, the results are undeniably compelling, given that their entire body of information came from primary source research performed in Emergency Departments and was overseen by the Chairman of the Department of Emergency Medicine at the University of Mississippi Medical Center.)
Of 16,178 patients analyzed in the Sterling et al study, there was no statistically significant change in mortality when administering antibiotics within 3 hours of diagnosis for sepsis or within 1 hour of administering antibiotics for severe sepsis and septic shock. Beyond the Kumar study, no other study has been able to replicate the “7.6%” claimed by the original study, and indeed, no other study notes anywhere as significant a decrease in mortality based on one-hour in antibiotic administration times (Sterling et al., 2015.) With this in mind, it is reasonable to conclude two things. The first being that more research is necessary within the field. The second is that the current diagnostic criteria, while well-meaning, may be based on a flawed study and is therefore inadequate to continue to use as a metric for antibiotic administration, specifically as it relates to time.
Conclusion
The SIRS methodology for the diagnosis of sepsis is a potentially incorrect mechanism to utilize to identify and treat cases of sepsis within Emergency Departments. More research is needed to determine more narrow criteria proper windows of time concerning antibiotic administration and patient mortality rates, as well as additional studies to determine the long-term impact of broad-spectrum antibiotics on overall health-related to this condition. It is important to weigh the long-term repercussions of heavy antibiotic administration against the health crisis that is sepsis. For further consideration, please see Kempker, Wang, and Martin’s 2018 commentary in Critical Care titled “Sepsis is a Preventable Public Health Problem”, which argues that instead of the current acute treatment methods for sepsis (namely broad-spectrum antibiotics), the global health community should be focused on three levels of prevention in order to reduce incidences of sepsis, as opposed to trying to catch up to it behind the ball. (Kempker et al., 2018).
Chapter Three: Methodology
Research Study and Design Introduction
The author of this proposal is stating that delaying broad-spectrum antibiotics until an infection source can be confirmed in patients diagnosed with sepsis but not yet in fluid refractory hypotension, will cause little or no increase in severity or mortality. There are many variables that may effect the collection of this information. These variables include the participants pre-existing health and comobidities, the length of stay of the patient (including whether or not they were admited), the type of infection or disease causing that particular person’s septic diagnosis, and the paticipants age. The researcher hopes to prove that by delaying broad spectrum antibiotics until proof posative that they are needed by way of SIRS criteria, known infection source, or other scale, that certain negative impacts may be avoided. This would include but not be limited to antibiotic resistance, side effects, or allergic reations that are unnecessary for patients who simply do not need the broad spectrum antibiotics at all.
This project is based upon assumptions being made by the researcher based upon priviously laid out facts discovered in literature review. The following will discuss the design that is proposed for use, as well as, what kind of sample is to be used. How and why the sample were determined as well as inclusion/exclusion criteria as justified below. Data collection tools will also be discussed and the reliability and validity of the one chosen will be examined for proper application to the method.
Assumptions
The research study is based on the Sepsis Alliance’s current protocols and the CDC’s SIRS guidelines (CDC, 2019) (The Sepsis Alliance Institute, 2021b). These assumptions include that sepsis is being diagnosed when a patient meets two SIRS critera, severe sepsis is only being diagnosed when two or more SIRS criteria are being met and there is either an elevated WBC level or hypotension involved. This study is reliant on the fact that accurate records are kept and that standard medications are ordered for all patients that are diagnosed with sepsis. Medications that would be standard in these situations include fluid boluses of 30ml/kg, two different broad spectrum antibiotics, and an antipyretic if a fever is included in the patients symptoms.
Reseach Design
Sample
Data Collection
Data Analysis
Severe Sepsis Scoring Tool
SIRS Criteria (≥ 2 meets SIRS definition)
Temp >38°C (100.4°F) or < 36°C (96.8°F)
No
Yes
Heart rate > 90
No
Yes
Respiratory rate > 20 or PaCO₂ < 32 mm Hg
No
Yes
WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands
No
Yes
Sepsis Criteria (SIRS + Source of Infection)
Suspected or present source of infection
No
Yes
Severe Sepsis Criteria (Organ Dysfunction, Hypotension, or Hypoperfusion)
Lactic acidosis, SBP <90 or SBP drop ≥ 40 mm Hg of normal
No
Yes
Septic Shock Criteria
Severe sepsis with hypotension, despite adequate fluid resuscitation
No
Yes
Multiple Organ Dysfunction Syndrome Criteria
Evidence of ≥ 2 organs failing
No
Yes
(Balk, Dr., 2021)
Changes in Septic Parameters
(Mehta et al., 2019)
Roy’s Adaption Theory
(Akyol & Bakan, 2008)
l Nursing2020CriticalCare l Volume 15, Number 2 |
References
Akyol, A. D., & Bakan, G. (2008). Roy Adaptation Model. In Wiley Online Library (pp. 596–608). Journal of Advanced Nursing. https://www.mjc.edu/instruction/alliedhealth/adnprogram/royadaptationmodel.pdf
Al-Khafaji, MD, MPH, A. H. (2020). Multiple Organ Dysfunction Syndrome in Sepsis Treatment & Management: Approach Considerations, Empiric Antimicrobial Therapy, Vasopressor Therapy. EMedicine. https://emedicine.medscape.com/article/169640-treatment
Al-Khafaji, MD, MPH., A. H. (2020, January 27). What is Multiple Organ Dysfunction Syndrome (MODS)? Medscape. https://www.medscape.com/answers/169640-99164/what-is-multiple-organ-dysfunction-syndrome-mods
Almulhim, A. S., & Alotaibi, F. M. (2018). Comparison of Broad-Spectrum Antibiotics and Narrow-Spectrum Antibiotics in the Treatment of Lower Extremity Cellulitis. International Journal of Health Sciences, 12(6), 3–7. International Journal of Health Sciences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6257879/
Antibiotic Resistance. (2020, July 31). World Health Organization. https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance#:~:text=A%20growing%20number%20of%20infections
Arens, C., Bajwa, S. A., Koch, C., Siegler, B. H., Schneck, E., Hecker, A., Weiterer, S., Lichtenstern, C., Weigand, M. A., & Uhle, F. (2016). Sepsis-Induced Long-Term Immune Paralysis – Results of a Descriptive, Explorative Study. Critical Care, 20(1). https://doi.org/10.1186/s13054-016-1233-5
Balk, Dr., R. A. (2021). SIRS, Sepsis, and Septic Shock Criteria. MDCalc. https://www.mdcalc.com/sirs-sepsis-septic-shock-criteria#use-cases
Belizário, J. E., & Faintuch, J. (2018). Microbiome and Gut Dysbiosis. Experientia Supplementum, 459–476. PubMed.gov. https://doi.org/10.1007/978-3-319-74932-7_13
Buffie, C. G., Jarchum, I., Equinda, M., Lipuma, L., Gobourne, A., Viale, A., Ubeda, C., Xavier, J., & Pamer, E. G. (2011). Profound Alterations of Intestinal Microbiota following a Single Dose of Clindamycin Results in Sustained Susceptibility to Clostridium difficile-Induced Colitis. Infection and Immunity, 80(1), 62–73. PubMed.gov. https://doi.org/10.1128/iai.05496-11
Carding, S., Verbeke, K., Vipond, D. T., Corfe, B. M., & Owen, L. J. (2015). Dysbiosis of the gut microbiota in disease. Microbial Ecology in Health & Disease, 26(0). https://doi.org/10.3402/mehd.v26.26191
CDC. (2020, February 10). How Do Germs Become Resistant? Centers for Disease Control and Prevention. https://www.cdc.gov/drugresistance/about/how-resistance-happens.html#anchor_1581367977327
Delano, M. J., & Ward, P. A. (2016). Sepsis-Induced Immune Dysfunction: Can Immune Therapies Reduce Mortality? The Journal of Clinical Investigation, 126(1), 23–31. https://doi.org/10.1172/JCI82224
Elvers, K. T., Wilson, V. J., Hammond, A., Duncan, L., Huntley, A. L., Hay, A. D., & Van Der Werf, E. T. (2020). Antibiotic-Induced Changes in the Human Gut Microbiota for the Most Commonly Prescribed Antibiotics in Primary Care in the UK: A Systematic Review. BMJ Open, 10(9),. BMJ. https://doi.org/10.1136/bmjopen-2019-035677
Filbin, M. R., Thorsen, J. E., Zachary, T. M., Lynch, J. C., Matsushima, M., Belsky, J. B., Heldt, T., & Reisner, A. T. (2020). Antibiotic Delays and Feasibility of a 1-Hour-From-Triage Antibiotic Requirement: Analysis of an Emergency Department Sepsis Quality Improvement Database. Annals of Emergency Medicine, 75(1), 93–99. PubMed.gov. https://doi.org/10.1016/j.annemergmed.2019.07.017
Francino, M. P. (2016). Antibiotics and the Human Gut Microbiome: Dysbioses and Accumulation of Resistances. Frontiers in Microbiology, 6. Frontiers. https://doi.org/10.3389/fmicb.2015.01543
Gonzalo, BSN, RN, A. (2014, August 19). Sister Callista Roy: Adaptation Model of Nursing. Nurseslabs. https://nurseslabs.com/sister-callista-roys-adaptation-model/#physiological-physical_mode
Gunn, N., Haigh, C., & Thomson, J. (2016). Triage of Sepsis Patients SIRS or qSOFA – Which is the Best? Emergency Medicine Journal, 33(12), 909.2-910. BMJ. https://doi.org/10.1136/emermed-2016-206402.23
Husabø, G., Nilsen, R. M., Flaatten, H., Solligård, E., Frich, J. C., Bondevik, G. T., Braut, G. S., Walshe, K., Harthug, S., & Hovlid, E. (2020). Early Diagnosis of Sepsis in Emergency Departments, Time to Treatment, and Association with Mortality: An Observational Study. PLOS ONE, 15(1), e0227652. https://doi.org/10.1371/journal.pone.0227652
Jennings, K. M. (2017). The Roy Adaptation Model. Advances in Nursing Science, 40(4), 370–383. https://doi.org/10.1097/ans.0000000000000175
Kelley Blue Book | New and Used Car Price Values, Expert Car Reviews. (2018). Kbb.com. https://www.kbb.com/
Kempker, J. A., & Martin, G. S. (2018). Severity and Timing of Onset Drive Economic Costs and Clinical Outcomes with Sepsis*. Critical Care Medicine, 46(12), 2043–2044. https://doi.org/10.1097/ccm.0000000000003376
Kempker, J. A., & Martin, G. S. (2020). A Global Accounting of Sepsis. The Lancet, 395(10219), 168–170. https://doi.org/10.1016/S0140-6736(19)33065-X
Kempker, J. A., Wang, H. E., & Martin, G. S. (2018). Sepsis is a Preventable Public Health Problem. Critical Care, 22(1). https://doi.org/10.1186/s13054-018-2048-3
Kumar, A., Roberts, D., Wood, K. E., Light, B., Parrillo, J. E., Sharma, S., Suppes, R., Feinstein, D., Zanotti, S., Taiberg, L., Gurka, D., Kumar, A., & Cheang, M. (2006). Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock*. Critical Care Medicine, 34(6), 1589–1596. https://doi.org/10.1097/01.ccm.0000217961.75225.e9
Lever, A., & Mackenzie, I. (2007). Sepsis: Definition, Epidemiology, and Diagnosis. BMJ (Clinical Research Ed.), 335(7625), 879–883. https://doi.org/10.1136/bmj.39346.495880.AE
LSU Health. (2007). Peer Reviewers Symptomatic Hypotension: ED Stabilization and the Emerging Role of Sonography Editor-in-Chief Associate Editor Editorial Board International Editors. https://www.medschool.lsuhsc.edu/emergency_medicine/docs/EMP%20Ultrasound%20&%20Hypotension.pdf
Marik, P. E., & Taeb, A. M. (2017). SIRS, qSOFA and New Sepsis Definition. Journal of Thoracic Disease, 9(4), 943–945. NCBI. https://doi.org/10.21037/jtd.2017.03.125
Martin, G. S., Mannino, D. M., Eaton, S., & Moss, M. (2003). The Epidemiology of Sepsis in the United States from 1979 Through 2000. New England Journal of Medicine, 348(16), 1546–1554. https://doi.org/10.1056/nejmoa022139
Mayo Foundation for Medical Education and Research. (2018). Low Blood Pressure (hypotension) – Symptoms and Causes. Mayo Clinic; https://www.mayoclinic.org/diseases-conditions/low-blood-pressure/symptoms-causes/syc-20355465
Mehta, A., Khalid, A., & Swaroop, M. (2019). Sepsis and Septic Shock. Clinical Management of Shock – the Science and Art of Physiological Restoration, Chapter 2: Figure 1. Intechopen. https://doi.org/10.5772/intechopen.86800
Nicks, MD, MHA., B. A. (2019). Acute Lactic Acidosis: Overview, Treatment Overview, Prehospital Care. Medscape. eMedicine. https://emedicine.medscape.com/article/768159-overview
Patterson, MBBS, B. (2019, February 18). How Important is the Timing of Antibiotics for Surviving Sepsis? – Infectious Disease Advisor. Infectious Disease Advisor. https://www.infectiousdiseaseadvisor.com/home/topics/sepsis/how-important-is-the-timing-of-antibiotics-for-surviving-sepsis/
Petiprin, A. (2020). Roy’s Adaptation Model of Nursing – Nursing Theory. Nursing Theory. https://nursing-theory.org/theories-and-models/roy-adaptation-model.php
Ribeiro, C. F. A., Silveira, G. G. de O. S., Cândido, E. de S., Cardoso, M. H., Espínola Carvalho, C. M., & Franco, O. L. (2020). Effects of Antibiotic Treatment on Gut Microbiota and How to Overcome Its Negative Impacts on Human Health. ACS Infectious Diseases, 6(10), 2544–2559. https://doi.org/10.1021/acsinfecdis.0c00036
Seckel, M. A. (2020). Current Sepsis Research. Nursing Critical Care, 15(2), 6–13. https://doi.org/10.1097/01.ccn.0000654796.79252.dc
Seladi-Schulman, Ph.D., J. (2020, November 11). Morbidity vs. Mortality Rate: What’s the Difference? Healthline. https://www.healthline.com/health/morbidity-vs-mortality
Sterling, S. A., Miller, W. R., Pryor, J., Puskarich, M. A., & Jones, A. E. (2015). The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock. Critical Care Medicine, 43(9), 1907–1915. PubMed.gov. https://doi.org/10.1097/ccm.0000000000001142
Tao, T., Zhao, X., Lou, J., Bo, L., Wang, F., Li, J., & Deng, X. (2012). The top cited clinical research articles on sepsis: a bibliometric analysis. Critical Care, 16(3), R110. https://doi.org/10.1186/cc11401
The Sepsis Alliance Institute. (2021a). Diagnosed with Sepsis. Sepsis Alliance. https://www.sepsis.org/education/patients-family/diagnosed-with-sepsis/
The Sepsis Alliance Institute. (2021b). What is Sepsis. Sepsis Alliance. https://www.sepsis.org/
US Census Bureau. (2019, May 10). Income & Poverty. The United States Census Bureau. https://www.census.gov/topics/income-poverty.html
Usman, O. A., Usman, A. A., & Ward, M. A. (2018). Comparison of SIRS, qSOFA, and NEWS for the Early Identification of Sepsis in the Emergency Department. The American Journal of Emergency Medicine, 37(8), 1490–1497. PubMed.gov. https://doi.org/10.1016/j.ajem.2018.10.058
WSSU. (n.d.). Key Elements of a Research Proposal Quantitative Design (pp. 1–4). Retrieved February 11, 2021, from https://www.wssu.edu/about/offices-and-departments/office-of-sponsored-programs/pre-award/_Files/documents/develop-quantitative.pdf
Zhang, S., & Chen, D.-C. (2019). Facing a New Challenge. Chinese Medical Journal, 132(10), 1135–1138. https://doi.org/10.1097/cm9.0000000000000245
Created by Christy Owen of Liberty University’s Online Writing Center [email protected]; last date modified: November 15, 2020 Table of Contents
(Only Included for Easy Navigation; Hyperlinked for Quick Access)
Sample APA Paper: Professional Format for Graduate/Doctoral Students ……………………………… 6
Basic Rules of Scholarly Writing ……………………………………………………………………………………… 7
Brief Summary of Changes in APA-7 ………………………………………………………………………………… 8
Running Head, Author Note, and Abstract …………………………………………………………………………. 9
Basic Formatting Elements …………………………………………………………………………………………….. 10
Font ………………………………………………………………………………………………………………….. 10
Line Spacing ……………………………………………………………………………………………………… 10
Spaces After Punctuation …………………………………………………………………………………….. 10
Footnotes …………………………………………………………………………………………………………… 11
Heading Levels—Level 1 ………………………………………………………………………………………………. 11
Level 2 Heading …………………………………………………………………………………………………. 12
Level 3 Heading ………………………………………………………………………………………. 13
Level 4 Heading. Must be bolded and indented ½”. Add a period, one
space, and begin your content on the same line as shown here. ………………………………… 13
Level 5 Heading …………………………………………………………………. 13
Specific Elements of Academic Papers ……………………………………………………………………………. 13
Tables of Contents and Outlines …………………………………………………………………………… 13
Annotated Bibliographies ……………………………………………………………………………………. 14
Appendices ………………………………………………………………………………………………………… 14Crediting Your Sources………………………………………………………………………………………………….. 15
Paraphrasing and Direct Quotes ……………………………………………………………………………. 15
Paraphrasing ……………………………………………………………………………………………. 15
Block Quotes …………………………………………………………………………………………… 16
How Often to Cite Your Source in Each Paragraph ………………………………………………… 17
Rule for Omitting the Year of Publication ……………………………………………………………… 17
Arranging the Order of Resources in Your Citations ………………………………………………. 17
Two Works by the Same Author in the Same Year …………………………………………………. 18
Two Works by Two Different Authors with the Same Last Name ……………………………. 18
Three or More Authors Cited In-Text ……………………………………………………………………. 18
Number of Authors in the Reference List ………………………………………………………………. 19
Numbers ………………………………………………………………………………………………………………………. 19
Displaying Titles of Works in-Text …………………………………………………………………………………. 19
Primary Sources versus Secondary Sources ……………………………………………………………………… 20
Personal Communications ……………………………………………………………………………………………… 20
Resources Canonically Numbered Sections (i.e., the Bible and Plays) …………………………………. 21
Bible and other Classical Works …………………………………………………………………………… 21
Plays …………………………………………………………………………………………………………………. 22
Lectures and PowerPoints ………………………………………………………………………………………………. 22
Dictionary Entries …………………………………………………………………………………………………………. 22
Changes in Reference Entries …………………………………………………………………………………………. 23Electronic Sources ………………………………………………………………………………………………………… 23
Adding Color ……………………………………………………………………………………………………………….. 24
Self-Plagiarism ……………………………………………………………………………………………………………… 25
Final Formatting Tweaks ……………………………………………………………………………………………….. 26
Exhaustive Reference List Examples & Additional Helpful Resources ………………………………… 26
Conclusion …………………………………………………………………………………………………………………… 29
References ……………………………………………………………………………………………………………………. 30Appendix ……………………………………………………………………………………………………………………… 40
Begin your abstract at the left margin. This is the only paragraph that should not be indented. Unless otherwise instructed, APA recommends an abstract be no more than 250 words. It should generally not contain any citations or direct quotes. This should be a tight, concise summary of the main points in your paper, not a step-by-step of what you plan to accomplish in your paper.
Avoid phrases such as “this paper will,” and just structure your sentences to say what you want to say. The following three sentences exemplify a good abstract style: There are many similarities and differences between the codes of ethics for the ACA and the AACC. Both include similar mandates in the areas of —-, —, and —. However, each differs significantly in the areas of —, —, and —. For more detailed information, see “Writing an Abstract” at https://www.liberty.edu/casas/academic–success–center/wp–content/uploads/sites/28/2019/04/ Writing_an_Abstract_Revised_2012.pdf (note that you would not include any links in your abstract). This is just now at 168 words, so eyeball how brief your abstract must be. Think of your paper as a movie you want to sound enticing, and the abstract as the summary of the plot you would share to draw people’s interest into wanting to come and see your movie. You want to really hook and intrigue them. What you have to say is important! Remember to stay under 250, words. Keywords highlight the search terms someone would use to find your paper in a database.
Keywords: main words, primary, necessary, search terms
The title of your paper goes on the top line of the first page of the body (American Psychological Association [APA], 2019, section 2.11). It should be centered, bolded, and in title case (all major words—usually those with four+ letters—should begin with a capital letter)—see
There are many changes in APA-7. One to mention here is that APA-7 allows writers to include subheadings within the introductory section (APA, 2019, p. 47). Since APA-7 now regards the title, abstract, and term “References” to all be Level-1 headings, a writer who opts to include headings in his or her introduction must begin with Level-2 headings as shown above (see section 2.27) for any divisions within the introductory section.
If you do choose to include headings in your introduction section (which is optional), be sure to include two or more subheadings, since APA (2019) forbids stand-alone heading levels. A second notable change in APA-7 is that writers are no longer required to cite their source every single sentence that content from it is mentioned (section 8.1). As demonstrated in this paper, since all of the content (other than the examples included for illustration and reference-entry variation purposes) comes directly from the APA-7 itself, citations to the APA-7 are only included for the first instance in each paragraph. Section and/or page numbers are included parenthetically throughout for the sake of students who desire to know exactly where the stated rule appears in the APA-7 itself. In your academic papers, however, it is critical to include the required author(s) and year, as applicable, for all citations that are included; this may include more than one citation for each resource per paragraph, as required to avoid any confusion about the source of that content.
Most beginning students have difficulty learning how to write papers and also format papers correctly using the seventh edition of the APA manual. However, the Liberty University
Online Writing Center’s (OWC) mission includes helping students learn how to be autonomous, proficient writers. The OWC also provides students with templates to help them with basic formatting elements, but this sample paper is designed to help graduate and doctoral students learn to master APA rules and formatting on their own, which will prove helpful as they progress in their studies and work toward future publication in scholarly journals.
For the purpose of instruction, this paper will use second person (you, your), but third person (this author) must be used in most student papers. First person (I, me, we, us, our) is not generally permitted in academic papers. Students should refrain from using first or second person in college courses (even though the APA manual encourages this in other writing venues) unless the assignment instructions clearly permit such (as in the case of personal reflection sections or life histories). If in doubt, students should clarify with their professors.
APA-7 delineates separate rules and guidelines between “student” and “professional” writers (APA, 2019). Because a primary purpose of graduate and doctoral studies is to prepare those students to publish professionally, Liberty University has decided to have undergraduate students follow APA-7’s guidelines for “student papers,” and graduate/doctoral students follow APA-7’s guidelines for “professional papers.” Separate templates are available for each level.
This sample paper illustrates and discusses the rules and formatting of professional papers, as required for all Liberty University graduate and doctoral courses using APA-7 style.
Most of these changes will be discussed in more detail below; this is just a very brief overview here. APA-7 reverts back to only one space after closing punctuation in the body of the paper (APA-6 required two spaces; APA, 2019, section 6.1). Student (undergraduate) papers no longer include a running head or abstract (sections 2.2 and 2.8); professional (graduate/doctoral) papers require an abstract but the running head is now the same on all pages (the added phrase
“Running head:” from APA-6 has been eliminated; see section 2.8). Title pages are different for both student and professional formats. The title of a paper is no longer limited to 12 words
(section 2.4).
Citations of all resources with three or more authors now use the first author’s last name and the term et al. (APA, 2019, section 8.17). Reference entries must name up to the first 19
authors before adding an ampersand and ellipsis (up from APA-6’s six authors; section 9.8).
APA-7 omits the phrase DOI and instead standardizes DOIs to be presented in hyperlink format (i.e., https://doi.org/10.1177%2F1524838017742386; section 9.35). Formatting guidelines for annotated bibliographies are included in APA-7 (section 9.51), as well as expanded and standardized reference entry examples. As discussed above, it is no longer necessary to cite a source every single time you refer to content gleaned from it as long as it is clear the content comes from that source (section 8.1); APA-7 also expanded the specific location noted in the citation to include page, paragraph, section (as used throughout this sample paper, to direct the student to the exact relevant content), chapter, timestamp, etc. (section 8.13).
APA-7 allows for “self-plagiarism” (clarified and defined below). It also invites writers to highlight the most relevant work first, rather than just present all works in alphabetical order (APA, 2019, section 8.12).
Heading-level formatting has changed, and APA-7 provides more flexibility in font and line spacing (APA, 2019). The Bible must now be included in the reference list and its citations must include the editor’s details and year (section 8.28); there are also new rules for dictionary entries. Publisher city and state details are omitted from all reference entries except those involving presentations or conferences, as is the phrase “retrieved from.” Hyperlinks should be live, but they may be either presented as blue underlining or plain black text.
APA (2019) delineates separate formatting requirements for what it terms “student” and “professional” papers. Its descriptions for those labels, however, suggests that it regards undergraduate-level writing to fall within the student purview, and graduate/doctoral-level writing (including dissertations and theses) to fall within the professional purview. Since a significant goal in graduate and post-graduate studies is preparing those students to publish in scholarly journals at and beyond graduation, it makes sense to train those students in the formatting that is required for professionals. As such, Liberty University has opted to require the APA-7’s “student” version format for all undergraduate assignments using APA, and its “professional” version for all graduate and doctoral assignments. To that end, this being the sample paper for professional formatting, it includes the additional elements required for such: a running head (same on all pages), an author’s note, and an abstract. Graduate and doctoral students will use this format.
Basic Formatting Elements
APA-7 does not prescribe a specific font or size (APA, 2019, section 2.19) but rather allows for some choice (e.g., 12-point Times New Romans, 11-point Calibri, 11-point Arial, 11point Georgia, or 10-point Lucinda Sans Unicode). Most journals and academic institutions will have a preference, however, as even APA-7 acknowledges on p. 44. For this reason—and because font size can easily be changed if an editor interested in publishing a student’s work prefers a different font—Liberty University recommends that students use 12-point Times New Romans or 11-point Calibri font for the body text in all academic papers. Data in charts, figures, and tables should be presented in 8- to 14-point size in either Calibri, Arial, or Lucinda Sans Unicode font. Students are not permitted to use any fonts such as script, calligraphy, poster, decorative, or others not found in published scholarly journals. Since APA-7 itself authorizes a variety of fonts and sizes, assignments will be gauged by word count rather than page count. Word count constitutes the number of words within the body of the paper, and excludes the title page, abstract, reference list, appendices, and other supplemental resources.
APA-7 adds extra/blank lines on the title page (APA, 2019, sections 2.5, 2.7, 2.21). It also specifies that spacing in tables and figures may be single-, 1-1/2-, or double-spaced; equations can be triple- or quadruple-spaced. Footnotes, when used at the bottom of a page, should be single-spaced (section 2.21).
APA-7 reverts back to just one space after closing punctuation in the body of the paper, as well as in reference entries (APA, 2019, section 6.1). Ordinarily, it would be improper to have a paragraph with only one sentence, though APA itself asserts that for its purposes “sentences and paragraphs of any length are technically allowed.”[1]
This leads to another new rule in APA-7, one allowing the inclusion of footnotes (APA, 2019, section 2.13). Footnotes should be use very sparingly and are appropriate to include information such as that in the prior section to alert the reader to supplemental material that is available online for that thought. Though APA-7 authorizes placement of footnote content either at the bottom of the page (as in this sample paper) or on a separate page after the reference list (section 2.21), Liberty University recommends that student place them, when used, at the bottom of the page, as shown here.
This sample paper uses primarily two levels of headings (Levels 1 and 2). APA style, however, has five heading levels, which will be demonstrated briefly for visual purposes. See section 2.27 of your APA-7 (APA, 2019) for more details on heading levels and formatting. In APA-7, all heading levels are now bolded and in title case (capitalize each major word—usually those with four or more letters, including hyphenated compound words). Do not capitalize articles (a, an, the) in headings unless they begin a title or follow a colon. Level 1 headings are centered, with the content falling on the line beneath each, in standard paragraph format.
Many students misunderstand that you progress from Level 1 to Level 2 to Level 3 to Level 4 to Level 5, but that is not correct. In fact, your paper may have only Level 1 headings, or just Levels 1 and 2. The rule of thumb is that you must have at least two of each heading level that you use, otherwise omit that heading level.
Headings are basically styling ways of organizing your paper, without using an outline format. APA specifies five levels of headings; you would likely never use Level 5 and only very rarely use Level 4 as a student. Think of each level as the different levels in an outline. Roman numerals, for example, would be Level 1 headings. Capital letters would be Level 2 headings. Numerals would be Level 3 headings. Lowercase letters would be Level 4. And lowercase Roman numerals would be Level 5. You must always have two or more of each subheading, but you do not need every level. You start with Level 1 and work down from that (but not consecutive 1-2-3-4-5). Under a Level 1, you would either have two+ Level 2 headings or none at all (just one big section in paragraphs before the next Level 1 section).
Special note about conclusion sections: Please note that some of the sample papers published by APA to demonstrate proper APA-7 format (including the “professional” sample on pp. 50-60 of the APA-7 manual) depict the “Conclusion” section with a Level-2 heading. This is limited to empirical papers that are being submitted for publication in scholarly journals, as those conclusions pertain to the “Discussion” sections in such papers and are not conclusions of the overall papers themselves. Conclusions in academic papers at Liberty University will be Level 1 headings (including dissertations and theses, which are divided by chapters, unlike journal article manuscripts).
Level 2 headings are left-justified (APA, 2019, p. 48). The supporting information is posed in standard paragraph form beneath it. Never use only one of any level of heading. You must use two or more of any level you use, though not every paper will require more than one level. The heading levels are simply demonstrated here for visual purposes, but you would always have two or more of each under a larger heading, as shown throughout all the other sections of this sample paper.
Level 3 headings are bolded, left-justified, and italicized; the content falls on the line underneath, as with Levels 1 and 2.
Level 4 Heading. Must be bolded and indented ½”. Add a period, one space, and begin your content on the same line as shown here.
Level 5 Heading. Same as Level 4, but also italicized. Despite heavy writing experience, this author has never used Level 5 headings.
Specific Elements of Academic Papers
APA (2019) does not regulate every type of paper and some elements in various assignments are not addressed in the APA-7 manual, including outlines and tables of content. In those cases, follow your professor’s instructions and the grading rubric for the content and format of the outline or annotations, and use standard APA formatting for all other elements (such as running head, title page, body, reference list, 1″ margins, double-spacing, permitted font, etc.). Note that most academic papers will not require a table of contents, nor would one be appropriate. One was included in this paper simply for ease-of-access so students could go directly to the content they want to see. Generally speaking, no table of contents would be necessary for papers less than 20 pages of content, unless otherwise required by your professor.
That being said, when organizing outlines in APA format, set your headings up in the proper levels (making sure there are at least two subheadings under each level), and then use those to make the entries in the outline. As discussed above, Level 1 headings become uppercase Roman numerals (I, II, III), Level 2 headings become capital letters (A, B, C), Level 3 headings become numbers (1, 2, 3), Level 4 headings become lowercase letters (a, b, c), and Level 5 headings become lowercase Roman numerals (i, ii, iii). Many courses now require “working outlines,” which are designed to have the bones and foundational framework of the paper in place (such as title page, abstract, body with title, outline/heading divisions, supporting content with citations, and references), without the full “meat” that fills out and forms a completed paper.
Many Liberty University courses also now require students to prepare and submit an annotated bibliography as a foundational step to building a research paper. There is significant merit in these assignments, as they teach students to critique the resources they have found and rationalize why each is relevant for their paper’s focus. APA (2019) includes a section on annotated bibliographies (9.51; see the example provided on p. 308). The appendix attached to this sample paper also includes a sample annotated bibliography.
Appendices, if any, are attached after the reference list (APA, 2019, section 2.14). You must refer to them (i.e., “callout”) in the body of your paper so that your reader knows to look there (see the yellow-highlighted callouts to Table 1 on p. 54 and to Footnote 1 on p. 55 of your
APA-7 for visuals on how this should appear in your paper). The word “Appendix” is singular; use it to refer to individual appendices. APA-7 regards it as a Level 1 heading so it should be bolded. I attached a sample Annotated Bibliography as a visual aid (see Appendix). You will see that I included the title “Appendix” at the top of the page and formatted it in standard APA format beneath that. Because I only included one appendix, it is simply titled as such. If there are more appendices, assign a letter to each and denote each by that: “Appendix A” and “Appendix
B.”
Crediting Your Sources
Paraphrasing is rephrasing another’s idea in one’s own words by changing the wording sufficiently without altering the meaning (remember not to just change a word here or there or rearrange the order of the original source’s wording). Quoting is using another’s exact words. Both need to be cited; failure to do so constitutes plagiarism. Include the author(s) and year for paraphrases, and the author(s), year, and page or paragraph number for direct quotes. APA-7 also expands this to include figure number, time stamp, etc.—whatever detail is necessary to get the reader directly to that content. Page numbers should be used for any printed material (books, articles, etc.), and paragraph numbers should be used in the absence of page numbers (online articles, webpages, etc.; see APA, 2019, section 8.13). Use p. for one page and pp. (not italicized in your paper) for more than one (section 8.25). Use para. for one paragraph and paras. (also not italicized in your paper) for two or more (section 8.28). For example: (Perigogn & Brazel, 2012, pp. 12–13) or (Liberty University, 2019, para. 8). Section 8.23 of the APA (2019) manual specifies that it is not necessary to include a page or paragraph number for paraphrases (just for direct quotes), but writers may choose to do so to help their readers find that content in the cited resource.
When naming authors in the text of the sentence itself (called a narrative citation), use the word “and” to connect them. For example, Perigogn and Brazel (2012) contemplated that . . .
Use an ampersand (&) in place of the word “and” in parenthetical citations and reference lists:
(Perigogn & Brazel, 2012).
Only use quotes when the original text cannot be said as well in your own words or
changing the original wording would change the author’s meaning. You cannot simply change one word and omit a second; if you paraphrase, the wording must be substantially different, but with the same meaning. Regardless, you would need to cite the resource you took that information from. For example, Benoit et al. (2010) wrote that “although, a link between attachment and posttraumatic stress disorder (PTSD) symptoms has been established, the mechanisms involved in this link have not yet been identified” (p. 101). A paraphrase for that quote might be: A link between dysfunctional attachment and the development of PTSD has been made, though there is insufficient data to determine exactly how this mechanism works (Benoit et al., 2010).
Quotes that are 40 or more words must be blocked, with the left margin of the entire quote indented ½ inch. Maintain double-spacing of block quotes. APA prefers that you introduce quotes but note that the punctuation falls at the end of the direct quote, with the page number outside of that (which is contrary to punctuation for non-blocked quotes). For example, Alone (2008) claims:[2]
Half of a peanut butter sandwich contains as much bacteria as the wisp of the planet Mars. Thus, practicality requires that Mrs. Spotiker nibble one bit at a time until she is assured that she will not perish from ingesting it too quickly. (p. 13)
Usually quotes within quotes use single quotation marks; however, use double quotation marks for quotes within blocked quotes, since there are no other quotation marks involved. Also understand that direct quotes should be used sparingly in scholarly writing; paraphrasing is much preferred in APA format (APA, 2019, section 8.23), as it demonstrates that you read, understood, and assimilated other writers’ content into one cohesive whole.
As already mentioned above, APA’s (2019) new official rule is that you no longer must cite your source every single time you refer to material you gleaned from it (section 8.1). It is now acceptable to cite your source the first time you refer to content from it in your paragraph, and then not again in that same paragraph unless your phrasing does not make the source of your content clear. This is demonstrated throughout this sample paper.
That being said, APA (2019) has clarified its special rule that excludes the year of publication in subsequent narrative in-text citations (when you name the authors in the text of the sentence itself), after the first narrative citation in each paragraph. It should continue to appear in all parenthetical citations (see section 8.16). For example, Alone (2008) portrays imagery of Mrs. Spotiker. This includes her devouring a peanut butter sandwich (Alone, 2008). Alone conveys this through the lens of astronomy. Note that the year of publication was omitted from the second narrative citation (underlined for visual purposes).
If the material you cited was referred to in multiple resources, separate different sets of authors with semicolons, arranged in the order they appear (alphabetically by the first author’s last name) in the reference list (i.e., Carlisle, n.d.-a; Prayer, 2015) (APA, 2019, section 8.12). APA-7 now invites writers to prioritize or highlight one or more sources as most prominent or relevant for that content by placing “those citations first within parentheses in alphabetical order and then insert[ing] a semicolon and a phrase, such as ‘see also,’ before the first of the remaining citations” (APA., 2019, p. 263)—i.e., (Cable, 2013; see also Avramova, 2019; De Vries et al., 2013; Fried & Polyakova, 2018). Periods are placed after the closing parenthesis, except with indented (blocked) quotes.
Authors with more than one work published in the same year are distinguished by lower- case letters after the years, beginning with a (APA, 2019, section 8.19). For example, Double (2008a) and Double (2008b) would refer to resources by the same author published in 2008. When a resource has no date, use the term n.d. followed by a dash and the lowercase letter (i.e.,
Carlisle, n.d.-a and Carlisle, n.d.-b; see APA, 2019, section 8.19).
Citations in the body of the paper should include only the last names, unless you have two or more resources authored by individuals with the same last name in the same year (or are citing a personal communication). When there are two different authors with the same last name but different first names who published in the same year, include the first initials: Brown, J.
(2009) and Brown, M. (2009) (APA, 2019, section 8.20).
When referring to material that comes from three or more authors, APA-7 now requires that all citations name just the first author’s last name followed by the words et al. (without italics) (APA, 2019, section 8.17). Et al. is a Latin abbreviation for et alii, meaning “and others,” which is why the word “al.” has a period, whereas “et” does not. Alone et al. (2011) stipulated that peacocks strut. Every single time I refer to their material, I would apply APA-7’s rule: Alone et al. (2011) or (Alone et al., 2011). Since et al. denotes plural authors, the verb must be plural to match, too: Alone et al. (2011) are… This applies to all citations within the body of the paper with three or more authors.
For resources with 20 or fewer authors in the reference list, write out all of the authors’ last names with first and middle initials, up to and including the 20th author (APA, 2019, section 9.8). APA-7 has a special rule for resources with 21 or more authors: Write out the first 19 authors’ last names with initials, insert an ellipsis (…) in place of the ampersand (&), and finish it with the last name and initials of the last author. See example #4 provided on page 317 of your
APA-7, as well as this paper’s reference list for visuals of these variances (Acborne et al. 2011;
Kalnay et al., 1996).
Numbers one through nine must be written out in word format (APA, 2019, section 6.33), with some exceptions (such as ages—see section 6.32). Numbers 10 and up must be written out in numerical format (section 6.32). Always write out in word format any number that begins a sentence (section 6.33).
The names of journals, books, plays, and other long works, if mentioned in the body of the paper, are italicized in title case (APA, 2019, section 6.17). Titles of articles, lectures, poems, chapters, website articles, and songs should be in title case, encapsulated by quotation marks
(section 6.7). The year of publication should follow the author’s name, whether in narrative or parenthetical format: Perigogn and Brazel (2012) anticipated…, or (Perigogn & Brazel, 2012).
The page or paragraph number must follow after the direct quote. Second (2015) asserted that
“paper planes can fly to the moon” (p. 13). You can restate that with a parenthetical citation as:
“Paper planes can fly to the moon” (Second, 2015, p. 13). Second (2011) is another resource by the same author in a different year.
APA (2019) strongly advocates against using secondary sources; rather, it favors you finding and citing the original (primary) resource whenever possible (section 8.6). On the rare occasion that you do find it necessary to cite from a secondary source, both the primary (who said it) and secondary (where the quote or idea was mentioned) sources should be included in the in-text citation information. If the year of publication is known for both resources, include both years in the citation (section 8.6). Only the secondary source should be listed in the reference section, however. Use “as cited in” (without the quotation marks) to indicate the secondary source. For example, James Morgan hinted that “goat milk makes the best ice cream” (as cited in Alone, 2008, p. 117). Morgan is the primary source (he said it) and Alone is the secondary source (he quoted what Morgan said). Only the secondary source is listed in the reference section (Alone, and not Morgan) because if readers want to confirm the quote, they know to go to page
117 of Alone’s book.
APA (2019) rationalizes the exclusion of references for information obtained through personal communication (such as an interview, email, telephone call, postcard, text message, or letter) in the reference list because your readers will not be able to go directly to those sources and verify the legitimacy of the material. Instead, these items are cited only in the body of the paper. You must include the individual’s first initial, his or her last name, the phrase “personal communication” (without the quotation marks), and the full date of such communication (section
8.9). As with other citations, such citations may be either narrative or parenthetical. For example,
13, 2015). The alternative is that he was advised to dip pretzel rolls in cheese fondue (L.
Applebaum, personal communication, July 13, 2015). Note that there is no entry for Applebaum in the reference list below.
These resources should be cited in book format (APA, 2019, Section 9.42). The Bible and other religious works are generally regarded as having no author; an annotated version would be treated as having an editor. Include republished dates as necessary. The OWC will publish a list of reference entries for various Bible versions on its APA Quick Guide webpage.
Works such as the Bible, ancient Greek or Roman works, and other classical works like Shakespeare must be cited in the body of the paper (APA, 2019, section 8.28). APA-7 now also requires that they be included in the reference list, too (section 9.42), which is a significant change from APA-6. Republished dates are included as well (see section 9.41). As such, you would add a parenthetical phrase at the end of your reference entry with the original publication details; note that there should be no punctuation following such parenthetical content at the end of a reference entry (the reference entries depicting this in the reference list below are correctly punctuated).
Citations for the Bible will include the Bible version’s name in the author’s position (as an anonymous work), original and republished years, and then the book chapter/verse (spelled out) in place of the page number (i.e., King James Bible, 1769/2017, Genesis 3:8)—see sections 8.28 and 9.42. Note that APA (2019) requires book titles to be italicized in every venue, including citations and reference entries. Because Liberty University is a distinctly-Christian institution and many of its courses require biblical integration, most if not all of its students will cite the Bible in virtually every course. The examples provided on pp. 274 and 325 of APA-7 are: (note the italics in each)
When citing plays, “cite the act, scene, and line(s), in a single string, separated by periods. For example, ‘1.3.36-37’ refers to Act 1 Scene 3, Lines 36-37” (APA, 2019, section 8.28; see also example #37 on p. 325).
APA (2019) has expanded and standardized its rules for citations and reference entries in an effort to best credit the original sources. It now includes rules for crediting content in course or seminar handouts, lecture notes, and PowerPoint presentations (see #102 on p. 347). When citing a PowerPoint presentation, include the slide number rather than the page number. For purposes of Liberty University course presentations and lectures (which are not readily available to the public), reference each as a video lecture with the URL (if available) for the presentation, naming the presenter(s) in the author’s position. Include the course number, lecture title, and enough details for others to identify it within that course, in a sort of book format, naming Liberty University as publisher. Peters (2012) is an example of this in the reference list of this paper. If the presenter for a Liberty University class lecture is not named, credit Liberty
University as the author; see Liberty University (2020) in the reference list below as an example.
In keeping with its efforts to standardize reference entries, APA (2019) now requires
citation and referencing of word definitions from dictionaries to follow the same rules for chapters in an edited book (see #47 and #48 on p. 328; section 8.13). As such, you will now name either the individual, group, or corporate author of the dictionary in the author’s place (e.g., Merriam-Webster, n.d.). If you searched online, include the retrieval date and the URL to the exact webpage. If you used a hard copy book, include the publisher details. The in-text citation in the body of the paper would follow standard author/year format (e.g., Merriam-Webster, n.d.).
There are a number of notable changes in APA-7 from past versions. For the most part, these simplify and unify the formats to be more consistent across the different resource venues.
Some of these have already been discussed above (i.e., naming up to 19 authors’ names before adding an ellipsis, and crediting authors and editors of classical works and dictionaries). Other changes include italicizing names of webpages and website resources in the reference list (APA,
2019, section 6.22), as well as book titles even when named in the author’s position (such as King James Bible). The city and state locations of publishers are no longer required; only include those details “for works that are associated with a specific location, such as conference presentations” (p. 297, section 9.31). Issue numbers are required for all journal articles that have such, regardless of what page number each issue begins with (section 9.25). If two or more publishers are listed on the copyright page, include all of them in the order listed, separated by semicolons (section 9.29). Omit the word Author in the publisher’s place when it is the same as
the author (section 9.24).
Note that since the APA 6th edition was published in 2010, great strides have been made in online and electronic resource accessibility, and APA’s position on electronic resources has shifted to embrace this. More and more resources are available electronically through the
Internet. The advent of this increased availability has resulted in APA-7’s effort to standardize the formatting of resources, which in turn simplifies them to some extent. All reference entries follow the same basic details: Author(s), year of publication, name of resource, and location details (i.e., either journal name/volume/issue/page numbers, or book publisher, or webpage).
APA (2019) requires inclusion of a Digital Object Identifier (DOI) in the references whenever available (section 9.34); if not, then a webpage, if available. In keeping with its unification of resources, APA-7 now standardizes all DOIs and URLs to be presented in https://doi.org/10.1177%2F1524838017742386 format. The phrase “Retrieved from” is now excluded except when the content may have changed (such as dictionary entries, Twitter profiles, Facebook pages; see section 9.16). APA-7 requires all hyperlinks to be active (so your reader can click on one to go directly to that webpage), but they may appear as either blue-underlined text or simple black text (section 9.35). There should be no period after any URL. APA-7 no longer requires authors to break long URLs with soft returns (hold down the Shift key and press the Enter key) at forward slashes, periods, or underscores to avoid unsightly spacing gaps, but it may be best to do so in academic papers.
Though APA (2019) authorizes writers to include the use of color in photographs and figures (section 7.26), Liberty University discourages this in academic papers. It risks becoming distracting for both students in their quest to be creative, and professors in their quest to focus on academic content.
APA (2019) also invites writers to repurpose some of their work in future papers.
Specifically, APA-7 states that:
In specific circumstances, authors may wish to duplicate their previously used works without quotation marks or citation …, feeling that extensive self-referencing is undesirable or awkward and that rewording may lead to inaccuracies. When the duplicated material is limited in scope, this approach is permissible. (p. 8.3) APA-7 adds “Do not use quotation marks or block quotation formatting around your own duplicated material” (p. 256).
Liberty University, however, has stringent rules against self-plagiarism, as do many scholarly journals. Liberty University students receive grades for their class papers; those who have received feedback and a grade from a prior professor on a prior paper have an advantage over their classmates, both in having the benefit of that feedback/grade and in not having to write a whole paper from scratch during the subsequent class. Student papers are also submitted to SafeAssign to deter plagiarism. For these reasons, Liberty University expressly forbids students using significant portions of a prior paper in a subsequent course (either a retake of the same course or a new class altogether). It is conceivable that students who are building their knowledge base in a subject matter—particularly at the graduate and post-graduate levels— would reasonably justify incorporating brief excerpts from past papers into current ones. In such case, Liberty University authorizes students to utilize APA-7’s disclosure (i.e., “I have previously discussed”), along with a citation to the prior class paper and a reference entry (i.e., Owen, 2012; Yoo et al., 2016). Such self-references and re-use of content from prior papers should be used sparingly and disclosed fully in the current paper; that content should not constitute a significant portion of any academic assignment, however.
The templates provided by Liberty University are already formatted with proper spacing, margins, heading level structure, and hanging indents, as necessary. With the exceptions of the title page, figures, and equations, papers in APA format should be double-spaced throughout, with no extra spacing between lines. Academic papers at Liberty University should also be in one of the accepted fonts throughout (recommended: Times New Romans, 12-point font). Sometimes when you format your paper or cut-and-paste material into it, things get skewed. One quick way to ensure that your paper appears correct in these regards is to do a final formatting tweak after you have completed your paper. Hold down the “Ctrl” button and press the “A” key, which selects and highlights all of the text in your paper. Then go to the Home tab in Microsoft Word and make sure that whichever acceptable font/size you choose to use is selected in the Font box. Next, click on the arrow at the bottom of the Paragraph tab. Set your spacing before and after paragraphs to “0 pt” and click the “double” line spacing. The extra spacing required on the title page is already programmed into the template and should not change even when you complete these actions.
The reference list at the end of this paper includes an example of a myriad of different sources and how each is formatted in proper APA-7 format. One example of each of the primary types of resources will be included in the reference list, as cited in the body of this paper. Remember that, for purposes of this paper only, many of the sources cited in the body of the paper were provided for illustrative purposes only and thus are fictional, so you will not be able to locate them if you searched online. Nevertheless, in keeping with APA-7 style, all resources cited in the body of the paper are included in the reference list and vice versa (except for personal communications, per APA-7’s published exceptions). Be absolutely sure that every resource cited in the body of your paper is also included in your reference list (and vice versa), excepting only those resources with special rules, such as personal communications and primary sources you could not access directly.
The reference list in this paper is fairly comprehensive and will include a book by one author who also appears as one of many authors in another resource (Alone, 2008; Alone et al.,
2011); chapters in edited books (Balsam et al., 2019; Haybron, 2008; Perigogn & Brazel, 2012; Weinstock et al., 2003); electronic version of book (Strong & Uhrbrock, 1923); electronic only book (O’Keefe, n.d.); edited books with and without DOIs, with multiple publishers (Hacker
Hughes, 2017; Schmid, 2017); work in an anthology (Lewin, 1999); journal articles (Andrews, 2016; Carlisle, n.d.-a, n.d.-b; De Vries R. et al., 2013; McCauley & Christiansen, 2019); newspaper article (Goldman, 2018; Guarino, 2017); online webpages (Liberty University, 2019;
Prayer, 2015); resource with corporate author as publisher (American Psychological Association, 2019); resources by two authors with the same last name but different first names in the same year of publication (Brown, J., 2009; Brown, M., 2009); two resources by same author in the same year (Double, 2008a, 2008b; Carlisle, n.d.-a, n.d.-b); two resources by the same author in different years (Second, 2011, 2015); resource with 20 authors (maximum allowed by APA-7 before special rule applies) (Acborne et al., 2011); resource with 21 or more authors (Kalnay et al., 1996); dictionary entries (American Psychological Association, n.d.; Graham, 2019;
Merriam-Webster, n.d.); Liberty University class lecture using course details (Peters, 2012);
PowerPoint slides or lecture notes, not including course details (Canan & Vasilev, 2019); citing a student’s paper submitted in a prior class, in order to avoid self-plagiarism (Owen, 2012); unpublished manuscript with a university cited (Yoo et al., 2016); code of ethics (American Counseling Association, 2014); diagnostic manual (American Psychiatric Association, 2013); religious and classical works, including the Bible (Aristotle, 350 BC/1994; King James Bible, 1769/2017; Shakespeare, 1623/1995); dissertation or thesis (Hollander, 2017; Hutcheson, 2012); review of a book (Schatz, 2000); video (Forman, 1975); podcast (Vedentam, 2015); recorded webinar (Goldberg, 2018); YouTube or other streaming video (University of Oxford, 2018); clip art or stock image (GDJ, 2018); map (Cable, 2013); photograph (McCurry, 1985); data set (Pew Research Center, 2018); measurement instrument (Friedlander et al., 2002); manual for a test, scale, or inventory (Tellegen & Ben-Porah, 2011); test, scale, or inventory itself (Project
Implicit, n.d.); report by a government agency or other organization (National Cancer Institute,
2018); report by individual authors at a government agency or other organization (Fried & Polyakova, 2018); annual report (U.S. Securities and Exchange Commission, 2017); conference session (Fistek et al., 2017); and webpages (Avramova, 2019; Centers for Disease Control and
Prevention, 2018; National Nurses United, n.d.; U.S. Census Bureau, n.d.).
Lastly, below are a few webpages that address critical topics, such as how to avoid plagiarism and how to write a research paper. Be sure to check out Liberty University’s Online Writing Center (https://www.liberty.edu/online/casas/writing–center/) for more tips and tools, as well as its Facebook page (https://www.facebook.com/groups/LUOWritingCenter). Remember that these links are only provided for your easy access and reference throughout this sample paper, but web links and URLs should never be included in the body of scholarly papers; just in the reference list. Writing a research paper (https://www.youtube.com/watch?v=zaa–PTexW2E or
https://www.youtube.com/watch?v=KNT6w8t3zDY and avoiding plagiarism
(https://www.youtube.com/watch?v=VeCrUINa6nU).
The conclusion to your paper should provide your readers with a concise summary of the main points of your paper (though not via cut-and-pasted sentences used above). It is a very important element, as it frames your whole ideology and gives your readers their last impression of your thoughts. Be careful not to introduce new content in your conclusion.
After your conclusion, if you are not using the template provided by the Online Writing Center, insert a page break at the end of the paper so that the reference list begins at the top of a new page. Do this by holding down the “Ctrl” key and then clicking the “Enter” key. You will go to an entirely new page in order to start the reference list. The word “References” (not in quotation marks) should be centered and bolded. Items in the reference list are presented alphabetically by the first author’s last name and are formatted with hanging indents (the second+ lines of each entry are indented 1/2” from the left margin). APA authorizes the use of singular “Reference” if you only have one resource.[3] Students would, of course, NOT include any color-coding or footnotes in their reference entries. However, for the sake of clarity and ease in identifying what each entry represents, each one included in the reference list of this sample paper is color-coordinated to its corresponding footnote, with a brief description of what each depicts.
Acborne, A., Finley, I., Eigen, K., Ballou, P., Gould, M. C., Blight, D., Callum, M., Feist, M.,
Carroll, J. E., Drought, J., Kinney, P., Owen, C., Owen, K., Price, K., Harlow, K., Edwards, K., Fallow, P., Pinkley, O., Finkel, F., & Gould, P. P. (2011). The emphasis of the day after tomorrow. Strouthworks. [4]
Alone, A. (2008). This author wrote a book by himself. Herald Publishers. [5]
Alone, A., Other, B., & Other, C. (2011). He wrote a book with others, too: Arrange
alphabetically with the sole author first, then the others. Herald Publishers. [6]
American Counseling Association. (2014). 2014 ACA code of ethics.
https://www.counseling.org/knowledge–center [7]
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). https://www.doi.org/10.1176/appi.books.9780890425596 [8]
American Psychological Association. (n.d.). Positive transference. In APA dictionary of psychology. Retrieved August 31, 2019, from https://dictionary.apa.org/positivetransference [9]
American Psychological Association. (2019). Publication manual of the American Psychological Association (7th ed.). [10]
Andrews, P. M. (2016). Congruence matters. Educational Leadership, 63(6), 12-15. [11]
Aristotle. (1994). Poetics (S. H. Butcher, Trans.). The internet Classics Archive.
http://classics.mit.edu/Aristotle/poetics.html (Original work published ca. 350 B.C.E.) [12]
Avramova, N. (2019, January 3). The secret to a long, happy, heathy life? Think age-positive. CNN. https://www.cnn.com/2019/01/03/health/respect–toward–elderly–leads–to–long–lifeintl/index.html [13]
Balsam, K. F., Martell, C. R., Jones, K. P., & Safren, S. A. (2019). Affirmative cognitive behavior therapy with sexual and gender minority people. In G. Y. Iwamasa & P. A. Hays (Eds.), Culturally responsive cognitive behavior therapy: Practice a supervision
(2nd ed., pp. 287-314). American Psychological Association.
https://doi.org/10.1037/0000119–012 [14]
Benoit, M., Bouthillier, D., Moss, E., Rousseau, C., & Brunet, A. (2010). Emotion regulation strategies as mediators of the association between level of attachment security and PTSD symptoms following trauma in adulthood. Anxiety, Stress, and Coping, 23(1), 101-118.
http://dx.doi.org/10.1080/10615800802638279
Brown, J. (2009). Ardent anteaters. Brockton.
Brown, M. (2009). Capricious as a verb. Journal of Grammatical Elements, 28(6), 11-12. 15
| Resources by two authors with the same last name but different first names in the same year of | |
| publication. Arrange alphabetically by the first initials | . |
15 Cable, D. (2013). The racial dot map [Map]. University of Virginia, Weldon Cooper Center for
Public Service. https://demographics.coopercenter.org/Racial–Dot–Map [15]
Canan, E., & Vasilev, J. (2019, May 22). [Lecture notes on resource allocation]. Department of
Management Control and Information Systems, University of Chile. https:// uchilefau. academia.edu/ElseZCanan [16]
Carlisle, M. A. (n.d.-a). Erin and the perfect pitch. Journal of Music, 21(3), 16-17. http:// makesure-it-goes-to-the-exact-webpage-of-the-source-otherwise-don’t-include [17]
Carlisle, M. A. (n.d.-b). Perfect pitch makes sweet music. Journal of Music, 24(8), 3-6. http:// make-sure-it-goes-to-the-exact-webpage-of-the-source-otherwise-don’t-include
Centers for Disease Control and Prevention. (2018, January 23). People at high risk of developing flu-related complications. https://www.cdc.gov/flu/highrisk/index.htm [18]
De Vries R., Nieuwenhuijze, M., Buitendijk, S. E., & the members of Midwifery Science Work Group. (2013). What does it take to have a strong and independent profession of midwifery? Lessons from the Netherlands. Midwifery, 29(10), 1122-1128.
https://doi.org/10.1016/j.midw.2013.07.007 [19]
Double, C. (2008a). This is arranged alphabetically by the name of the title. Peters.
Double, C. (2008b). This is the second (“the” comes after “arranged”). Peters. 21
| Two resources by same author in the same year. Arrange alphabetically by the title and then | |
| add lowercase letters (a and b, respectively here) to the year | . |
21 Fistek, A., Jester, E., & Sonnenberg, K. (2017, July 12-15). Everybody’s got a little music in them: Using music therapy to connect, engage, and motivate [Conference session].
Autism Society National Conference, Milwaukee, WI, United States.
https://asa.confex.com/asa/2017/webprogramarchives/Session9517.html [20]
Forman, M. (Director). (1975). One flew over the cuckoo’s nest [Film]. United Artists. [21]
Fried, D., & Polyakova, A. (2018). Democratic defense against disinformation. Atlantic Council.
https://www.atlanticcouncil.org/in–depth–research–reports/report/democratic–defenseagainst–disinformation/ [22]
Friedlander, M. L., Escudero, V., & Heatherton, L. (2002). E-SOFTA: System for observing family therapy alliances [Software and training videos] [Unpublished instrument].
http://www.softa–soatif.com/ [23]
GDJ. (2018). Neural network deep learning prismatic [Clip art]. Openclipart.
https://openclipart.org/detail/309343/neural–network–deep–learning–prismatic [24]
Goldberg, J. F. (2018). Evaluating adverse drug effects [Webinar]. American Psychiatric
Association. https://education.psychiatry.org/Users/ProductDetails.aspx?
Goldman, C. (2018, November 28). The complicate calibration of love, especially in adoption.
Chicago Tribune. [26]
Graham, G. (2019). Behaviorism. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy
(Summer 2019 ed.). Stanford University.
https://plato.stanford.edu/archives/sum2019/entries/behaviorism 29
Guarino, B. (2017, December 4). How will humanity react to alien life? Psychologists have some
| predictions. The Washington Post | . https://www.washingtonpost.com/news/speaking–of– |
science/wp/2017/12/04/how–will–humanity–react–to–alien–life–psychologists–have–some–
| predictions/ |
Hacker Hughes, J. (Eds.). (2017). Military veteran psychological health and social care:
Contemporary approaches. Routledge. [28]
Haybron, D. M. (2008). Philosophy and the science of subjective well-being. In M. Eid & R. J.
Larsen (Eds.), The science of subjective well-being (pp. 17-43). Guilford Press. [29]
Hollander, M. M. (2017). Resistance to authority: Methodological innovations and new lessons from the Milgram experiment (Publication No. 10289373) [Doctoral dissertation,
University of Wisconsin-Madison]. ProQuest Dissertations and Theses Global. [30]
Hutcheson, V. H. (2012). Dealing with dual differences: Social coping strategies of gifted and lesbian, gay, bisexual, transgender, and queer adolescents [Master’s thesis, The College
of William & Mary]. William & Mary Digital Archive.
| https://scholarworks.wm.edu/etd/1539272210/ |
Kalnay, E., Kanimitsu, M., Kistler, R., Collins, W., Deaven, D., Gandin, L., Iredell, M., Saha, S.,
White, G., Whollen, J., Zhu, Y., Chelliah, M., Ebisuzaki, W., Higgins, W., Janowiak, J.,
Mo, K. C., Ropelewski, C., Wang, J., Leetmaa, A., … Joseph, D. (1996). The
NCEP/NCAR 40-year reanalysis project. Bulletin of the American Meteorological
Society, 77(3), 437-471. http://doi.org/ fg6rf9 [32]
King James Bible. (2017). King James Bible Online. https://www.kingjamesbibleonline.org/
(Original work published 1769) 36
Lewin, K. (1999). Group decision and social change. In M. Gold (Ed.), The complex social scientist: A Kurt Lewin reader (pp. 265-284). American Psychological Association. https://doi.org/10.1037/10319–010 (Original work published 1948) [33]
Liberty University. (2019). The online writing center. https://www.liberty.edu/online/casas/
Liberty University. (2020). BIOL 102: Human biology. Week one, lecture two: Name of class lecture. https://learn.liberty.edu 39
McCauley, S. M., & Christiansen, M. H. (2019). Language learning as language use: A crosslinguistic model of child language development. Psychological Review, 126(1), 1-51.
https://doi.org/10.1037/rev0000126 [36]
McCurry, S. (1985). Afghan girl [Photograph]. National Geographic.
https://www.nationalgeographic.com/magazine/national–geographic–magazine–50–yearsof–covers/#/ngm–1985–jun–714.jpg [37]
Merriam-Webster. (n.d.). Heuristic. In Merriam-Webster.com dictionary. Retrieved 01/02/2020, from http://www.m–w.com/dictionary/heuristic [38]
National Cancer Institute. (2018). Facing forward: Life after cancer treatment (NIH Publication No. 18-2424). U.S. Department of Health and Human Services, National Institutes of
Health. https://www.cancer.gov/publications/patient–education/life–after–treatment.pdf [39]
National Nurses United. (n.d.). What employers should do to protect nurses from Zika.
https://www.nationalnursesunited.org/pages/what–employers–should–do–to–protect–rnsfrom–zika [40]
O’Keefe, E. (n.d.). Egoism & the crisis in Western values. http:// www. onlineoriginals.com/ showitem.asp?itemID-135 [41]
Owen, C. (2012, Spring). Behavioral issues resulting from attachment have spiritual implications [Unpublished manuscript]. COUN502, Liberty University. [42]
Perigogn, A. U., & Brazel, P. L. (2012). Captain of the ship. In J. L. Auger (Ed.) Wake up in the dark (pp. 108-121). Shawshank Publications. 47
Peters, C. (2012). COUN 506: Integration of spirituality and counseling. Week one, lecture two:
Defining integration: Key concepts. Liberty University.
https://podcasts.apple.com/us/podcast/defining-integration-keyconcepts/id427907777?i=1000092371727 [43]
Pew Research Center. (2018). American trend panel Wave 26 [Data set].
https://www.pewsocialtrends.org/dataset/american–trends–panel–wave–26 [44]
Prayer. (2015). http:// www exact-webpage [45]
Project Implicit. (n.d.). Gender–Science IAT. https://implicit.harvard.edu/implici/taketest.html [46]
Schatz, B. R. (2000, November 17). Learning by text or context? [Review of the book The social life of information, by J. S. Brown & P. Duguid]. Science, 290, 1304.
https://doi.org/10.1126/science.290.5495.1304 [47]
Schmid, H.-J. (Ed.). (2017). Entrenchment and the psychology of language learning: How we reorganize ad adapt linguistic knowledge. American Psychological Association; De
Gruyter Mouton. https://doi.org/10.1037/15969–000 [48]
Second, M. P. (2011). Same author arranged by date (earlier first). Journal Name, 8, 12-13.
Second, M. P. (2015). Remember that earlier date goes first. Journal Name, 11(1), 18. [49]
Shakespeare, W. (1995). Much ado about nothing (B. A. Mowat & P. Werstine, Eds.).
Washington Square Press. (Original work published 1623) [50]
Strong, E. K., Jr., & Uhrbrock, R. S. (1923). Bibliography on job analysis. In L. Outhwaite
(Series Ed.), Personnel research series: Vol. 1, Job analysis and the curriculum (pp. 140-
146). https://doi.org/10.1037/10762–000 [51]
Tellegen, A., & Ben-Porah, Y. S. (2011). Minnesota Multiphasic Personality Inventory–2
Restructured Form (MPI-2-RF): Technical manual. Pearson. 57
U.S. Census Bureau. (n.d.). U.S. and world population clock. U.S. Department of Commerce.
Retrieved July 3, 2019, from https://www.census.gov/popclock [52]
U.S. Securities and Exchange Commission. (2017). Agency financial report: Fiscal year 2017. https://www.sec.gov/files/sec–2017–agency–financial–report.pdf [53]
University of Oxford. (2018, December 6). How do geckos walk on water? [Video]. YouTube.
https://www.youtube.com/watch?v=qm1xGfOZJc8 [54]
Vedentam, S. (Host). (2015-present). Hidden brain [Audio podcast]. NPR. https://www.npr.org/ series/423302056/hidden–brain [55]
Weinstock, R., Leong, G. B., & Silva, J. A. (2003). Defining forensic psychiatry: Roles and responsibilities. In R. Rosner (Ed.), Principles and practice of forensic psychiatry (2nd ed., pp. 7-13). CRC Press. 62
Yoo, J., Miyamoto, Y., Rigotti, A., & Ryff, C. (2016). Linking positive affect to blood lipids: A cultural perspective [Unpublished manuscript]. Department of Psychology, University of
Wisconsin-Madison. [56]
Annotated Bibliography
Cross, D. & Purvis, K. (2008). Is maternal deprivation the root of all evil? Avances en
Psycologia Latinoamericana, 26(1), 66-81.
Weaving spiritual applications throughout the article, the authors incorporate a plethora of references to substantiate that maltreatment has a direct connection to attachment disorders. They provide articulate and heavily-supported reasoning, detailing the specific causes of maternal deprivation individually and then incorporating them in a broader sense to answer the article’s title in the affirmative.
Feldman, R. (2007), Mother-infant synchrony and the development of moral orientation in childhood and adolescence: Direct and indirect mechanisms of developmental continuity.
American Journal of Orthopsychiatry, 77(4), 582-597.
This longitudinal study tracked 31 Israeli children from ages 3 months to 13 years (infancy to adolescence). There were direct parallels noted between increased attachment/coherence and the child’s moral cognition, empathy development, and verbal IQ. Toddlers who were able to regulate their own behavior later proved to excel in lead- lag structures and language skills.
[1] See https://blog.apastyle.org/apastyle/2016/05/index.html
[2] Note that there are no quotation marks for block quotes, as shown in the example.
[3] https://apastyle.apa.org/instructional–aids/creating–reference–list.pdf
[4] Resource with 20 authors (maximum allowed by APA before special rule applies).
| Entry by author who also appears as one of many authors in another resource (single author | |
| appears first in list | ). |
[6] Multiple authors appear after same single-author resource.
[7] Code of ethics.
[8] Diagnostic manual.
[9] Entry in a dictionary, thesaurus, or encyclopedia, with group author.
[10] Resource with corporate author as publisher.
[11] Journal article without DOI, from most academic research databases or print version.
[12] Ancient Greek or Roman work.
[13] Webpage on a news website.
[14] Chapter in an edited book with DOI.
[15] Map.
[16] PowerPoint slides or lecture notes.
| Online journal article with a URL and no DOI; also depicts one of two resources by the same | |
| author with no known publication date | . |
[18] Webpage on a website with a group author.
[19] Journal article with a DOI, combination of individual and group authors.
[20] Conference session.
[21] Video.
[22] Report by individual authors at a government agency or other organization.
[23] Measurement instrument.
[24] Clip art or stock image.
[25] Webinar, recorded.
[26] Newspaper article without DOI, from most academic research databases or print version 29 Entry in a dictionary, thesaurus, or encyclopedia, with individual author.
[27] Online newspaper article.
[28] Edited book without a DOI, from most academic research databases or print version.
[29] Book chapter, print version.
[30] Doctoral dissertation, from an institutional database.
[31] Thesis or dissertation, from the web (not in a database).
[32] Resource with 21 or more authors. Note the ellipse (…) in place of the ampersand (&). 36 Religious work.
[33] Work in an anthology.
[34] Online webpage with URL.
[35] Liberty University class lecture with no presenter named.
[36] Typical journal article with doi.
[37] Photograph.
[38] Dictionary entry.
[39] Report by a government agency or other organization.
[40] Webpage on a website with no date.
[41] Electronic only book.
[42] Citing a student’s paper submitted in a prior class, in order to avoid self-plagiarism. 47 Chapter from an edited book.
[43] Liberty University class lecture using course details.
[44] Data set.
[45] Online resource with no named author. Title of webpage is in the author’s place.
[46] Test, scale, or inventory itself.
[47] Review of a book.
[48] Edited book with a DOI, with multiple publishers.
[49] Two resources by the same author, in different years. Arrange by the earlier year first.
[50] Shakespeare.
[51] Electronic version of book chapter in a volume in a series 57 Manual for a test, scale, or inventory.
[52] Webpage on a website with a retrieval date.
[53] Annual report.
[54] YouTube or other streaming video.
[55] Podcast. 62
| Chapter in an edited book without a DOI, from most academic research databases or print | |
| version | . |
[56] Unpublished manuscript with a university cited.
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