Recognizing and Treating an Opioid Overdose

EDUC 765: Trends and Issues in Instructional Design

Pat Maus

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RECOGNIZING AND TREATING AN OPIOID OVERDOSE

SPONSORING ORGANIZATION
MC is a large academic health system with a focus on caring for patients with serious
and complex illnesses. MC operates in five states and cares for more than a million
people a year from all 50 states and 140 countries.
MC Mission: To inspire hope and contribute to health and well-being by
providing the best care to every patient through integrated clinical
practice, education and research.
MC Primary Value: The needs of the patients come first.

MC Office of Patient Education (OPE) is the group that will sponsor this project within
the MC system. MC Patient Education supports the MC clinical practice in their efforts
to educate patients across the multi-state Enterprise Health System.

The OPE mission statement: The Office of Patient Education will proactively promote
and facilitate the delivery of high-quality, outcome-based patient education for MC
patents and health care providers throughout the Enterprise.

Vision Statement: Make a difference through patient education.

PROJECT DESCRIPTION
Opioid use in America has reached epidemic proportions. In October of 2016 the
Surgeon General released a report stating that 20 million Americans suffer from a form
of addiction. (U.S. Department of Health and Human Services (HHS), Office of the
Surgeon General, Facing Addiction in America: The Surgeon General’s Spotlight on
Opioids. Washington, DC: HHS, September 2018).

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More than 130 people each day die from an opioid-related drug overdose. Drug
overdose is the leading cause of accidental death in the USA and more than 6 out of 10
overdose deaths involved an opioid. (Rudd RA, Seth P, David F, Scholl L.
Increases in Drug and Opioid-Involved Overdose Deaths — United
States, 2010–2015. MMWR Morb Mortal Wkly Rep. ePub: 16 December
2016. DOI.) Naloxone is a medication that quickly reverses an opioid
overdose and restores breathing in an individual with an opioid
overdose. Research has shown that when naloxone and overdose
education are available to the community, overdose deaths decrease
in that community. (U.S. Department of Health and Human Services (HHS), Office
of the Surgeon General, Facing Addiction in America: The Surgeon General’s Spotlight
on Opioids. Washington, DC: HHS, September 2018). Therefore, making naloxone
available to patients with known access to opioids is a critical step in reducing opioid-
related deaths.
MC has the opportunity to provide education to patients their
significant others on how to identify an opioid overdose and safely
treat that overdose with the life-saving administration of naloxone.

AIM
Provide patients and their significant others with the education and skills to identify an
opioid overdose and immediately treat that overdose with naloxone and other
supportive measures. These supportive measures include maintenance of a clear
airway, activating the emergency response system by calling 911, maintaining a safe
environment and recognizing the need for dosage clarification or adjustment following
an overdose.

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TARGET AUDIENCE
All MC patients who are dismissed from the inpatient or outpatient setting with an opioid
prescription greater than 90 mme will receive a naloxone (Narcan) prescription. The
target audience is these patients and their available significant others.

DELIVERY OPTIONS

Instruction will be delivered online through the Patient Online Services patient portal.
This delivery option will place the content in a location that is accessible to patients in
their homes, on their devices or in the medical setting. The content will remain on the
portal and be available for repeat viewing and/or to share with significant others.

There is the opportunity to also make this instruction available on the MC Connect
website for Pain Rehabilitation and Addictions patients and families. These groups of
patients would access the content via a password provided by their health care provider.

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INSTRUCTIONAL NEED

According to Rossett (1999) naloxone administration falls into the existing performance
problem category. MC clinicians have noted that patients with access to opioids have a
knowledge and skill deficit related to identifying and safely treating an opioid overdose.

MC has not routinely prescribed naloxone to patients at risk for opioid overdose. A
proposed initiative to provide a naloxone prescription to all patients receiving an opioid
prescription above 90 mme is an effort to prevent the critical incident need of an opioid
overdose death. The difficult part of this instructional need is that the patient is the
individual that Mayo is reliably able to educate on overdose and naloxone. However,
the patient’s significant other is the individual that will actually be in the position to
recognize an overdose, administer the naloxone and take other safety measures. In
order to for patients to effectively receive naloxone treatment, the patient must prepare
the individual or individuals that are most likely to be present at the time of the
overdose. Patients and family members must be aware of the risks associated with
opioids, be able to identify signs of an opioid overdose, know how to administer
naloxone and take the necessary steps following naloxone administration to maintain
safety of the patient and of the person administering the overdose treatment.

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LEARNER ANALYSIS

Primary Audience
 Adult chronic pain patients being discharged from the inpatient or outpatient
setting with a naloxone prescription
 Adult acute pain patients being discharged from the inpatient or outpatient
setting with an opioid and a naloxone prescription

Secondary Audience
 Families or significant others of the adult chronic pain patient
 Families or significant others of the adult acute pain patient

General Learner Characteristics

Patients are a very unique audience. While there is typically a wide variation in
expertise and experience on topics associated with their health care and condition, they
do share some unique qualities. Typically, they are being educated on a topic that has
not been a part of their expertise or knowledge base. They are often quite impacted by
pain, stress and fear. Most patients are experiencing some sort of loss that may include
loss of function, independence, the vision of themselves as a healthy person, their
future plans etc. There are relatively common worries such as cost of health care,
caring for family, income interruption etc. All of these factors must be considered as
potential barriers to learning. And, even as patients in the same diagnosis or treatment
or procedure group, there are commonalities in the barriers yet the impact is very
personal. The audience for this project is no exception. Patients with acute or chronic
pain who be prescribed naloxone covers all socioeconomic, diversity, cultural, adult
ages, educational levels and prior experience with pain and pain medications.
 Primary Audience, Patient
o Potentially under the influence of opioid medications or other
substances
o Experiencing acute or chronic pain

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 o Experiencing the stress of a disease, condition, diagnosis and/or
treatment
o Assumed low health literacy based on likelihood of pain and stress
o Culturally diverse population
o Diversity of educational background
o Socioeconomic diverse population
o Variable skill or background with medical intervention

 Secondary Audience, Family or Significant Other

o Potential family or relationship stress
o Assume target 6-8th grade literacy level as is standard for health
education due to wide variation of the learners
o Culturally diverse
o Diverse educational background
o Socioeconomic diversity
o Variable skill or background with medical intervention

Entry Characteristics
 There are no consistent or reliable entry characteristics for the primary or
secondary learners. We cannot assume any prior skills related to opioid
overdose or naloxone administration, knowledge of opioids or a specific
attitude toward the topic of opioids or overdose. Due to lack of entry
characteristics in this broad audience this instruction must be designed in a
simple manner with specific, concrete content. The intent is mastery of the
basic, key concepts and important self-management skills rather than on
developing educationally challenging or demanding content. The patient, by
the very nature of the patient role, is assumed to have a low health literacy
level and learning barriers.

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  The audience may have some sensitivity related to labels such as addict or to
the stigma of addiction or substance use disorder. Care must be taken to
avoid any judgmental language or labels.

CONTEXTUAL ANALYSIS

Orienting Context
 Learn to recognize the signs of an opioid overdose, understand how naloxone
works to reverse an opioid overdose, administer naloxone by intramuscular or
intranasal routes, identify how to access emergency treatment, practice methods
to manage an open airway during naloxone administration
 Naloxone injection will reverse an opioid overdose and is a life-saving
intervention.
 With this intervention the patient can provide a significant other with the skills and
knowledge to save the life of a person experiencing an opioid overdose.
 Reversing and reporting an overdose may be perceived as leading to a limit of
the patient’s access to opioids. Significant others may fear that they will be
unable to effectively intervene leading to a failed opioid overdose reversal, death
and legal repercussions. Addressing these concerns in the education is important
to learner engagement.

Instructional Context
 The link to this online module will be contained within a standard smart text that
is sent to an individual patient’s portal through the electronic medical record by
the clinician prescribing the opioid and/or naloxone prescription. The patient can
view this module on their personal devices and share it with significant
others/family at any time.
 Pharmacists will reinforce the importance of the naloxone medication module for
patients who fill their prescription at a MC pharmacy.

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  In addition, the module will likely also be used as part of an opioid
overdose/naloxone class in Addiction Services and in the Pain Rehabilitation
Center
Technology Inventory
 Patients will need access to a computer, tablet or cell phone and a MC patient
portal app that has been activated.
 1.5 million MC patients have a patient online services account. 71% of patients
seen at the MC have a patient online services account. Staff will be encouraged
to assist patients in signing up for portal access and navigating to educational
content.

Transfer Context

The skills learned in this module are useful only in the context of an opioid overdose.
Patients and families will have access to this module to review the content at any time,
but MC Patient Education research has demonstrated that it is unlikely that they will
view it more than once. Clear instructions are provided with the naloxone product that
will prompt the patient as they apply their learnings from this module in an emergency
situation. The health care provider will be encouraged to re-assess understanding of
opioid overdose and re-send the module with each prescription refill. MC will likely also
create a written educational pamphlet that may be more quickly accessed in an
emergency.

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APPLICATION OF LEARNING THEORIES

Knowles Adult Learning Theory’s 6 important characteristics of adult learners will be

considered in the development of this education..
Problem-centered: The information in this naloxone module will provide patients and
significant others with an accessible solution to the very real risk of a potentially fatal
opioid overdose.
Results-oriented: Adults prefer education to lead to results. This content will provide
patients with all the information necessary to safely manage an opioid overdose.
Self-directed: This content will be highly recommended for all those who receive a
naloxone prescription. Patients may complete this module on their own schedule and
have the ability to choose whether to participate or not.
Skeptical about new information: Information about the dangers of opioid use,
overdose and reports of high profile individuals dying of opioid overdoses are prevalent
in the media, making this topic relevant. Including a small amount of science about how
naloxone works to reverse an opioid overdose is intended to make the information
logical and demonstrate the evidence supporting the efficacy and safety of naloxone
injections.
Relevant to their lives and needs: Pushing this module to the patient at the time an
opioid prescription and a naloxone prescription is prescribed and discussed with the
patient/family is the right time for education on the safe use of these medications. There
exists a fairly common level of anxiety about opioid prescriptions, making the content
relevant to those using opioid medications.
Responsible for their own learning: The module will be self-directed learning. The
patient’s health care provider will advocate that the content be completed, but the
learning will be independent.

https://www.rit.edu/academicaffairs/tls/course-design/instructional-design/adult-
learners

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APPLICATION OF MOTIVATIONAL THEORIES

John Keller’s ARCS model of motivation advocates the use of problem solving skills to
assess learning needs, identify instructional components and methods that motivate the
learner, then applying and evaluating the instructional approach. The focus is on
engaging the learner by catching their attention. Linking the knowledge of naloxone
delivery with the powerful ability to safe a life is an engagement strategy that is
consistent with Keller’s meaningful example, linking the content to an individual’s value
and providing clear communication and feedback to promote learner confidence are all
motivational strategies that are advocated in Keller’s work. The use of scenarios to
which the learner may apply and evaluate their new knowledge is also a strong
motivator according to Keller’s model.

There will also be a bit of Attribution theory applied in the modules. This social
psychology based theory is important to this education because in order to be
successful, the learner must understand that they have the power and control to reverse
an opioid overdose and save a life. Attribution relates to perceived ability to make a
change. This theory supports the design of educational interventions that allow
students to be successful. These include carefully recognizing learner effort, providing
well placed rewards and offering the opportunity for success when effort is made.

An attributional theory of emotion and motivation

B Weiner - 1986 - New York: Springer-Verlag

Demetriou, Cynthia. “The Attribution Theory of Learning and Advising Students on Academic
Probation.” NACADA Journal, vol. 31, no. 2, 2011, pp. 16–21., doi:10.12930/0271-9517-31.2.16
Fritz, Ron. “Weiner's Attribution Theory of Motivation: Definition & Examples.”
Study.com, Study.com, study.com/academy/lesson/weiners-attribution-theory-of-
motivation-definition-examples-quiz.html.

Praveen Shrestha, "Weiner Attribution Theory," in Psychestudy, November 17, 2017,

https://www.psychestudy.com/social/weiner-attribution-theory

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IMPACT OF A DIVERSE AUDIENCE ON INSTRUCTION

The audience for this education is very broad and will be very diverse. Keeping this in
mind, the design of the course must be simple, written in plain language with short
sentences, supporting visuals and an awareness of cultural sensitivity. MC has
interpreters available to review education with patients for whom English is not their
primary language. There is also the opportunity to translate the module into Arabic and
Spanish at a future date. These are the two most common languages encountered in
this health care system.

Hopefully, in the future, there will be the ability to use some of the power of the
electronic medical record to assess patients and match education to their individual
needs. There are currently some NIH funded studies beginning to assess patient’s
receptivity and access to non-opioid alternatives to pain management and then direct
education to those alternatives for that patient. Research like this may soon impact the
design and delivery of modules that are created for a diverse audience.

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GOAL ANALYSIS
Step 1

Original goal(s):

1. Tell someone where your naloxone is and how to use it

2. Identify opioid medications
3. Recognize the signs of an opioid overdose to determine need for naloxone
4. Administer naloxone
5. Maintain the airway
6. Remain safe and activate the emergency response system
7. Monitor patient until emergency personnel arrive

Step 2

1. Know what opioids are. Know what opioid(s) they are taking
2. Tell someone where the naloxone is and how to use it
3. Recognize signs/symptoms of an opioid overdose
(unresponsiveness, slow or stopped breathing, pale color, blue/grey color
around mouth, cool skin)
4. Know when to administer naloxone.
5. Give intranasal naloxone
6. Keep airway clear of vomit: roll and prop the patient on their side or turn head to
the side in anticipation of vomiting
7. Be safe: move out of reach of the patient/stay behind them to avoid injury if they
awake in a combative manner and to avoid vomit
8. Call 911 or ask bystanders to call 911 giving exact location of overdose and time
of naloxone administration and patient response to naloxone.
9. Monitor patient for recurrence of overdose signs (unresponsiveness, decreased
or no respiration) until emergency response team arrives

10. Repeat naloxone dose in three minutes if the patient does not recover. Also
repeat dose if patient recovers and then stops breathing and/or becomes
unresponsive. Use a new nasal injector for each dose.
11. If possible, Remove opioids from the patient’s possession until the dosage is
evaluated to avoid a repeat overdose

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Step 3

1. Know what opioids are. Know what opioid(s) they are taking
2. Tell someone where the naloxone is and how to use it
3. Recognize signs/symptoms of an opioid overdose
(unresponsiveness, slow or stopped breathing, pale color, blue/grey color
around mouth, cool skin)
4. Know when to administer naloxone.
5. Give intranasal naloxone
6. Keep airway clear of vomit: roll and prop the patient on their side or turn head to
the side in anticipation of vomiting
7. Be safe: move out of reach of the patient/stay behind them to avoid injury if they
awake in a combative manner and to avoid vomit
8. Call 911 or ask bystanders to call 911 giving exact location of overdose and time
of naloxone administration and patient response to naloxone.
9. Monitor patient for recurrence of overdose signs (unresponsiveness, decreased
or no respiration) until emergency response team arrives

10. Repeat naloxone dose in three minutes if the patient does not recover. Also
repeat dose if patient recovers and then stops breathing and/or becomes
unresponsive. Use a new nasal injector for each dose.
11. If possible, Remove opioids from the patient’s possession until the dosage is
evaluated to avoid a repeat overdose

Step 4

1. From a list of medications, identify those that are opioids.

2. Be able to identify supportive individuals and tell them where the naloxone is
kept and how to use it. Show them how to access this educational module.
3. Can check for the three classic signs/symptoms of an opioid overdose by taking
these actions: shouting the name, shaking their shoulders, grinding knuckles into
the breastbone and checking for breathing, pale skin color and clammy skin
4. Spray Naloxone intranasal in one nostril

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 5. Maintain a safe airway by rolling the patient on their side to prevent aspiration of
vomit
6. Maintain a safe environment for the naloxone administrator and bystanders by
staying out of reach of the patient and/or staying behind them to avoid
combativeness on becoming responsive and to avoid exposure to vomit.
7. Call 911 or ask bystanders to call 911. Tell them exact location of the overdose
patient, time of naloxone administration and the patient’s response to naloxone.
8. Until the emergency response team arrives, continue to monitor the patient for
recurrence of the 3 main opioid overdose signs: unresponsiveness, absence or
slow breathing and pale/clammy skin. If patient does not become responsive
within 3 minutes of the naloxone dose, administer a second dose with a new
naloxone nasal injector. If the patient initially responds and then becomes
unresponsive or stops breathing administer another dose with a new injector.

INSTRUCTIONAL GOAL

Accurately recognize a naloxone overdose by assessing responsiveness, breathing and

skin color and appropriately administer intranasal naloxone. Maintain a safe
environment by protecting the patient’s airway, taking steps to insure the safety of the
administrator and to activate the emergency response system. Monitor the patient for
necessary additional doses of naloxone until emergency response arrives.

TASK ANALYSIS METHOD

I selected a procedural task analysis because my goal consists of observable steps that
are necessary for success. These steps occur in a sequence that must be carefully
identified to complete the goal effectively.

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PROCEDURAL TASK ANALYSIS

1. Identify the supportive individual(s) around you and tell them where your
naloxone is and how to use it.
2. Identify opioid medications from a list of medications
1. Heroin
2. Hydrocodone (Vicodin)
3. Morphine (MSContin, Avinza)
4. Oxycodone (Percocet, Oxycontin, Percodan)
5. Hydromorphone (Dilaudid)
6. Oxymorphone (Opana)
7. Methadone
8. Codeine ( Tylenol with Codeine, Tylenol #3)
9. Merperidine (Demerol)
10. Fentanyl (Duragesic)
3. List the signs/symptoms of an opioid overdose
1. Unconscious or unresponsive
2. Not breathing or slow/shallow breathing
3. Cold/clammy skin
4. Checking for the signs of opioid overdose
1. Try to wake the person up: Shout, shake them by the shoulders, grind
your knuckles into their breastbone for 5-10 seconds to see if they will
wake up
2. Check for breathing: listen for breathing and look closely at the chest to
see if it moves with breathing
3. Look at the color of the skin: looking for blue around mouth

5. Call or have a bystander call 911 giving the location, time of naloxone dose and
the patient’s response to the dose.
6. Administer naloxone: If not responsive, not breathing or not conscious with very
shallow/irregular breathing
1. Peel open the naloxone nasal injector package, hold the device with your
first and middle fingers on either side of the nozzle and your thumb on the
bottom of the plunger.
2. Insert the tip of the injector gently into one of the patient’s nostrils until
your fingers on either side of the nozzle are touching the patient’s nose
3. Press the plunger on the injector firmly with your thumb

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 4. Remove the nasal injector after giving the dose.
5. Each naloxone injector contains one dose and cannot be reused.
6. Serious side effects from naloxone administration are rare

7. Protect the patient’s airway as vomiting is common and expected after naloxone
administration.
1. Roll and prop the patient on their side or turn their head to one side in
anticipation of vomiting
8. Maintain a safe environment:
1. Move out of reach of the patient or stay behind them to avoid injury if they
are agitated upon awakening and to avoid contact with vomit.
2. Monitor the person’s level or consciousness, breathing and skin color
carefully until emergency response arrives
9. Be prepared to repeat naloxone dose
1. Repeat dose with a new injector in three minutes if there is no response to
the first dose
2. If the patient wakes up after first dose, continue to monitor responsiveness
and breathing as naloxone often wears off in 30-60 minutes.
3. Give a second dose with a new naloxone injector if the patient has
responded but then becomes unresponsive or stops breathing.
10. Remove opioids from the patient’s possession until the dosage is evaluated to
avoid a repeat overdose
11. All people should be monitored for opioid toxicity for at least 4 hours from the
last dose of naloxone. People who overdosed on long-acting opioids should be
monitored for a longer period of time.

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 Objectives

Terminal Objective:
Identify the supportive individual(s) around you, tell them where your naloxone is and how to
use it. Cognitive (Remembering)

Enabling Objectives

1. Write down the name(s) of supportive people around you. Cognitive

(Remembering)
2. Before the end of the day, text or talk to the identified people to tell them where
your naloxone is stored and how to access this educational program. Cognitive
(Remembering)

Terminal Objective:
Given lists of medications, identify with 100% accuracy the medications that are opioids.
Cognitive (Remember)
Enabling Objectives:
1. Given a list of medications, correctly identify (circle) all of these opioid
medications. Cognitive (Remember)
a. Hydrocodone (Vicodin)
b. Morphine (MSContin, Avinza)
c. Oxycodone (Percocet, Oxycontin, Percodan)
d. Hydromorphone (Dilaudid)
e. Oxymorphone (Opana)
f. Methadone
g. Codeine ( Tylenol with Codeine, Tylenol #3)
h. Merperidine (Demerol)
i. Fentanyl (Duragesic)
j. Heroin

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Terminal Objective:
After establishing that the patient is unresponsive and not breathing due to an opioid
overdose, administer intranasal naloxone according to the 5 steps presented in this
module. Cognitive (remember)
Enabling Objectives:

1. Given an example of three patients and their symptoms, correctly identify the
patient that exhibits an opioid overdose. Cognitive (Apply)
2. Given an overdose scenario, identify (circle) 3 critical actions (rub knuckles on
sternum, call name, confirm absence of or minimal breathing) that must be
taken to determine that naloxone administration is needed. Cognitive
(remember)
3. Given a list of steps in the naloxone administration process , place them in
correct order ( number 1-5). Cognitive (remember)
4. Given photos of ways to hold and use the naloxone nasal injector, identify
(mark with an x) the photos that have been used in this presentation to
represent the appropriate technique. Cognitive (remember)
5. Given photos of the proper way to administer naloxone nasal spray, place them
in the proper order (number them in order 1-4). Cognitive (remember)

Terminal Objective:
Following the administration of naloxone, identify 3 actions to maintain safety and 3
pieces of information to provide in a 911 call. Cognitive (remember)

Enabling Objectives:
1. Given photos of positions, select (put a check by) the appropriate position to
maintain a safe airway. Cognitive (remember)
2. Given a list of safety concerns, identify (click on) the three safety actions that
were presented in this module. Cognitive (remember)

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 3. Given a scenario in which 911 is called, select (click on) the 3 critical pieces of
information to be conveyed in the call to include location, time of naloxone
administration and patient’s response to naloxone. Cognitive (remember)
4. Given a list of options, identify (click on) the three most important things to
monitor in an individual after the administration of naloxone to include
responsiveness, breathing, clear airway. Cognitive (remember)
5. Given scenarios of different responses to naloxone administration (vomiting,
responsiveness, breathing), identify the examples in which it is appropriate to
repeat a naloxone administration. Cognitive (remember)

Enabling Objectives Matrix

Title: Recognizing and Treating an Opioid Overdose

Target Audience
All MC patients who are dismissed from the inpatient or outpatient setting with an
opioid prescription greater than 90 mme will receive a naloxone (Narcan) prescription.
The target audience is these patients and their available significant others.
Terminal Objective:
After establishing that the patient is unresponsive and not breathing due to an opioid
overdose, administer intranasal naloxone according to the 5 steps presented in this
module. Cognitive (remember)

Overview
Giving naloxone to an individual who has overdosed on naloxone is a life-saving action.
This module will walk you through the 5 steps of giving intranasal (in the nose)
naloxone. Understanding the steps in giving naloxone will provide you with confidence
to act in an emergency overdose setting.

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 Enabling Objective Level on Bloom’s Learner Delivery Method
Taxonomy Activity

Given an example of three Cognitive (Apply) Work through Self-paced Articulate

patients and their a module module
symptoms, correctly identify tutorial on
the patient that exhibits an opioid
opioid overdose. overdose.Then
view three
examples of
patients and
select (click
on) those
patients that
demonstrate
opioid
overdose
symptoms
Given an overdose Cognitive(remember) View a module Self-paced Articulate
of the module
scenario, identify (circle) 3
assessment
critical actions (rub knuckles criteria of an
individual with
on sternum, call name,
an opioid
confirm absence of or overdose.
Review a
minimal breathing) that must
presented
be taken to determine that opioid
overdose
naloxone administration is
scenario and
needed. select (click
on) the 3
actions that
must be taken
to confirm an
overdose

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 Enabling Objective Level on Bloom’s Learner Delivery Method
Taxonomy Activity

Given a list of steps in the

Cognitive View the Self-paced Articulate
naloxone administration
(remember) learning module
process , place them in module on the
steps of
correct order ( number 1-5).
naloxone
administration.
Review a list
of 5 steps in
the process of
naloxone
administration,
place them in
the correct
order by
numbering
them 1-5
Cognitive View the Self-paced Articulate
(remember) learning module
Given photos of the proper
module of the
way to administer naloxone procedure for
naloxone
nasal spray, place them in
administration.
the proper order (number Review 4
photos that
them in order 1-4). Cognitive
represent the
(remember) steps in
naloxone
administration.
Place them in
the correct
order by
numbering
them 1-4

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References
Morrison, G.R., Ross, S.M., Kalman, H.K. & Kemp, J.E. (2013). Designing Effective Instruction (7 th ed.)
Introduction to the Design Process (pp 1-22). Hoboken, New Jersey: John Wiley & Sons, Inc.

Morrison, G.R., Ross, S.M., Kalman, H.K. & Kemp, J.E. (2013). Designing Effective Instruction (7 th ed.)
Introduction to the Design Process (pp 1-22). Hoboken, New Jersey: John Wiley & Sons, Inc.

Keller, J. (2016, June 28). arcsmode.com. Retrieved from http://www.arcsmodel.com/

Keller, J. (2016, June 28). ARCS Explained. Retrieved from

https://www.arcsmodel.com/motivational-design-cyrv

(2019). Instructional Design Models. Retrieved from

https://www.instructionaldesigncentral.com/instructionaldesignmodels

(2007, June 4). Kemp design model. Retrieved September 2, 2019 from
http://edutechwiki.unige.ch/en/Kemp_design_model

Pappas, C. (2018, March 21). Applying The Kemp Design Model In eLearning: A Guide For
eLearning Professionals. Retrieved from https://elearningindustry.com/applying-kemp-
design-model-elearning-guide-elearning-professionals

(2019) Kemp Design Model. Retrieved from

https://www.instructionaldesign.org/models/kemp_model/

An attributional theory of emotion and motivation

B Weiner - 1986 - New York: Springer-Verlag

Demetriou, Cynthia. “The Attribution Theory of Learning and Advising Students on Academic Probation.”
NACADA Journal, vol. 31, no. 2, 2011, pp. 16–21., doi:10.12930/0271-9517-31.2.16

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