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It’s Hard to Drink from a Fire Hose: Learning Theory and SIMVANA


180 Seconds in Clinical Anesthesia

The transcript below is a rough recreation of the first three minutes of my first anesthetic:

“Hold the mask tighter.”

“Did you tighten the APL valve?  Tighten it up a smidge.”

“You’re not squeezing the bag enough.”

“The APL is too tight.  Loosen it up.”

“Cut the flow rate up.”

“I see he’s allergic to penicillin.  My mom nearly died from a penicillin allergy.”

“Take another blood pressure.”

“How’s the APL valve?  Maybe you should tighten it.”

“Did the patient take his metoprolol this morning?”

“You’re still not holding the mask tight enough.”

“Whatever you do, don’t let the laryngoscope touch his teeth.”

“Do you see the vocal cords?”

“Take another blood pressure—no telling what it is if he didn’t take his metoprolol.”

“You’re too close to the teeth.”

“Here, just step aside and let me do it.”

I was in an unfamiliar environment, performing an unfamiliar task, surrounded by unfamiliar equipment.  Within those same three minutes, the circulating nurse asked me five different questions, I had to be reminded to turn on the vaporizer, I struggled to figure out the ventilator controls, and I still hadn’t checked to see if the patient took his metoprolol.  I simply hoped I survive the day without doing permanently damage to anyone or anything. 

Then, the surgeon entered the room and wanted to know why the patient wasn’t draped, yet.  The entire room nodded in my direction as the surgeon rolled his eyes and walked back out.

What did I learn that day? Absolutely nothing.

Well, that’s not exactly true.  I did learn where the bathroom was--not much else, though.

What’s the Problem?

In my example above, why did I learn so little? Cognitive Overload.

There was so much information arriving at me at once that it was like trying to drink from a fire hose.  The new environment, new equipment, new procedures, an arcane sequence of medications, endless comments, endless questions…it was just too much to process at once.

In 1988, An Australian educational psychologist named John Sweller proposed an explanation for the limitations in our ability to process information.  He called it cognitive load theory.  In it, he stated that the amount of information that our environment can present is potentially infinite.  Likewise, our long-term memory capacity is potentially infinite (at least, no one has reached the brain’s maximum capacity, yet).  However, our working memory—that is, the resources our mind has available at any given moment to process new information, is limited.  That’s why phone numbers are 7 digits and not 50.

Sweller’s theory states:

...that to maximize the efficiency of a learning event, we need to reduce the cognitive load on the learner by decreasing the extrinsic load and intrinsic load of the situation.  Extrinsic load refers to any extraneous information not directly related to the learning objective.

In the example of my first induction, my instructor’s statements about her mother’s allergy to penicillin is extraneous and serves only to clog up information processing resources that could be used to process more relevant information.

Additionally, Sweller states that you must reduce the intrinsic load of the task by reducing its complexity.  For example, to maintain an airway pressure sufficient to ventilate the patient, you must maintain a delicate balance between the gas flow rate, the APL valve setting, and the pressure applied to the breathing bag.  A new student can’t possibly appreciate the complexities of all three variables in this relationship during their first induction.

In 1997, a researcher named Jeroen Merriënboer proposed a learning theory called Four-Component Instructional Design that would have addressed some of the issues I experienced on my first day.  This theory would have recommended providing me more supporting information and would have allowed me to try partial tasks such as squeezing the breathing bag while my instructor handled the flowmeters and APL valve for me.

Overcoming Cognitive Overload

Both Cognitive Load Theory and Four-Component Instructional Design are tightly integrated into the fundamental design of SIMVANA.  Every learning objective is broken into the most atomic components possible which are then sequenced in an order where each step builds upon the last by a tiny increment without interference of extra information.  By doing this, we simultaneously reduce the cognitive load of the learner by removing extrinsic information and decrease the intrinsic complexity of the task.

For example, when teaching the CO2 absorber in SIMVANA, we break it into six different lessons: 

  1. explain what it is and what it does
  2. show the learner where it is and ask them to verify it by simply touching it
  3. demonstrate how to recognize when it is exhausted
  4. teach the learner how to recognize the effects of an exhausted CO2 absorber on the patient monitor
  5. demonstrate two methods to address the issue
  6. lastly, the user enters a challenge lesson where they must apply the information they’ve learned to solve a real-world problem.

Within each lesson, the learner is encouraged to ‘play’ in a way that allows them to gain an understanding of the relationships between interconnected concepts.


Although healthcare education has long promoted the experience of cognitive overload exemplified by mantras such as ‘see one, do one, teach one’ and ‘trial by fire is the best way to learn’, modern learning theories demonstrate greater efficiency and less learner frustration.

SIMVANA embraces these concepts in order to provide a nonthreatening learning environment that guides the student at their own pace and in a way that encourages discovery.

Fraser, K. L., Ayres, P., & Sweller, J. (2015). Cognitive Load Theory for the Design of Medical Simulations. Simulation in healthcare : journal of the Society for Simulation in Healthcare10(5), 295–307.

Janssen-Noordman, A. M., Merriënboer, J. J., van der Vleuten, C. P., & Scherpbier, A. J. (2006). Design of integrated practice for learning professional competences. Medical teacher28(5), 447–452.

Meguerdichian, M. J., Bajaj, K., & Walker, K. (2021). Fundamental underpinnings of simulation education: describing a four-component instructional design approach to healthcare simulation fellowships. Advances in simulation (London, England)6(1), 18.