Education for Health

: 2012  |  Volume : 25  |  Issue : 1  |  Page : 64--65

In the News! An Opinion - Higher Fidelity Does not Equal More Effective Learning

J van Dalen 
 Associate Editor, Education for Health

Correspondence Address:
J van Dalen
The Journal office

How to cite this article:
van Dalen J. In the News! An Opinion - Higher Fidelity Does not Equal More Effective Learning.Educ Health 2012;25:64-65

How to cite this URL:
van Dalen J. In the News! An Opinion - Higher Fidelity Does not Equal More Effective Learning. Educ Health [serial online] 2012 [cited 2022 Jan 27 ];25:64-65
Available from:

Full Text

For some decades now, health professions' training has increasingly been relying on simulation. The advancement of skills training in clinical skills centers since 1970 has played an important role in the development of simulators, human or instrumental.

A huge spectrum of instrumental simulators is available, and the finance involved shows an equally wide range - from $5 for a homemade stick-on model for venepuncture to $80,000 for the METI cardiovascular simulator or the Harvey heart sound simulator.

The general assumption justifying the use of simulators is the belief that transfer is facilitated when the situation where one learns a skill resembles the situation where the skill will eventually be applied. While in general this is an easy slogan, and not untrue, the reality is a little more complicated. As the literature shows, the evidence for successful training on a simulator is often based on successful performance on that very simulator. [1],[2] Moreover, most often the evidence is based on comparisons between practicing on a simulator and no practice or routine clinical work. Additionally, 'looking similar' is only one aspect that influences transfer, where 'feeling similar' or 'having similar resistance' (so called haptic feedback) - when other things are equal - turns out to be of greater influence on correct performance in real life. [3]

In the July 2012 issue of Medical Education, there was a very thoughtful review addressing evidence for the relationship between (higher or lower) fidelity of simulators and their effect on correct performance. [4] The authors found 24 studies contrasting high-fidelity and low-fidelity simulators and their relation to performance. The relation was studied in three different fields of skills: auscultation skills; surgical techniques; and complex management skills such as cardiac resuscitation.

The review is introduced by addressing some of the assumptions regarding simulation: 1) instruction on simulators results in meaningful learning; 2) skills acquired on the simulator can be applied to real patients; 3) the closer to the 'real world' (and the more expensive the simulation), the better the transfer to real life; 4) authenticity - the resemblance of the simulation to an equivalent real-life scenario - is the critical determinant of transfer; and 5) more complex skills demand more complex simulators. For each of these assumptions, reality is more subtle and complex.

The review then tries to clarify two issues: the relationship between performance on a high-fidelity simulator and performance on a structured control intervention, often a low-fidelity simulator but occasionally an instructional video; and the relationship between learning on a simulator and performance outcomes. No self-reports are included in the review, since the relation between self-reports and actual behavior is often questionable at best.

The results are surprising. Although, in general, any kind of simulation is better than didactic training involving no actual hands-on practice, there is hardly any demonstrable difference between the contributions of high- versus low-fidelity simulators, despite the differences in appeal, prestige, or face value of the different simulators. The authors conclude their paper with an attempt to interpret these findings. They propose rethinking of our common understanding of context (is 'looking similar' enough?), of complexity and cognitive load (in relation to the timing of the use of different simulators), of the nature of the tasks, and of the interaction of simulators with expertise of the learner.

In view of the differences in financial investment, this paper needs to be read by those setting up a skills training center. Moreover, it is a strong appeal to those who are interested in increasing our understanding of transfer: what makes it happen?

J van Dalen

Associate Editor, Education for Health


1McGaghie WC, Issenberg SB, Petrusa ER. Editorial: simulation - savior or saint? A rebuttal. Advances in Health Sciences Education 2003;8:97-103.
2Norman G. Editorial: simulation - savior or saint? Advances in Health Sciences Education 2003;8:1-3.
3Brydges R, Carnahan H, Rose D, Rose L, Dubrowski A. coordinating progressive levels of simulation fideluity to maximize educational benefit. Academic Medicine 2010;85:806-812.
4Norman G, Dore K, Grierson L. The minimal relationship between simulation fidelity and transfer of learning. Medical education 2012;46:636-647.