What compromises in fidelity can you afford in simulation?

It's important that even the small details, such as a thermometer, are in line with a real encounter.

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The goal of any simulation is to maintain as high fidelity as possible. Therefore, when providing students with a learning experience, it is obviously necessary for it to mirror their real-world encounters as much as possible. However, many simulation programs are limited by budget and other resource concerns, requiring compromise in the production of simulations. But how do these compromises affect the transfer of skills from the simulation room to the patient’s room?

While many human-based simulations faithfully replicate the designated skill, they often fail to accurately replicate other components of the patient encounter. For instance, a tracheostomy simulation may be entirely faithful to the experience of tracheostomy care. However, when the learner was collecting vital signs, she was handed a piece of paper instead of relying on the instruments she would have in the real world. While seemingly insignificant, this break in realism can hamper the transfer of skills from the simulation to a real patient encounter later.

In an October 2011 article in Human Factors titled “Physical Fidelity Versus Cognitive Fidelity Training in Procedural Skills Acquisition,” Hochmitz and Yuviler-Gavish set out to examine how different teaching styles affected the participants’ ability to transfer skills from training to a real-world test. It found that real-world experience was the best method of ensuring a task is completed quickly and correctly. It further found:

Given that procedural skills are likely to be specific to a certain task and given that such skills are acquired through repeated practice, ensuring that a training simulation resembles the actual task is likely to be important for successful transfer.1

This concept is nothing new in academia. “Under the first approach, originally proposed by Thorndike and Woodworth (1901), transfer from the first task (the simulation) to the second, real-world task occurs most efficiently when the two tasks have identical component activities. The more elements that are shared between the two tasks, the better the transfer (Baldwin & Ford, 1988).”1

Whenever designing a training simulation, it must maintain the correct stimulus-response relationship. For example, if the simulation scenario calls for a hypertensive patient, but the blood pressure returns 120/80, the instrument readings aren’t congruent with the simulation. The simulated participant could be grabbing their chest and complaining of pain, but conflicting vital signs inhibit the student from fully immersing themselves in the exercise.

The physical fidelity approach claims that the simulator should replicate the real-world task to the greatest degree possible (Alexander et al., 2005; Liu et al., 2009)1

The 2005 Article “From Gaming to Training: A Review of Studies on Fidelity, Immersion, Presence, and Buy-in and Their Effects on Transfer in PC-Based Simulations and Games” examined the skills transfer from computer-based alternatives to live military training exercises. The authors attempted to understand the methods most able to reliably transfer skills practiced in simulation to their counterparts in reality.

In their study, the authors found that skills transfer relied extensively on the user (or student in our case) having a high buy-in to the simulation. The higher the buy-in, the more skills were successfully translated into a real-world encounter.

The conjecture is that higher levels of buy-in imply that the user will invest more effort to extract generalizable lessons from training, and more effort to transfer those lessons to the real world. Transfer is consequently more frequent and successful as a result.2

They also found that even the smallest of detail could derail the learning opportunity. Anything ruining the immersion of the simulation can mentally pull the learner out of the experience.

In one study (Carnegie Mellon Entertainment Technology Center et al. 2004; described in Stapleton, 2004), PC game technology was used to construct a training system for fire/rescue teams. When the system was presented to the practitioners, they were unhappy with the ‘level of realism’ of the system. However, changing the colors of the uniforms and vehicles to correspond to those used by the practitioners improved user acceptance… However, transfer is only possible if the intended users use the system, which in turn may be dependent on user identification with the avatars and simulated environment.2

The authors found that buy-in was directly related to the fidelity and the perceived realism of the scenario. Thus, even when the users could identify analogs between the simulation and authentic experience, if the simulated environment was not faithful to a real-world encounter, then the buy-in was low.

In a military education setting (Woodman, personal correspondence), two groups of military officers participated in a training exercise in two virtual environments in which aspects of command and control were to be practiced. The first was a realistic WWII-era military environment, while the second environment was based on the modern military. While the underlying training goals and design were the same, participants argued that the WWII environment was not adequate for training because it did not correspond to their experience. Assuming that the resource capabilities and communications apparatus were exact analogs between the two conditions, the identity of the enemy and the characteristics of the avatar uniforms should have no bearing on training impact. Still, these characteristics were important to the participants, and these seemingly small details could prove to be big impediments to training.2

While necessity dictates that we must sometimes make compromises in our simulations, we must ensure that we are not sacrificing elements critical to skill retention. As more and more demands are being placed on nurses, they must have every advantage possible to retain lessons learned.

If you want to ensure your learners are in as immersive an experience as possible, you may want to book a meeting with your solutions consultant.


1. Hochmitz, I., & Yuviler-Gavish, N. (2011). Physical fidelity versus cognitive fidelity training in procedural skills acquisition. Human Factors: The Journal of the Human Factors and Ergonomics Society, 53(5), 489–501. https://doi.org/10.1177/0018720811412777

2. Alexander, Amy & Brunyé, Tad & Sidman, Jason & Weil, Shawn. (2005). From Gaming to Training: A Review of Studies on Fidelity, Immersion, Presence, and Buy-in and Their Effects on Transfer in PC-Based Simulations and Games.

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