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Nurse Educ Today. 2018 Oct;69:81-94. doi: 10.1016/j.nedt.2018.06.025. Epub 2018 Jun 30.

The effect of mannequin fidelity on the achievement of learning outcomes for nursing, midwifery and allied healthcare practitioners: Systematic review and meta-analysis.

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School of Health and Social Care, London South Bank University, K2 Building (Room V602), 103 Borough Road, London SE1 0AA, United Kingdom. Electronic address:
School of Health and Social Care, London South Bank University, K2 Building (Room V614), 103 Borough Road, London SE1 0AA, United Kingdom. Electronic address:



Simulation has demonstrated superiority over purely didactic instruction in multiple contexts, and educationalists have embraced this modality for enhancing access to clinical skills. However, there remains uncertainty if increasing the realism (fidelity) of simulation equipment heightens performance. To address this within nursing and allied health, this review examines if increasing equipment fidelity improves learning outcomes.


A systematic search of; CINAHL, Academic Search Complete, AMED; British Education Index, ERIC, MEDLINE, PsycARTICLES, PsycINFO, Maternity and Infant Care, INTERMID, Google Scholar, American Doctoral Dissertations, EThOS, and ISRCTN registers was conducted for trials comparing two or more fidelity levels for knowledge, psychomotor or affective/non-technical outcomes. Data extraction and quality appraisal were performed and independently verified. Subgroup meta-analyses were undertaken (where viable), at post-intervention, intermediate, and long-term assessment time-frames.


18 RCTs and quasi-experimental trials containing ~1192 participants met the inclusion criteria. Almost ¾ of included trials exhibited high risk-of-bias. Training on higher-fidelity mannequins was associated with improved performance immediately post-intervention when compared with training on lower-fidelity mannequins for knowledge (p < 0.00001) and psychomotor outcomes (p < 0.00001). A similar directional effect for affective/non-technical skills was considered less robust due to substantial weaknesses in available studies. During follow-up testing at intermediate (1-3 weeks) and long-term (1-6 months) data points, there was insufficient evidence to determine any advantage in the use of higher fidelity mannequins. Repeated-intervention training was also insubstantially reported.


Higher-fidelity mannequins exhibited modest advantages when testing closely followed training. However results need to be confirmed using a larger number of high quality RCTs. A greater body of research using repeated-interventions and extended time-frames is also required before the influence of sustained training with alternative mannequins can be fully elucidated.


Allied health; Fidelity; Knowledge; Non-technical; Nursing; Psychomotor; Simulation; Systematic review

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