From Realism to Learner Engagement: Rethinking Fidelity in Simulation-Based Education

Simulation has become an essential pedagogical tool in health professions education, traditionally valued for its ability to approximate clinical practice. Higher simulation fidelity is often assumed to directly enhance learner engagement and improve educational outcomes; however, this assumption oversimplifies a complex relationship. Fidelity is multidimensional, encompassing physical, emotional, and contextual dimensions, as well as qualitative and quantitative considerations, each influencing learners' perception of realism in distinct ways. Engagement is shaped not only by these dimensions of fidelity but also by intrinsic factors such as motivation, prior experience, stress, and emotional resilience, and by extrinsic factors including instructional design, facilitation, debriefing, and psychological safety. A central mediator in this process is the fiction contract, an implicit agreement that enables learners to suspend disbelief and engage authentically despite inherent limitations in realism. Technological sophistication alone does not necessarily translate into greater educational impact. Rather, fidelity should be intentionally aligned with learning objectives: advanced patient simulators may support procedural training, standardized patients may enhance communication skills, and task trainers may optimize focused psychomotor practice. This viewpoint advocates for a goal-oriented, multimodal approach that redefines high-fidelity simulation not as the pursuit of maximum realism, but as the deliberate alignment of fidelity with pedagogy to optimize learner engagement and educational effectiveness.