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Exploring auditory fidelity use in simulation programs

 Janet K. Willhaus, PhD, RN, 1 Ashley L. Snyder1
University of Wyoming, Fay W. Whitney School of Nursing, Laramie, WY

The authors declare no conflict of interest.

Corresponding Author: Janet K. Willhaus, PhD, RN, Faye W. Whitney School of Nursing, University of Wyoming, Laramie, WY (email: jwillhau@uwyo.edu) 

Brief description

Auditory fidelity, the sound aspect of high-fidelity simulation, is thought to promote a more realistic learning environment in simulation education; however, beyond a description of auditory fidelity, little is known on its prevalence or effect on learning.

 Using the Society for Simulation in Healthcare SIM Center directory, a contact list was created and used to distribute a survey about auditory fidelity. The 13-question author-developed questionnaire was based on gaps in the literature about auditory fidelity.

Respondents who indicated they had the ability to create auditory fidelity in simulation (82.6%, n = 72) reported using options of pre-programmed sound from the manikin, a computer application external to the manikin, live voice actors or actresses, or an external electronic device. Approximately half of respondents using auditory fidelity or 53.09% (n = 43) reported that learners notice or comment on auditory fidelity and just under half or 46.5% (n = 36) reported noticing a difference in learner performance since implementing auditory fidelity.

Auditory fidelity is widely used in the simulation centers sampled. However, many simulation centers have not appraised its value.

Exploring auditory fidelity use in simulation programs

Fidelity is defined as the “degree to which a simulation replicates the real event and/or workplace including physical, psychological, and environmental elements” (Lioce et al., 2020, p. 16). To enhance reality, many high-fidelity simulations may utilize a mix of elements including audio and visual cues.

This manuscript specifically focuses on the auditory aspect of fidelity in simulation; the sounds that replicate a real event in a workplace or accurately reflect the voice of the patient portrayed in the simulation. Although the Healthcare Simulation Dictionary (Lioce et al., 2020) does not offer a specific definition for auditory fidelity, it does acknowledge that there are many types of fidelity in simulation. The authors investigated how widespread the use of auditory fidelity is in the simulated environment, specifically background sounds in the environment and/or congruence of age or gender of the voice to the manikin.

Although simulation education has become more widely used and fidelity has increased with use of advancing technology, published literature on operations topics like auditory fidelity is limited. Beyond its mention as an aspect of high-fidelity simulation, auditory fidelity is not specifically studied in current literature. According to the Healthcare Simulation Standards of Best Practice: Simulation Design™ (2021), the use of various types of fidelity help create the perception of realism with cues and stimuli that help the learner take appropriate action. Sound can be part of the physical, conceptual, or psychological fidelity simulation environment.

The authors aimed to increase what is known about auditory fidelity in healthcare simulation as a background for future study of auditory fidelity and its value.


Because manikins often lack the physical characteristics of movement and facial expressions of human responses, students interact differently with them than they would humans. Learners appreciate when the plastic manikin has the ability to answer questions through microphones and speakers (Power et al., 2016), however report they sometimes find it difficult to simulate communications with task trainers and manikins in scenarios (Barry et al., 2012). Learners also anecdotally describe difficulty with realism when the manikin voice is incongruent with the expected age or gender of the simulated patient.

High fidelity characteristics can create a more realistic patient and simulation scenario. However, the effect of learning may not be proportional to fidelity level (Kim et al., 2016). High-fidelity background noises that are not associated with or are incongruent with the objectives may confuse learners and learning may be impacted. Some realism is too intense for training conditions. For example, replicating realistic high noise conditions such as clinical patient care conditions in an aircraft have been shown to negatively impact performance and increase errors (McNeill, 2018).

Survey Methods

A 13-question exploratory survey was created by the research team and deployed using Qualitrics™ survey software. Questions were created based on gaps in the literature and comments from learner feedback. Question types included multiple choice, select all that apply, and some free response options where respondents could expand further on the questions. Using the Society for Simulation in Healthcare SIM Center Directory, an email contact list of programs in the United States and Canada was created and used to distribute the survey link. This project received a research exemption from the University of Wyoming Institutional Review Board.


The survey was deployed to 311 email addresses and posted on two simulation organization electronic message boards. A total of 24 emails were returned as non-deliverable. In all, a total of 112 partial and complete responses were received for a response rate of 39% (n = 112).

Approximately 83% (n = 76) of respondents indicated their facility had the ability to create auditory fidelity in simulations while the remaining 16% (n = 15) indicated they did not have auditory fidelity capabilities. The most commonly reported technique to demonstrate auditory fidelity was “manikin voice” (n = 57) followed by use of voice actors and actresses (n = 50), computer application external to the manikin software (n = 39), and voice changing external devices (n = 24). In the free response option to the question some answered “matching instructor voice” (i.e., using male instructor voice when the simulated patient is a male, or a female instructor voice when the simulated patient is a female) (n = 10). Others reported using pre-recorded unique audio to match the simulation scenario (n = 3).

The use of background noise in scenarios was reported by 40.22% (n = 37) respondents, while 56.52% (n = 52) indicated they did not use background noises. Using the free response option, respondents indicated they used background noises such as first responder sirens/fire alarms, sounds depicting a place, sounds simulating a disaster or mass casualty situation, and equipment alarms commonly heard in the hospital or clinical setting.

Many centers reported serving multiple types of learners. Nursing students, nurses, and other health professionals were the most frequently identified learner categories. Medical students, physicians, emergency medical services and pharmacy students were also identified in descending order of numbers served. Additional health groups served identified in the free response box were physician assistant students, dental students, physical/occupational therapy, graduate nursing/DNP students, respiratory therapy, social work, certified nurse aides/medical assistant students and hospital employees (not clinical staff). Results reported are displayed in Table 1. The number of learner types is larger than the number of responding centers due to the diversity of learners served.

Of the respondents that use auditory fidelity, a majority (n = 43) indicated their learners do notice or comment on the use of auditory fidelity in scenarios. Less than 20% (n = 16) indicate their learners do not notice or do not comment on its use, and slightly more than a quarter (n = 22) indicate they have not assessed or are unsure whether their learners notice or comment on auditory fidelity use.

Just under half of respondents, (n = 36) using auditory fidelity noticed a difference in learner performance while less than 8% (n = 6) did not notice a difference, and many (n = 36) had not assessed or were unsure about differences in learner performance. Difference in learner engagement (n = 53), learner anxiety levels (n = 36), learner satisfaction (n = 32), learner clinical judgement (n =14), learner confidence (n = 13), and simulated patient outcomes (n = 11) were areas that respondents thought may be impacted by auditory fidelity.

Facilitator performance was also impacted by auditory fidelity. After implementing auditory fidelity respondents reported differences in facilitator and learner interactions (n = 35), facilitator satisfaction (n = 17), and facilitator performance (n = 3). 

Just under half of respondents (n = 36) who use auditory fidelity reported they had received feedback from learners on the use of auditory fidelity, while just over half (n = 42) indicated they have not received any student feedback. Free text narrative answers stated opinions and experiences since implementing auditory fidelity. Respondents said they believed that Auditory fidelity increased realism experienced by the students, including sounds and background noises heard in healthcare settings, and increased the ease of assessment and navigation during simulation scenarios. Some reported reduced stress with the use of auditory fidelity, although it is unclear whether this was from the learner or the operations viewpoint. Two respondents indicated their students engage more with the manikin when they do not recognize the voice through the microphone, achieved through the use of voice changing technologies. One respondent further explained that a higher level of engagement is noticed when a female instructor’s voice is changed to a male voice. However, respondents also indicated that there is sometimes difficulty understanding and hearing the manikin’s voice in simulation during high stress simulations or when many learners are present. Some respondents also indicated that the use of alarms has been distracting, especially to new learners or students who have not had experience with simulation manikins.


Although the impact of auditory fidelity has not been studied in simulation, the survey findings show that many simulation centers employ auditory fidelity resources during simulations and that it is a contributor to attempted realism. There is currently no literature available that identifies a link between the fidelity of sound in a simulation and learning, although many of the survey respondents clearly believe that sound plays a role in learner engagement. Despite this affirmation, only about half of respondents indicated their learners notice or comment on the use of auditory fidelity. Learners may not notice or recognize the use of auditory fidelity if the sounds are as expected for the patient and environment and they may not comment unless feedback is directly solicited. Unless simulationists intentionally assess for differences in engagement, learner performance, and other variables it is unclear whether auditory fidelity plays a major or minor role in simulation and simulation design. Although some respondents said they noted differences in learner anxiety, satisfaction, and confidence and others identified differences in learner clinical performance, the contribution of auditory fidelity is difficult to tease out unless there is a discussion about sound accuracy as a part of the debriefing process or some other learning assessment.

Learners do not expect a child-sized manikin to have a booming bass voice or manikins who represent male patients to have the voice of a female facilitator; however, we don’t yet know whether this impacts learning or engagement.  We do know that the majority of simulation centers responding to this survey have the technology or capability of creating congruence of age and gender with the voice of the manikin. Again, more study is needed to determine whether it is worth the cost and effort for programs and centers without patient voice congruence methods to upgrade their simulation capabilities.

There also seems to be a divide between simulation centers and labs that do or do not use background noises during simulation scenarios. The most commonly reported background noises used by respondents were alarms found in the clinical settings such as call lights. Alarms can serve as a learning tool that require a call to action such as with fire alarms or IV pump alarms, but background noises can also create distractions that divide a learner’s attention. If the sound is part of a cue that supports the learning objectives of the scenario, it could be a positive tool. Noises that confuse or distract the learner undermine the learning purpose, therefore background noise for the purpose of fidelity must be carefully selected.

Many different learner types use simulation as a method to further educate and develop clinical skills; therefore, different types of audio fidelity may be indicated for different disciplines and scenarios. The background sound of a fetal heartrate dropping may be an excellent cue to action during an obstetric scenario for maternal child health professions learners, while the shrill tone of a bed alarm might be a better cue for others in a long-term care scenario portraying a confused elder. Given that many disciplines and types of learners use simulation, carefully selected audio prompts could enhance the simulation learning experience. 



The definition of auditory fidelity is not well known which may have resulted in limited understanding of survey questions by respondents. The contact list numbers of simulation centers used for the survey are low in relation to the number of centers/labs throughout the United States and Canada. Additionally, the sample reflects centers that are affiliated with one simulation organization and therefore cannot be generalized. The survey format allowed for questions to be skipped, leading to a varied number of responses per question.


Although the literature contains references to different types of fidelity in simulation, there are very few that mention sound or auditory fidelity. Many simulation centers have the ability to employ sound as a part of scenarios, however, we do not yet understand how that may relate to learning. Although sound can provide cues, it can also be a distractor and depends on the objective of the simulated activity. Future inquiry about auditory fidelity is needed to determine the importance of its impact.


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