Sociological Fidelity in Healthcare Simulation

By: Victoria Brazil (@SocraticEM)

Discussions about the ‘fidelity’ of simulation often focus on the physical realism of mannikins or other training equipment. Another interpretation of the term is ‘functional task alignment’, describing the authenticity of clinical tasks required of scenario participants. But maybe there is even more to fidelity. Maybe simulation activities can be designed to recreate some of the most important influences on healthcare team performance – issues of power, hierarchy, and professional boundaries – and achieve ‘sociological fidelity’? Without attention to these relational issues and cultural norms, we may fail to transfer lessons from simulation-based team training to real world practice.

In coining the term sociological fidelity’, Sharma et al. write that “despite the interprofessional tensions and wider sociological factors present in clinical work – we have noted that such issues are not currently represented in conventional simulation scenarios”, but lament that “Operationalizing (these) concepts which are complex and nuanced will be challenging”.

In situ simulation might offer one step in this direction. Simulation delivered in real clinical environments, with real clinical teams, may naturally embrace power dynamics, hierarchies and conflicts from the real world. One example is Purdy’s findings of a bidirectional ‘leakiness’ of psychological safety between the simulation ‘safe container’ and the real world. But these examples are of incidental sociological fidelity. Can we intentionally design simulations to authentically capture complex social phenomena, without them appearing clunky or tokenistic, and without participants acting differently as a result of being in a simulation?

Two recent articles show that perhaps we can.  Park et al. undertook a study in which obstetric attendings participated in simulations as ‘partial confederates’ and were primed to perform ‘challenge moments’/ scripted errors within an inter-disciplinary team who didn’t know the attendings were acting. When interviewed afterwards, these senior doctors were shocked at how their team members didn’t speak up or question their actions.

In similar vein, Garber et al. explored the experience and behaviours of obstetric residents/ trainees when faced with a simulation scenario involving an erroneous and potentially dangerous clinical decision by a medical supervisor. The study team found these junior staff engaged in complex and nuanced strategies in an attempt to ‘speak up’, indicative of the sheer weight of hierarchy they perceived.

These articles tell us much about hierarchy in healthcare and are worth reading for those findings alone. But they are also exemplars for how we might operationalise sociological fidelity in simulation practice. Notably, deception was required to authentically replicate these ‘challenge moments’. This underlines the need for a thoughtful approach, as deception will affect the delicate balance between facilitators and participants in simulation and may even impact relationships back in the real world. 

For a fascinating insight into the studies and their findings, listen to this Simulcast podcast episode with two of the authors.

The success of these study teams opens the door to considering other important issues through simulation e.g. exploring power dynamics between healthcare consumers and providers, exploring cultural differences, and (carefully) considering issues of equity, diversity and inclusion. Perhaps at the very least we need to pay attention to the sociological phenomena we routinely observe in simulation, and ensure we are not perpetuating problematic power dynamics and hierarchies.


1.Pack R, L Columbus L, TH Duncliffe et al. Maybe I’m not that approachable”: using simulation to elicit team leaders’ perceptions of their role in facilitating speaking up behaviors. Adv Simul. 2022;7(1):31.

2. Garber AB, G Posner, T Roebotham et al. Facing hierarchy: a qualitative study of residents’ experiences in an obstetrical simulation scenario. Adv Simul. 2022;7(1):34

Image: The Anatomy Lesson of Dr. Nicolaes Tulp, 1632 by Rembrandt van Rijn

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