Introduction: Simulation often relies on a case-based learning approach and is used as a teaching tool for a variety of audiences. The knowledge transfer goes beyond the mere exchange of soft skills and practical abilities and also includes practical knowledge and decision-making behavior; however, verification of knowledge or practical skills seldom unfolds during simulations. Simulation-based learning seems to affect many learning domains and can, therefore, be considered to be multifactorial in nature. At present, studies examining the effects of learning environments with varying levels of reality on the cognitive long-term retention of students are lacking.
Aim: The present study focused on the question whether case scenarios with varying levels of reality produce differences in the cognitive long-term retention of students, in particular with regard to the learning dimensions knowledge, understanding and transfer.
Material and methods: The study was conducted on 153 students in the first clinical semester at the Justus-Liebig University of Giessen. Students were randomly selected and subsequently assigned, also in a random fashion, to two practice groups, i.e. realistic and unrealistic. In both groups the students were presented with standardized case scenarios consisting of three case studies, which were accurately defined with a case report containing a detailed description of each scenario and all relevant values so as to ensure identical conditions for both groups. The unrealistic group sat in an unfurnished practice room as a learning environment. The realistic group sat in a furnished learning environment with various background pictures and ambient noise. Students received examination questions before, immediately following and 14 days after the practice. Examination questions were identical at each of the three time points, classified into three learning dimensions following Bloom's taxonomy and evaluated. Furthermore, examination questions were supplemented by a questionnaire concerning the individual perception of reality and own learning success, to be filled in by students immediately after the practice. Examination questions and questionnaires were anonymous but associated with each other.
Results: Even with less experienced participants, realistic simulation design led to a significant increase of knowledge immediately after the end of the simulation. This effect, however, did not impact the cognitive long-term retention of students. While the realistic group showed a higher initial knowledge after the simulation, this "knowledge delta" was forgotten within 14 days, putting them back on par with the unrealistic comparison group. It could be significantly demonstrated that 2 weeks after the practice, comprehension questions were answered better than those on pure knowledge. Therefore, it can be concluded that even vaguely realistic simulation scenarios affect the learning dimension of understanding.
Conclusion: For simulation-based learning the outcome depends not only on knowledge, practical skills and motivational variables but also on the onset of negative emotions, perception of own ability and personality profile. Simulation training alone does not appear to guarantee learning success but it seems to be necessary to establish a simulation setting suitable for the education level, needs and personality characteristics of the students.