Edgar Dale's Pyramid of Learning in medical education: A literature review

Figures & data

Table

Practice points

The Pyramid of Learning and associated percentages attributed to Edgar Dale and the NTL have no valid basis. They are cited widely in medical education literature. Researchers have been misled, have made crucial errors, and there is no agreement on the percentages of learning retention. Continued citing of the Pyramid of Learning in medical education research should be avoided.

Figure 1. The NTL Learning Pyramid, “sometimes with slightly different percentages, appears as [this figure]” (Raymond, 2012).

Figure 2. The Pyramid of Learning attributed by the NTL to Edgar Dale from his Audio-Visual Methods in Teaching.

Figure 3. Edgar Dale's Cone of Experience, as presented in Audiovisiual methods in teaching. 3rd ed. p 107 (Dale, 1969) (earlier versions of the Cone did not include television).

Figure 4. Article selection process.

Table 1  List of references, the medical discipline, the person to whom the Pyramid and/or percentages are attributed, and the cited source of the information

References	Discipline	Attrib. to	Citing
Afandi et al. (2009)	Bioethics	“Learning Pyramid Theory”	Lalley and Miller (2007)
Akaike et al. (2012)	Simulation/clinical skills	Dale	Sprawls (2008)
Arthurs (2007)	Nursing	None	Bowman (1997); Nilson (2003)
Avers and Wharton (1991)	Geriatric rehabilitation	Dale	Dale 1969[b]
Baykan and Naçar (2007)	Physiology	None	University of Newcastle Upon Tyne (2004)
Boctor (2013)^2	Nursing	Dale	Kennedy (2006)
Brueckner and MacPherson (2004)	Dental gross anatomy	"The learning pyramid"	Eyler and Giles (1999)
Croley and Rothenberg (2007)	Critical care	Dale	Dale (1969)
Dark and Perret (2007)	General healthcare	None	Chandler and Sweller (1991)
Darmer et al. (2004)	Nursing	NTL	Lowery (n.d.)
Dickerson (2003)	Nursing	None	Jackson (1993)
Gallagher et al. (2012)	Cross-discipline	NTL	World Bank (n.d.)
Garden (2009)	Obstetrics and gynaecology	NTL	NTL
Gordon (1996)	Medical communication skills	None	None
Hazlett (2009)	Cross-discipline	NTL	Lowery (n.d.)
Jalali and Wood (2012)	Anatomy	Dale	Dale (1954)
Jarvis et al. (2009)	Pharmacy (medication disposal)	Industrial Audio Visual Association	Pakes (1995); Montero (1998)
Karabulut and Cetinkaya (2011)	Patient education	"In the literature"	Ergin (1995)^3
Katsuragi (2005)	Dentistry	Brurmer [sic]	Brurmer (n.d.)^4
Kennedy (2006)	Patient education	Dale	Dale (1969)
Keulers and Spauwen (2003)	Patient education	None	Murphy (1998)
Krishna et al. (2006)	Patient education	“the theory of learning and retention”	Dale (1969)
Kumar et al. (2009)	Cross-discipline	None	None
Lott (2006)	Nursing	None	Dickerson (2003)
Lou (2012)	Chemistry	NTL	Dale (1969) and NTL
Manning (1983)	Nursing	None	Medearis (1974)
Mitchell (2007)	Patient education	None	Rief (1993)
Murphy (1998)	Patient education	None	None
Okolie et al. (2007)	Nursing and radiography	TB Dale	Dale (2000)^5
Okuda et al. (2009)	Simulation	None	Croley and Rothenberg (2007)
Oldaker (1992)	Patient education	Dale	Dale (1969)^6
Pei (2003)	Pharmacy	None	Lagowski (1990)^7
Rao and Kate (2012)	Surgery	Bruner	Friel (2009)
Sarikcioglu et al. (2011)	Physiology	Dale	Arthurs (2007)
Shah et al. (2012)	Cross-discipline	None	Bonwell and Eison (1991)
Shenoy et al. (2012)	Cross-discipline	None	University of Newcastle Upon Tyne (2004)
Sprawls (2008)	Medical physics	Dale	None
Sujatha et al. (2011)	Clinical skills	"Learning Pyramid"	None
Thomas and Baker (2008)	Nursing	NTL	NTL
Videla (2010)	Cross-discipline	"Learning Pyramid"	Unknown^8
Weinrich et al. (1994)	Patient education	None	Wiman and Meierhenry (1969)^9
Wood (2004)	Biochemistry	NTL	NTL
Zeraati et al. (2008)	Cross-discipline	None	University of Newcastle Upon Tyne (2004)

¹This is a citation to a non-existent reference: Merrill CE. 1969. Dale E. Cone of experience. In: Wiman C, editor. Educational media. See discussion below for further information about this reference.

²This article was in press and available electronically at the time of the search. This reference has been updated to reflect its current citation details.

³This reference is given as: Ergin Ö. “Instructional Technolog [sic] and Communication.” Tegem Publication Ankara, 1995, p 102. The existence of this text cannot be verified.

⁴This reference is given as: “Brurmer [sic] JS. Learning pyramid. The process of learning. Bethel, Maine: National Training Laboratories.” It appears to be a conflation of Bruner's The Process of Education and the NTL's Pyramid.

⁵Reference given as: Dale TB. 2000. Teaching materials. Am J Educ 38(9):63–69. But, in 2000, the American Journal of Education published volume 108. Volume 38 (as The School Review), was published in 1930. Volume 38 (9) runs from pp 641 to 720.

⁶This citation is also to the non-existent section in Wiman and Meierhenry (1969).

⁷Cited as Lagowski (1990) Retention rates for student learning. J Chem Educ 67:811. There is no such paper. There is a 1990 editorial by Lagowski (1990) entitled “Teaching is more than Lecturing” in the J Chem Educ 67(10):811. That editorial quotes the percentages, citing its source as a 1987 article from Eng Educ by Stice (1987).

⁸The reference was to “Learning Pyramid; 2004,” with a URL: www.coe.uncc.edu/maps/wspowerpoint/w2pp/sld004.htm but this URL no longer exists.

⁹Reference in the citation given as Wiman and Meierhenry as authors.

Figure 5. Stewart's Simulation through Use of Instructional Media (Stewart, 1969), p 161, “Based in part on Edgar Dale's ‘Cone of Experience’”.

Table 2  Percentages of information retention given by the authors

Activity: References	Read	Hear/ lecture	See/audio visual	Dem.	Say/Disc. group	See and hear	Do	Say	Say, hear, see and do	Teaching others
Afandi et al. (2009)					50
Akaike et al. (2012)									90^1
Arthurs (2007)		10–20	20–50^2		80				90
Avers and Wharton (1991)	5–10	10–20	30–50					70^3	90
Baykan and Naçar (2007)	20	30	40		50		60		90
Boctor (2013)	10	20	30						90
Brueckner and MacPherson (2004)	10	5			50					90
Croley and Rothenberg (2007)	10	20	30			50		70	90
Dark and Perret (2007)	10	20							90
Darmer et al. (2004)^4	10	5	20	30	50		75			90
Dickerson (2003)	5–15^5		10–20				40–50
Gallagher et al. (2012)^6	5									90
Garden (2009)	10	5	20	30	50		75			80
Gordon (1996)		25	45				70
Jalali and Wood (2012)^7	10								90
Jarvis et al. (2009)	10	20	30			50
Karabulut and Cetinkaya (2011)	10	20	30			50
Katsuragi (2005)		5
Kennedy (2006)	10	20		30					90
Keulers and Spauwen (2003)^8	40	20							80
Krishna et al. (2006)				50^9					90
Kumar et al. (2009)	20	30	40		50		60
Lott (2006)^10	5	15	10–20				40–50
Lou (2012)	10		20	30	50		75			90
Manning (1983)	10	20	30			50		80	90
Mitchell (2007)	10	20	30		70	50			90
Murphy (1998)	40	20							80^11
Okuda et al. (2009)^12	10						90
Oldaker (1992)	5–10	10–20				30-50		70^13	90
Okolie et al. (2007)	10	20	30		70	50			90
Pei (2003)	10	50							90
Rao and Kate (2012)	5		20		50				75^14
Sarikcioglu et al. (2011)^15		10–20
Shah et al. (2012)	20	30	40		50		60		90
Shenoy et al. (2012)	20	30	40		50		60		90
Sprawls (2008)	10	20	30			50		70^16	90
Sujatha et al. (2011)				30					90
Thomas and Baker (2008)	10	5	20	30	50		75			90
Videla (2010)		5^17
Weinrich et al. (1994)	10	20	30		50			70^18	90
Wood (2004)	10	5	20	30	50		75			90
Zeraati et al. (2008)	20	30	40		50		60		90

¹“Active Learning”

²“Adding visual material to a presentation such as pictures or graphics almost doubles student recall. With lecture and visuals, faculty can increase retention to approximately 50%”.

³Say and Write.

⁴This is given as a “rough guide”.

⁵Read or hear.

⁶Citing (Lalley & Miller, 2007), the authors note that “the authority and origins of the [Learning Retention Pyramid] are disputed in some quarters.”

⁷After two weeks.

⁸Citing Murphy.

⁹“According to Edgar Dale's Cone of Learning, passive methods of learning lead to a maximum of 50% content retention whereas interactive learning methods provide up to 90% retention of the content.”

¹⁰Citing Dickerson.

¹¹“Up to 80% of what they receive through interactive multimedia programs.”

¹²Citing Croley & Rothenberg.

¹³“Verbalize and write.”

¹⁴Specifically, Problem-Based Learning (PBL).

¹⁵Citing Arthurs.

¹⁶“Say and Write”.

¹⁷“According to the learning pyramid the average rate of retention is 5% if the class is only theoretical.”

¹⁸“Say or Write”.

Raymond A, ([email protected]). 2012. Pyramid of learning. [email] message to Ken Masters ([email protected]) cc: to Info [email protected]. 4 October 2012

 Google Scholar

Dale E. Audiovisiual methods in teaching3rd. Holt, Reinhart & Winston, New York 1969

 Google Scholar

Afandi D, Budiningsih Y, Safitry O, Purwadianto A, Novitasari D, Widjaja IR. Effects of an additional small group discussion to cognitive achievement and retention in basic principles of bioethics teaching methods. Med J Indones 2009; 18(1)48–52

 Google Scholar

Lalley JP, Miller RH. The learning pyramid: Does it point teachers in the right direction?. Education 2007; 128(1)64–79

 Google Scholar

Akaike M, Fukutomi M, Nagamune M, Fujimoto A, Tsuji A, Ishida K, Iwata T. Simulation-based medical education in clinical skills laboratory. J Med Invest 2012; 59: 28–35

 PubMedGoogle Scholar

Sprawls P. Evolving models for medical physics education and training: A global perspective. Biomed Imag Interv J 2008; 4(1)e16, . Available from http://www.biij.org/2008/1/e16/ (Accessed 22/09/2012)

 PubMedGoogle Scholar

Arthurs JB. A juggling act in the classroom: Managing different learning styles. Teach Learn Nurs 2007; 2: 2–7

 Google Scholar

Bowman S. Presenting with pizzazz! terrific tips for topnotch trainers. Bowperson, Tulsa 1997

 Google Scholar

Nilson L. Teaching at its best: A research-based resource for college instructors2nd. Anker, Boston 2003

 Google Scholar

Avers D, Wharton MA. Improving exercise adherence: Instructional strategies. Topics Geriatr Rehabil 1991; 6(3)62–73

 Google Scholar

Baykan Z, Naçar M. Learning styles of first-year medical students attending Erciyes University in Kayseri, Turkey. Adv Physiol Educ 2007; 31: 158–160

 PubMed Web of Science ®Google Scholar

University of Newcastle Upon Tyne. 2004. Study guide. [Accessed 22 September 2012] Available from http://www.ncl.ac.uk/students/wellbeing/assets/documents/StudySkillsGuide.pdf

 Google Scholar

Boctor L. Active-learning strategies: The use of a game to reinforce learning in nursing education. A case study. Nurse Educ Pract 2013; 13(2)96–100

 PubMed Web of Science ®Google Scholar

Kennedy L. PD trivia: Making learning fun. CANNT J 2006; 16(3)46–48

 PubMedGoogle Scholar

Brueckner JK, MacPherson BR. Benefits from peer teaching in the dental gross anatomy laboratory. Eur J Dent Educ 2004; 8(2)72–77

 PubMedGoogle Scholar

Eyler J, Giles D, Jr. Where's the learning in service-learning?. Jossey-Bass, San Francisco 1999

 Google Scholar

Croley WC, Rothenberg DM. Education of trainees in the intensive care unit. Crit Care Med 2007; 35(Suppl)S117–S121

 PubMedGoogle Scholar

Dark G, Perret R. Deconstructing the construction of a learning module on practice development. Eur J Cancer Care 2007; 16: 201–205

 PubMed Web of Science ®Google Scholar

Chandler P, Sweller J. Cognitive load theory and the format of instruction. Cogn Instruct 1991; 8: 293–332

 Web of Science ®Google Scholar

Darmer MR, Ankersen L, Nielsen BG, Landberger G, Lippert E, Egerod I. The effect of a VIPS implementation programme on nurses’ knowledge and attitudes towards documentation. Scand J Caring Sci 2004; 18: 325–332

 PubMed Web of Science ®Google Scholar

Dickerson PS. 10 tips to help learning. J Nurses Staff Dev 2003; 19(5)240–246

 Google Scholar

Jackson T. Activities that teach. Red Rock Publishing, Cedar City 1993

 Google Scholar

Gallagher P, Tweed M, Hanna S, Winter H, Hoare K. Developing the one-minute preceptor. Clin Teacher 2012; 9: 358–362

 PubMedGoogle Scholar

Garden A. How to teach. BJOG 2009; 116(Suppl)86–87

 PubMedGoogle Scholar

Gordon D. MD's failure to use plain language can lead to the courtroom. Can Med Assoc J 1996; 155(8)1152–1154

 Web of Science ®Google Scholar

Hazlett C. Prerequisite for enhancing student learning outcomes in medical education. SQU Med J 2009; 9(2)119–123

 Google Scholar

Jalali A, Wood TJ. Podcasting as a goal oriented toy in education. Adv Health Sci Educ 2012; 17: 605–606

 PubMed Web of Science ®Google Scholar

Dale E. Audiovisiual methods in teaching2nd. Holt, Reinhart & Winston, New York 1954

 Google Scholar

Jarvis CI, Seed SM, Silva M, Sullivan Karyn M. Educational campaign for proper medication disposal. J Am Pharm Assoc 2009; 49: 65–68

 Google Scholar

Pakes GE. A guide to effective presentation skills for drug information personnel. Drug Inf J 1995; 29(1)139–146

 Google Scholar

Montero J. Effective drug information dissemination and presentation. Applied drug information: Strategies for information management, M Millares. Applied Therapeutics, Vancouver 1998; 1–53, (Chapter 11)

 Google Scholar

Karabulut N, Cetinkaya F. The impact on the level of anxiety and pain of the training before operation given to adult patients. Surg Sci 2011; 2: 302–311

 Google Scholar

Katsuragi H. Adding problem-based learning tutorials to a traditional lecture-based curriculum: A pilot study in a dental school. Odontology 2005; 93: 80–85

 PubMedGoogle Scholar

Keulers B, Spauwen P. Can face-to-face patient education be replaced by computer-based patient education?. Eur J Plast Surg 2003; 26: 280–284

 Google Scholar

Murphy KR. Computer-based patient education. Otolaryngol Clin North Am 1998; 31(2)309–317

 PubMed Web of Science ®Google Scholar

Krishna S, Balas EA, Francisco BD, Konig P. Effective and sustainable multimedia education for children with asthma: A randomized controlled trial. Child Health Care 2006; 35(1)75–90

 Web of Science ®Google Scholar

Kumar LR, Voralu K, Pani S, Sethuraman K. Predominant learning styles adopted by AIMST University students in Malaysia. South East Asian J Med Educ 2009; 3(1)37–46

 Google Scholar

Lott TF. Creating a new nursing services orientation program. J Nurses Staff Dev 2006; 22(5)214–221

 PubMedGoogle Scholar

Lou B-S. Applying principles from Scientific Foundations for Future Physicians to teaching chemistry in the department of medicine at Chang Gung University. Kaohsiung J Med Sci 2012; 28: S36–S40

 PubMed Web of Science ®Google Scholar

Manning S. Characteristics of burn orientation programs. J Burn Care Rehabil 1983; 4(1)49–55

 Google Scholar

Medearis N. Training your staff effectively. Nursing (Lond) 1974; 4(3)43–50

 Google Scholar

Mitchell F. Patient education at a distance. Radiography 2007; 13: 30–34

 PubMedGoogle Scholar

Rief SF. How to reach and teach ADD/ADHD children: Practical techniques, strategies, and interventions for helping children with attention problems and hyperactivity. Jossey-Bass, San Francisco 1993

 Google Scholar

Okolie V, Ogbu SOI, Ezenduka P. Use of models and charts in teaching – Learning situation of university students in South Eastern Nigeria. J Med Res Technol 2007; 4(2)30–36

 Google Scholar

Okuda Y, Bryson EO, DeMaria S, Jr, Jacobson L, Quinones J, Shen B, Levine AI. The utility of simulation in medical education: What is the evidence?. Mt Sinai J Med 2009; 76: 330–343

 PubMed Web of Science ®Google Scholar

Oldaker SM. Live and learn: Patient education for the elderly orthopaedic client. Orthop Nurs 1992; 11(3)51–56

 PubMedGoogle Scholar

Pei W. Supporting student learning: Curriculum redesign of general pharmacy in Xi’an Jiaotong University. The China papers: Tertiary science and mathematics teaching for the 21st century, M Peat. UniServe Science, The University of Sydney, Sydney 2003; 70–73

 Google Scholar

Lagowski J. Teaching is more than lecturing. J Chem Educ 1990; 67(10)811

 Web of Science ®Google Scholar

Rao BB, Kate V. Problem solving interactive clinical seminars for undergraduates. J Pharmacol Pharmacother 2012; 3(2)205–206

 PubMedGoogle Scholar

Friel N. Report on interactive lecturing. University of Glasgow, Glasgow 2009

 Google Scholar

Sarikcioglu L, Senol Y, Yildirim FB, Hizay A. Correlation of the summary method with learning styles. Adv Physiol Educ 2011; 35: 290–294

 PubMed Web of Science ®Google Scholar

Shah C, Patel S, Diwan J, Mehta H. Learning habits evaluation of first M.B.B.S students of Bhavnagar Medical College. Int J Med Sci Public Health 2012; 1(2)81–86

 Google Scholar

Bonwell C, Eison J. Active learning: Creating excitement in the classroom. George Washington University, Washington, DC 1991

 Google Scholar

Shenoy UG, Kutty K, Shankar V, Annamalai N. Changes in the learning style in medical students during their MBBS course. Int J Scientific Res Publ 2012; 2(9)1–4

 Google Scholar

Sujatha VV, Gillelamudi SB, Chacko TV, Govindan VK, Kaul R, Modugu AR, Deshpande G, Gurumurthy R, Kaza S, Pendyala R, et al. Medical students as teachers in clinical skills training. Educ Med J 2011; 3(2)e76

 Google Scholar

Thomas MH, Baker SS. Nursing the hybrid wave. Teach Learn Nurs 2008; 3: 16–20

 Google Scholar

Videla RL. Passive classes, active classes and virtual classes transmitting or constructing knowledge?. RAR 2010; 74(2)187–191

 Google Scholar

Weinrich SP, Weinrich MC, Boyd M, Atwood J, Cervenka B. Teaching older adults by adapting for aging changes. Cancer Nurs 1994; 17(6)494–500

 PubMed Web of Science ®Google Scholar

Wiman RV, Meierhenry WC. Educational media: Theory into practice. Charles E Merrill, Columbus, OH 1969

 Google Scholar

Wood E. Problem-based learning: Exploiting knowledge of how people learn to promote effective learning. Biosci Educ 2004; 3, . Available from http://journals.heacademy.ac.uk/doi/abs/10.3108/beej.2004.03000006 (Accessed 22/09/2012)

 Google Scholar

Zeraati A, Hajian H, Shojaian R. Learning styles of medical and midwifery students in Mashhad University of Medical Sciences. J Med Educ 2008; 12(1 & 2)17–22

 Google Scholar

Stewart DK. A learning-systems concept as applied to courses in education and training. Educational media: Theory into practice, RV Wiman, WC Meierhenry. Charles E Merrill, Columbus, OH 1969; 134–171

 Google Scholar