From operating room to leadership room: a systematic review of simulation-based interventions for leadership development in general surgery

OBJECTIVE: To evaluate the effect of simulation-based leadership training on behavioral and safety-related outcomes in surgical and clinical environments. Leadership and non-technical skills (NTS) are critical for safe surgical practice. Simulation-based education can be helpful in the improvement of these skills. While simulation-based education is widely used to improve technical skills, its influence on leadership, teamwork, and patient safety outcomes is reported inconsistently. METHODS: Following the PRISMA guidelines, studies evaluating leadership or NTS using simulation within surgical or perioperative contexts were included. Study characteristics, simulation format, assessment frameworks, leadership outcomes, and patient safety indicators were extracted. Risk of bias was evaluated using ROBINS-I and RoB-2, and visualised through the robvis platform. RESULTS: Twelve studies with 430 participants met inclusion criteria. Sample sizes ranged from 14-69; most involving multidisciplinary teams of 2-6 members. High-fidelity modalities were used in approximately 70% of studies, while others incorporated wet-lab, video-based, or in-situ simulations. Leadership performance improved, with reported gains of 2-4 points on behavioral scales. Communication and teamwork scores increased by approximately 2-3 points, and Non-Technical Skills for Surgeons (NOTSS) domain means typically ranged from 2.8-3.5 on 4-point scales. Technical performance differences between senior and junior trainees averaged 30-40%. Checklist-supported teams missed only 6% of critical actions. CONCLUSIONS: Simulation-based training was consistently associated with improvements in leadership, communication, teamwork, and safety-related performance across surgical and multidisciplinary settings. Although results were positive, heterogeneity in design and measurement shows the need for further high-quality, standardised research.