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The Crucible simulation

Behavioral simulation improves clinical leadership skills and understanding of complex health policy change

Cohen, Daniel; Vlaev, Ivo; McMahon, Laurie; Harvey, Sarah; Mitchell, Andy; Borovoi, Leah; Darzi, Ara

doi: 10.1097/HMR.0000000000000162

Background: The Health and Social Care Act 2012 represents the most complex National Health Service reforms in history. High-quality clinical leadership is important for successful implementation of health service reform. However, little is known about the effectiveness of current leadership training.

Purpose: This study describes the use of a behavioral simulation to improve the knowledge and leadership of a cohort of medical doctors expected to take leadership roles in the National Health Service.

Methodology: A day-long behavioral simulation (The Crucible) was developed and run based on a fictitious but realistic health economy. Participants completed pre- and postsimulation questionnaires generating qualitative and quantitative data. Leadership skills, knowledge, and behavior change processes described by the “theory of planned behavior” were self-assessed pre- and postsimulation.

Results: Sixty-nine medical doctors attended. Participants deemed the simulation immersive and relevant. Significant improvements were shown in perceived knowledge, capability, attitudes, subjective norms, intentions, and leadership competency following the program. Nearly one third of participants reported that they had implemented knowledge and skills from the simulation into practice within 4 weeks.

Conclusions: This study systematically demonstrates the effectiveness of behavioral simulation for clinical management training and understanding of health policy reform. Potential future uses and strategies for analysis are discussed.

Practice Implications: High-quality care requires understanding of health systems and strong leadership. Policymakers should consider the use of behavioral simulation to improve understanding of health service reform and development of leadership skills in clinicians, who readily adopt skills from simulation into everyday practice.

Daniel Cohen, PhD, FRCS, is Research Fellow, Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, United Kingdom.

Ivo Vlaev, DPhil, is Professor of Behavioural Science, Warwick Business School, University of Warwick, United Kingdom. E-mail:

Laurie McMahon, is Visiting Professor of Strategy and Organisational Design, Cass Business School and Director, The Realisation Collaborative, United Kingdom.

Sarah Harvey, PhD, is Director, The Realisation Collaborative United Kingdom (

Andy Mitchell, FRCP, is Medical Director, NHS London, Southside, United Kingdom.

Leah Borovoi, PhD, is Lecturer, Open University of Israel.

Ara Darzi, PC, KBE, FRS, FMedSci, is Director, Institute of Global Health Innovation, Imperial College London, United Kingdom.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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