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BACKGROUND: Game elements may inform the design of both simulations and games. However, evidence on how individual game elements inform the design of military trauma training simulations and their educational purpose remains limited. OBJECTIVE: This systematic review aimed to examine which game elements are used in the design of educational simulations for military trauma management, how they are implemented, for what purpose, and what outcomes are reported related to the game elements. METHODS: This is a systematic review conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included qualitative, quantitative, mixed methods, and design studies describing simulation-based training for military trauma management that incorporated game elements. Studies focusing solely on assessment, noninteractive interventions, or psychological trauma were excluded. Searches were conducted in Medline (Ovid), PubMed, IEEE Xplore, ERIC, Web of Science, ACM Digital Library, and CINAHL from inception to October 14, 2025, identifying 2487 records. Screening and data extraction were performed independently by 2 reviewers. Methodological quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI) and the Côté and Turgeon grid. Results were synthesized using qualitative thematic synthesis. RESULTS: Forty-two studies published between 1986 and 2025 were included. Most studies were conducted in the United States and included a wide range of simulation modalities and learner populations. Sixteen game elements were identified, with narrative, sensation, imposed choice, time pressure, and scoring being most prevalent. The thematic synthesis identified multiple categories describing how these game elements were implemented. Justifications for the use of game elements were rarely provided; when present, they were primarily linked to realism, emotional engagement, adaptive learning, and feedback. Elements such as badges and competition were seldom used. No study explicitly linked individual game elements to specific educational outcomes. This review is constrained by heterogeneity across studies, an imperfect fit of quality appraisal tools for some study types, and the possibility of missed studies due to search vocabulary limitations. CONCLUSIONS: This systematic review is innovative in providing the first comprehensive synthesis of how game elements are used in military trauma simulations. Unlike previous reviews, it explicitly focuses on the pedagogical purposes of these elements. It offers an overview of the prevalence of game elements in military trauma care education and synthesizes the pedagogical rationales for their use. The lack of studies explicitly linking individual game elements to learning outcomes highlights the need for more intentional research and transparent reporting. Future studies should treat gamification as a set of targeted design choices rather than as a single overarching strategy, and explore how its motivational dimensions can be effectively leveraged in military trauma training. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/45969.
Stathakarou et al. (Sat,) studied this question.