Game Elements in Military Trauma Simulations: Results from a Systematic Review

Introduction: Gamification, the use of game elements in non-game contexts, has shown promise in enhancing engagement and motivation in educational settings. In military trauma training, simulations incorporating game elements can replicate austere conditions, providing a safe environment for medics to practise essential skills. Despite this potential, the literature remains inconsistent, with controversies likely arising from a lack of understanding of how game elements and their combinations work. This systematic review aims to examine the use of game elements in the design of military trauma simulations and to evaluate the outcomes reported. Methods: We systematically searched multiple databases, screening 1,168 abstracts and narrowing them down to 630 after removing duplicates. A total of 34 studies met our inclusion criteria. Two reviewers independently extracted data using a structured form. We coded game elements based on established gamification frameworks and assessed study quality using MERSQI and Côté and Turgeon’s tool. A reflexive thematic analysis was conducted to understand the motivations—both deliberate and unintentional—behind the use of these game elements in the included studies. Results: The reflexive thematic analysis identified five themes: Recognizing the World; Believing and Feeling; Play by Choice; Varying Challenges; and Keep on Playing. The game elements most frequently used were plot, scoring, time pressure, avatars, and imposed choice. Multimedia was commonly used to enhance immersion. Conclusion: The reflexive thematic analysis revealed that game elements in military trauma simulations are often motivated by the need to create realism, facilitate immersion, empower learner agency, promote variation, and sustain motivation. While some elements were included intentionally, many were integrated without a deliberate gamification strategy. Our results suggest that simulations could benefit from a more intentional approach to gamification, making them more flexible and engaging in supporting military trauma training.