Agentic education · Learning science

Actionable companion · Feedback & scaffolding

Learning with agency: Game Elements in Military Trauma Care Education: Systematic Review

AI-assisted editorial implementation guide, separate from the original research. Proposed actions are not claims or recommendations attributed to the source authors. No independent peer review of this guide is asserted.

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Evidence and context

Title and abstract screening; stage labels describe reported settings, not verified numerical ages. Design labels require full-text appraisal. Reported stage(s): Age / stage not established. Verify the participant population and task before transferring the findings.

Original authors’ abstract, reproduced under the linked source license:

Abstract 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 Keywords: gamification, game elements, military trauma care, simulation-based learning

What kind of evidence is this?

Intelligent tutoring & adaptive learning · Evidence synthesis

Stage: Age / stage not established. Screening labels describe reported context and study-design language. They are not a risk-of-bias rating or proof of effectiveness for an age band.

Study methods · source passage

A systematic review protocol for this study has been published in JMIR Research Protocols (PMID: 37682596) [32]. No changes were made to the planned synthesis methods after protocol publication. The results are reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [33]. The PRISMA checklist, the PRISMA-S checklist, the PRISMA for Abstracts checklist, and SWiM (Synthesis Without Meta-analysis) reporting items are provided in Multimedia Appendices 1-4, respectively.

Limitations and uncertainty · source passage

This review was designed and conducted as a systematic literature review, following a published protocol [32] and transparent, reproducible procedures for searching, screening, extraction, synthesis, and quality appraisal [94]. The purpose was to retrieve international evidence of the impact of game elements in trauma management training and inform design practices and future research. Although the first research questions involved descriptive accounting of design features, which might be considered a hallmark of a scoping review [94,95], the subsequent thematic syntheses produced a structured and critically appraised summary of the use and educational justification for game elements in trauma management simulation reported in the literature. However, we acknowledge that the borderlines between different types of systematic reviews are often blurred in practice [94-96].

Design the system before the pilot

Document the learner model, mastery rule, hint sequence and adaptation signal. Compare adaptive routing with the same content in a non-adaptive sequence. Check whether early errors lead to persistent low-expectation pathways.

  • Give feedback on the learner’s reasoning, then fade hints. Record whether the learner can complete the next task without that scaffold.
  • Measure engagement separately from achievement. Check whether novelty-driven participation persists and whether it translates to independent performance.
  • Use common rubrics, blind scoring where feasible and a fresh unaided reasoning task. Document permissible assistance and avoid treating AI-detector scores as proof of misconduct.

A 90-day district pilot

  1. Days 1–15 · Appraise. Have the curriculum lead and a teacher read the methods and limitations. Record the study design, sample, comparator, outcomes and evidence gaps. Define a local question that the study can help inform.
  2. Days 16–30 · Design. Treat the paper as background evidence until its population is verified in the full text. Do not assign an age-specific intervention or extend adult results to children. Name an accountable owner and set the baseline, success threshold and budget before implementation.
  3. Days 31–60 · Test. Start with a small voluntary cohort, preserve an accessible non-AI route and require teacher review. Use synthetic or de-identified examples; approve data handling and tool terms through district processes.
  4. Days 61–90 · Decide. Extract the participant ages or education stage, recruitment, task and comparator before selecting a local pilot. If these cannot be established, retain the paper for design discussion rather than age-band efficacy claims. Compare with baseline, document uncertainty and stop or revise if learning worsens, access is unequal or critical errors persist.

The board decision brief

Report the learning problem, evidence quality, participating population, total cost including review time, measured benefit, errors, access differences and remaining uncertainties. Make a dated recommendation to stop, revise or expand. A positive perception survey alone does not establish learning improvement.

Attribution and reuse

Natalia Stathakarou; Andrzej A Kononowicz; Maxine G Harjani; Cara Swain; Klas Karlgren. Game Elements in Military Trauma Care Education: Systematic Review. JMIR Serious Games (2026-03-17). https://doi.org/10.2196/79163

Companion prepared 2026-10-30. Original authorship and DOI are preserved. The abstract is an attributed source extract; the implementation plan is new AI-assisted editorial material, offered under the same CC BY 4.0 license. This guide has not undergone independent peer review.