The following research objectives guided our CTA study:

To understand the cognitive aspects of the tasks involved in trauma care

This study used a Cognitive Task Analysis (CTA) approach, following the methodological guidance outlined in Working Minds: A Practitioner's Guide to Cognitive Task Analysis by Crandall et al. (26). CTA involves a series of qualitative methods aimed at uncovering the knowledge, decision-making processes, and cognitive demands of individuals working in complex, high-stakes environments. Key attributes of the CTA methodology include: time (e.g., gathering information in the present as tasks are performed, reviewing past instances such as caring for a patient who experienced IPV, and considering future changes to tasks or performance needed to facilitate IPV screening and assessment); realism (e.g., focusing on the performance of real-world tasks); and difficulty (e.g., understanding tasks that may be highly routine and specialized). Given the cognitively intense nature of trauma care and the underutilization of IPV screening in these settings, CTA was deemed an appropriate methodology to explore the clinical reasoning that underpins trauma care providers' actions and judgments related to IPV identification and response. CTA methods are typically interview-based, recognizing that the voices of experts are necessary to elicit complex cognition at work (27).

The study was conducted at two urban trauma centres in Edmonton, Alberta, Canada: the University of Alberta Hospital (a Level 1 trauma centre) and the Royal Alexandra Hospital (a Level 2 trauma centre). Trauma centres are designated by levels that reflect their resources and capabilities for managing traumatic injuries—Level 1 being the highest and Level 3 the lowest. Level 1 centres provide comprehensive care, including 24/7 access to specialized medical and surgical services, advanced diagnostic technology, and multidisciplinary trauma teams. They also have mandated roles in research, education, and quality improvement. In contrast, Level 2 trauma centres offer similar acute care services but may lack some of the subspecialty and academic infrastructure of Level 1 centres. Lower-level trauma centres (e.g., Level 3) typically provide initial stabilization and coordinate transfer to higher-level facilities for definitive care.

Alberta has one of the highest rates of IPV in Canada (28), making it a relevant setting for exploring the integration of an IPV screening program into trauma care. We used purposive sampling to recruit a multidisciplinary sample of trauma care providers across various professional roles, including trauma surgeons, nurse practitioners, social workers, registered nurses, and a patient care manager. Eligibility criteria included current employment in trauma services and direct experience with the acute care management of injured patients.

A total of nine trauma care providers participated in the study. This sample size is consistent with CTA guidelines, which suggest a minimum of three to five experts is needed to identify expert cognitive processes (26, 29). Six participants were recruited from the University of Alberta Hospital and three from the Royal Alexandra Hospital. The sample included three trauma surgeons, two nurse practitioners, two social workers, one patient care manager, and one charge nurse. This composition allowed for a diverse exploration of cognitive processes and knowledge structures related to IPV screening interventions in trauma care.

Several methods of knowledge elicitation are described within CTA, as defined by Crandall et al. (26). Among these, we incorporated two complementary methods: the Critical Decision Method (CDM) and Applied Cognitive Task Analysis (ACTA) (30). We used CDM, a semi-structured, retrospective interview technique developed to elicit decision-making processes in high-stakes situations, to probe participants' experiences with IPV screening during critical or atypical trauma cases. This method allowed us to examine how providers recognized cues, assessed situations, adapted their routines, and made time-sensitive decisions under pressure. In parallel, ACTA interview techniques were used to capture more routine cognitive demands across the trauma care workflow. ACTA emphasizes task decomposition and knowledge auditing (i.e., identifying the types of knowledge experts rely on to perform a task), and was particularly useful for mapping provider roles, interprofessional coordination, and information flow during typical trauma care scenarios (31). Together, CDM and ACTA provided a more comprehensive understanding of the cognitive and contextual conditions that shape IPV screening and assessment behaviour in trauma care settings. Table 1 describes the five steps used in the CTA process.

Before conducting the CTA interviews, the research team participated in guided walkthroughs of the trauma units at the University of Alberta Hospital and the Royal Alexandra Hospital. These site visits provided contextual insight into the physical layout, workflow, and unit dynamics. Observational notes were captured to inform interview facilitation. Group CTA interviews were held virtually using Zoom™ conferencing software at each hospital site, facilitated by a researcher trained in CTA (SM). Each session began with an overview of the study objectives, followed by structured questions based on a CTA-informed interview guide. The group interviews lasted 90 min, were audio-recorded, and transcribed verbatim.

We employed a hybrid analytical approach that combined elements of grounded theory (32) with the structured procedures outlined by Crandall et al. (26). This approach enabled us to examine both the cognitive strategies and contextual factors influencing IPV screening in trauma care settings. This analysis was informed by principles of implementation science and complexity science, which provided conceptual lenses for interpreting how individual cognition and system-level conditions interact in sharing IPV screening practices. We drew conceptually from the Consolidated Framework for Implementation Research (CFIR) (33) and Proctor et al.'s (34) taxonomy of implementation outcomes to situate emerging themes within broader domains of implementation, such as intervention characteristics, organizational context, and individual provider factors (see Figure 1). This orientation supported our interpretation of findings in relation to key implementation constructs, including the acceptability, appropriateness, and feasibility of IPV screening interventions in complex, time-sensitive trauma care environments.

Data analysis proceeded in four iterative and overlapping phases: preparation, data structuring, discovering meaning, and representing findings (26). In the preparation phase, the research team (SM, SD and Research Assistant) listened to audio recordings and reviewed transcripts to become familiar with the interview data, and began visualizing concept maps with participants. This phase allowed us to focus the analysis on key task domains, cognitive strategies, and contextual factors related to IPV screening.

The data structuring phase involved open coding of transcripts to identify recurring patterns related to cognitive work, decision-making, and knowledge use. We employed a coding framework based on CTA constructs, including situational awareness, task goals, decision-making cues, mental models, and knowledge requirements (26), combined with grounded theory's constant comparative method, to stay open to emergent themes. Transcripts were independently coded by two team members (SM and a Research Assistant) and compared to ensure consistency and rigour.

In the discovering meaning phase, we examined the relationships among codes to understand how trauma care providers recognized cues, adapted workflows, coordinated with other providers, and made judgment calls about IPV screening. We explored both routine and atypical decision-making processes to uncover how tacit knowledge and contextual pressures influenced behaviour and decision-making. Through axial coding and iterative team discussion, we refined thematic categories and linked them to broader cognitive domains.

In the final representing findings phase, we synthesized insights into conceptual diagrams (Figures 2–7) and thematic narratives. These representations combined verbal data and concept maps to illustrate how IPV identification is cognitively and contextually integrated into trauma care tasks. The emerging themes depict both the real-time complexity of trauma care environments and the implicit decision strategies that influence providers' decisions on IPV identification and response. The concept map and themes were shared with participants for feedback, and the themes were refined during virtual meetings with the principal knowledge user of the study (NB).

Ethical approval was obtained from the University of Alberta Research Ethics Board (Pro00119940). All participants were provided with information about the study and given the opportunity to give informed consent. Considering the group interview format, participants were reminded of the importance of maintaining confidentiality and engaging respectfully. Data were anonymized, securely stored, and only accessible to the research team.

Trauma care providers described a cognitively demanding workflow that begins with patient arrival in the ED and extends through to admission, stabilization, and interprofessional management (Figure 2). Providers emphasized the high acuity and rapid pace of trauma care, where the priority is to stabilize patients, perform diagnostic assessments, and implement life-saving interventions. The cognitive demands of this workflow were described as intense, requiring providers to synthesize clinical, social, and environmental information under time constraints. As one trauma nurse practitioner explained:

Navigating this complex and critical environment means providers have to swiftly process clinical, social, and environmental factors with very little time. The urgency of trauma care means that immediate clinical priorities often dominate provider attention, leaving little space for broader psychosocial assessments—including those related to IPV. As one trauma surgeon emphasizes, “it's all about context.”

Participants noted that opportunities to consider IPV and other social determinants of health typically arise later in the care trajectory. However, there is no standardized process for IPV assessment, and the decision to screen or intervene is often left to the individual provider's judgment and availability of time and resources. A social worker described the layered and adaptive thinking required in such situations:

This quote reflects the dynamic decision-making processes involved in balancing clinical, safety, and contextual considerations in real time.

One trauma surgeon offered a nuanced perspective on why screening or assessing for IPV at the point of entry may not be appropriate, highlighting the physical and emotional vulnerability patients experience during trauma resuscitation:

This quote highlights how the physical positioning, sensory disconnection, and depersonalization of acute trauma care can further disorient patients and inhibit trust-building, which is important for meaningful disclosure. In such moments, IPV inquiry might not only be ineffective but also potentially harmful or retraumatizing.

Several participants acknowledged that the biomedical focus of trauma care often sidelines psychosocial needs:

Together, these reflections show how trauma care processes affect providers' cognitive demands and decision-making priorities. While the clinical environment permits some IPV-related inquiry, this often relies on individual initiative and informal judgment to identify when, where, and how to address IPV issues, highlighting the need for structural support to incorporate IPV screening programs into routine care (Figure 2).

Participants emphasized that trauma care is inherently team-based, requiring close collaboration among physicians, nurses, social workers, and other allied health professionals (Figure 3). Nurses were identified as key providers in building rapport with patients. They usually serve as the first point of trust with patients, which helps them notice signs of IPV and initiate supportive conversations. Social workers were similarly recognized for their specialized role in uncovering psychosocial risks and navigating the complexities of safety planning and resource navigation. One trauma surgeon expressed appreciation for the vital role nurses and social workers play in their trauma ward.

In this interprofessional environment, the emotional intelligence and communication strategies used by team members—such as humour, empathy, and cultural humility—were described as essential to building patient trust. Interprofessional communication was viewed as both a strength and a challenge—while effective teams demonstrated seamless sharing of information, some reported uncertainty about who was responsible for initiating IPV screening and assessment. A conversation between two social workers highlighted the complex challenges of conducting IPV assessments in a hospital setting. One social worker described how disclosure is often delayed due to the pressures of the acute care environment:

Building on this reflection, another social worker emphasized the importance of relational trust and the compounding factors that shape patients' willingness to disclose:

These reflections reveal that while strong interprofessional collaboration can enhance IPV detection and response, role clarity, the setting itself, and timing constraints often limit effective identification and response of IPV.

Trauma care providers described critical clinical situations as cognitively demanding and highly structured, involving predefined team roles, rapid assessment, and coordinated task execution (Figure 4). In these moments, IPV screening was not prioritized unless physical signs or behavioural cues explicitly suggested abuse. Providers discussed the tension between their moral imperative to address psychosocial concerns and the clinical necessity of treating life-threatening injuries. A social worker shares the importance of predefined roles of providers within the trauma ward:

Leadership, situational awareness, and adaptive problem-solving were crucial cognitive skills employed during critical incidents. Some participants recounted situations where, after a patient had been stabilized, they intentionally revisited psychosocial concerns such as IPV, but these opportunities were inconsistently pursued.

Participants acknowledged that formal IPV screening was uncommon and not systematically integrated into institutional protocols at both trauma centres. Although the electronic medical record (EMR) includes three to four safety-related questions, these are not derived from any validated or published IPV screening approach. Moreover, the EMR flowsheet containing these questions is accessible only to nursing staff and not to physicians, further limiting its use in routine trauma care. As a result, there was no standardized or consistently applied IPV screening tool embedded within the EMR system. Identification of IPV usually happens informally, triggered by obvious physical signs or injuries, patient behaviour, or collateral information shared by other staff. One social worker describes the cognitive and emotional considerations that shape IPV identification and assessment:

Additionally, a nurse shared a scenario where a patient's resistance to discharge prompted further inquiry. They shared an example of using informal team-based observations to validate suspicions:

Participants described multiple systemic and situational barriers that can hinder screening and identification practices (Figure 5). Time pressures, high patient volumes, a lack of standardized tools, limited provider knowledge, and inadequate institutional guidance and support were frequently described as challenges. One trauma surgeon reflected:

Additionally, providers also expressed concern about retraumatizing patients or eliciting disclosures they were ill-equipped to manage. One nurse emphasized the importance of patient-centredness, particularly when screening processes are embedded in digital workflows:

Participants noted that social workers were often relied upon to “pick up the pieces” in cases where IPV was disclosed, but this model was described as unsustainable. Furthermore, the intersection of IPV with other complex social issues—such as substance use, housing insecurity, and mental health—introduced added complexity and uncertainty around when and how to intervene. These overlapping issues contributed to hesitation and variability in IPV screening and response practices across trauma care providers.

Trauma care providers conveyed a strong desire to understand the lived experiences of patients affected by IPV (Figure 6). They recognized that building trust and rapport was foundational to eliciting disclosures and providing adequate care. Participants noted that patients may withhold information due to fear, shame, or cultural barriers, requiring providers to adopt a patient-centred and nonjudgmental approach. Some providers reported modifying their communication style—slowing down, sitting at eye level, using humour or small talk—to create a safer space for disclosure. The cognitive challenge of balancing empathy with clinical detachment was described as emotionally taxing but essential to trauma-informed practice. Others reflected on cases in which disclosure occurred only after repeated interactions, highlighting the importance of continuity and consistency in care. A trauma nurse practitioner recounted one example where continuity of medical care from a team was provided following a trauma patient disclosing IPV:

Participants across both trauma care sites consistently reported a lack of institutional protocols, policies and formalized training related to IPV screening and response. Providers described the current approach to IPV identification and assessment as reactive, fragmented, and highly variable across teams and shifts. Many participants expressed frustration with the absence of clear referral pathways, limited access to community-based resources, and insufficient administrative support. One trauma surgeon describes,

Time constraints were frequently cited as a significant barrier to IPV screening or identification. Providers emphasized that screening for IPV requires more than a checklist—it can lead to disclosures that demand time, coordination, and follow-up. One trauma surgeon emphasized:

Staffing limitations—particularly the lack of dedicated social work coverage—further compounded these challenges. A patient care manager explains,

Training on IPV, when available, was optional and often limited to social work staff. Participants advocated for systemic solutions, including integrating standardized screening prompts into EHRs, mandating IPV training for all trauma care team members, and ensuring visible institutional leadership that prioritizes IPV as a serious clinical concern.

Several providers also emphasized the importance of aligning IPV screening with broader organizational commitments to trauma-informed care, cultural safety, and health equity. Without institutional buy-in and system-level supports, even well-intentioned efforts to identify IPV were likely to remain inconsistent and unsustainable.

In sum, the results of this study highlight a complex interplay of individual, interpersonal, and systemic factors that shape trauma care providers' ability to identify and respond to IPV. While there is recognition of the importance of IPV screening, substantial cognitive, emotional, and structural barriers inhibit its routine integration into trauma care workflows. These findings provide critical direction for designing and implementing contextually sensitive IPV interventions that are both feasible and sustainable in acute care settings.

Although CFIR and Proctor et al.'s implementation outcomes taxonomy were not used as deductive coding frameworks, they offered important conceptual lenses for understanding how cognitive, relational, and organizational factors influenced the feasibility of IPV screening in trauma care (see Table 2). Several CFIR domains/constructs and Proctor outcomes stood out across the findings. For example, at the CFIR inner setting level, structural factors (such as high-acuity workflows, staffing constraints, and limited social work coverage), implementation climate, and available resources determined whether IPV screening was seen as feasible or appropriate. Although this study was not designed to compare trauma centre levels, the inclusion of both a Level 1 and a Level 2 trauma centre provides important contextual insight into how organizational infrastructure shapes the cognitive and implementation conditions for IPV screening. Despite these structural differences, participants across the University of Alberta Hospital Trauma Centre (Level 1) and Royal Alexandra Hospital (Level 2) described similar cognitive pressures, workflow constraints, and reliance on informal judgment in identifying and responding to IPV. This suggests that the barriers identified in this study are not solely a function of resource availability, but are embedded in the core cognitive and organizational dynamics of acute trauma care. Among CFIR characteristics of individuals, providers' knowledge, beliefs about consequences, self-efficacy, and emotional labour were vital to screening decisions. Additionally, IPV screening was viewed as a complex intervention rather than a simple task, requiring time, trust, and coordination. The lack of integration with trauma workflows and EMR systems decreased perceived compatibility. Building on the alignment presented in Table 2, the discussion below focuses on what these implementation-relevant findings mean for the design and delivery of IPV screening programs in hospital trauma care.

Trauma care providers acknowledged the significance of IPV as a health and safety issue, yet the actual implementation of screening practices or identification of IPV was limited and inconsistent. This disconnection between institutional policy on IPV screening and identification and day-to-day practice reflects broader challenges in integrating psychosocial assessments into clinical care environments. Providers highlighted numerous cognitive and contextual barriers to screening and identification of IPV, including competing clinical priorities, a lack of clarity around professional roles, emotional labour associated with IPV disclosures, time constraints, and insufficient institutional resources. These findings are consistent with prior research documenting the underutilization of IPV screening in emergency and trauma care (14, 35).

Our study expands on this body of work by revealing how these structural and practice barriers manifest cognitively. For example, trauma care providers described the emotional and mental effort required to switch between life-saving interventions and the relational work needed to encourage and support IPV disclosures. These shifts are not merely logistical—they reflect different ways of thinking, requiring providers to transition from algorithmic decision-making to complex judgment and emotional sensitivity.

Using CTA allowed us to explore the mental models that guide trauma providers' IPV-related judgments. Participants' conceptions of when and how IPV assessment becomes relevant often depended on observable injuries or patient disclosures, rather than a proactive or standardized approach. While providers demonstrated strong situational awareness and team-based coordination during high-acuity care, they lacked a shared cognitive framework for integrating IPV screening or identification into routine assessments. This fragmentation resulted in ad hoc approaches, typically initiated by providers with greater confidence or perceived role alignment, such as nurses or social workers.

These findings highlight the need to rethink how IPV is understood within trauma care. Instead of viewing IPV as a secondary concern, it should be regarded as central to patient safety and recovery. This shift requires both cognitive and structural changes, including creating shared mental models, normalizing screening practices, and integrating IPV-related cues into diagnostic reasoning and decision-making pathways.

The study underscored the critical role of relational work in facilitating IPV disclosure. Nurses, in particular, emerged as relational gatekeepers—using empathy, humour, and continuity to build trust with admitted patients. However, this relational labour is often invisible, unrecognized in formal workflows, and unsupported by institutional systems. Moreover, providers expressed concern about the emotional toll of repeated IPV encounters without appropriate training, debriefing, or systemic follow-up. These findings align with trauma-informed care literature, which emphasizes the need for institutional cultures that recognize and support the relational aspects of healing (36).

Findings from the CTA provide important insights into how trauma care providers cognitively navigate the complex and time-sensitive environment of acute care, offering guidance for how IPV screening programs can be designed and integrated. First, the findings emphasize that the timing of IPV screening must be aligned with the trauma care trajectory. Immediate screening during resuscitation or early stabilization is not appropriate, as patients are physically vulnerable, cognitively overwhelmed, and unfamiliar with providers. Instead, screening efforts should be initiated once clinical stabilization is achieved, have had time to orient to their surroundings, and a therapeutic relationship has begun to form—typically later in admission or during early recovery. Second, the findings suggest that who conducts IPV screening and assessment matters. While social workers are often relied upon, a more distributed, team-based model of responsibility is needed (22). Nurses and allied health providers who spend prolonged time with patients are well-positioned to detect subtle cues and follow up on suspicions and disclosures collaboratively.

Trauma care team members require clear roles, adequate training, and support to navigate disclosures effectively. Moreover, the effectiveness of screening is contingent not only on who asks and when, but also on how it is conducted—requiring trauma-informed, patient-led approaches grounded in trust and cultural safety. Complexity science highlights the importance of emergent factors, such as provider workload, relational dynamics, and patient readiness, which can vary over time and across contexts.

Comprehensive IPV screening and response efforts must be systemically supported through formal protocols, consistent staff training, embedded screening tools in the EHR, and sufficient staffing—particularly access to social work beyond weekday daytime hours. Without these institutional supports, screening remains informal and reliant on individual judgment, limiting its consistency and impact. These strategies support the implementation of contextually sensitive IPV screening interventions that are feasible within the cognitive and operational realities of trauma care.

Mapping findings to CFIR and Proctor's taxonomy also clarifies where implementation strategies should be targeted. To improve feasibility (Proctor), system-level strategies that address CFIR inner setting constructs are necessary, including expanded social work coverage, clear referral pathways, and EMR-integrated prompts aligned with trauma workflows. Enhancing appropriateness involves intervention adaptability, allowing IPV screening to occur later in admission when cognitive load is reduced and relational trust has been established. Improving acceptability depends on investing in provider training that addresses emotional labour, trauma-informed communication, and shared mental models across disciplines. Importantly, our CTA findings highlight that implementation strategies must reduce, not add to, cognitive burden. Embedding comprehensive IPV screening practices within existing team roles, decision points, and documentation systems is more likely to support sustained uptake than introducing standalone screening interventions.

This study contributes to implementation science by deepening the understanding of how cognitive and contextual factors influence the feasibility of IPV screening interventions in complex clinical settings. Using principles of complexity science, our CTA approach demonstrated that IPV screening and assessment is not a linear process, but an adaptive practice embedded within a dynamic system marked by fluctuating acuity, shared cognitive work across the trauma care team, variable team composition, and significant emotional labour. Instead of focusing solely on the adoption of a screening protocol, our findings emphasize the importance of designing flexible, system-aware implementation strategies that align with the real-time workflow, mental models, and tacit decision-making processes of trauma care providers. The study highlights key points for future implementation research on IPV screening interventions, such as embedded decision supports, iterative training based on real-world practice, and adaptive feedback mechanisms that facilitate ongoing learning and adjustment. Incorporating complexity-informed strategies—such as sensemaking, distributed leadership, and context-specific facilitation—may better support the adoption, sustainability, and fidelity of IPV screening programs in high-pressure care environments like hospital trauma care centres. These findings further emphasize the need for research on relational implementation strategies (37) informed by complexity, focusing not only on context and process but also on providers' dynamic mental capacity as they navigate high-stakes care environments and the structural vulnerabilities that shape patient experiences in trauma care.

A strength of this study is its use of CTA to uncover the cognitive dimensions of IPV identification and screening, offering a level of depth and specificity rarely captured in standard qualitative interviews. Our interprofessional participant sample and concept mapping approach added further richness to the data. Additionally, this research brings implementation science closer to the cognitive realities of clinical practice. While implementation frameworks often consider contextual, organizational, and behavioural factors, they rarely delve deeply into the real-time cognitive strategies that influence provider behaviour—such as situational awareness, mental load, implicit decision rules, and adaptive judgment (38–40). By using CTA, we identified how trauma providers perceive, prioritize, and respond to IPV-related cues amidst competing demands. This adds nuance to our understanding of contextual factors and highlights the need for implementation strategies that account for cognitive demand, implicit mental models, and clinical judgment—not just attitudes or knowledge deficits.

However, the study also has limitations. The sample size was small and limited to two hospitals within a single urban region, potentially limiting generalizability. Group interview dynamics may have influenced what participants shared, and the absence of patient perspectives is a notable gap.