In the context of pressing challenges, such as workforce shortages and aging populations [1], digital technologies have emerged as a potential means to improve the working conditions of health care professionals while enhancing the quality of care [2,3]. As a result, research on digital health technologies has expanded significantly across a range of disciplines, including engineering, medicine, nursing, psychology, philosophy, and sociology [4]. However, the interdisciplinary nature and broad scope of this research landscape make it increasingly complex and difficult to navigate [5].

Despite the growing interest in this area, most studies and reviews of digital health technologies tend to focus primarily on physician or patient outcomes, although nurses constitute approximately 44.7% of the global health workforce, accounting for around 27.9 million nurses worldwide [1]. Given their central role in patient care, nurses are key users of digital nursing technologies (DNTs) and play a crucial role in their adoption and effective implementation in nursing care settings [6]. DNTs are tools designed to help nurses provide high-quality care by facilitating rapid decision-making (eg, decision support systems for adherence to clinical guidelines) or complementing nursing tasks with technological solutions (eg, robots that assess vital signs before consultations or sensors that detect bed-exit events to prevent falls) [7]. These technologies serve multiple purposes, including enhancing patient safety, improving workflow efficiency, and reducing the physical and cognitive burden on nurses [8]. DNTs can function as stand-alone tools for individual nurses or be embedded in broader organizational care processes, such as integrated electronic health record systems or automated medication dispensing systems. By addressing specific clinical or operational needs, DNTs aim to optimize resource use and support nurses in managing complex care environments [7,8]. A detailed document outlining the DNT categories and definitions is provided in Multimedia Appendix 1 [7].

In recent years, there has been an increasing number of research and innovation initiatives at national and international levels, driven by high expectations of improving care through the implementation of DNTs [8-10]. However, the rate of successful implementation and sustainable uptake remains rather low, regardless of these efforts [7,11]. This may be due to a range of factors, such as organizational resistance [9], limited infrastructure [10], or insufficient training [11], which hinder the seamless integration of DNTs into care workflows and limit their potential to transform nursing practice. The complex and dynamic nature of the nursing care setting makes it challenging to determine clear cause-and-effect relationships in technology implementation [12]. DNTs can have both positive and negative impacts, which may not always be immediately apparent or easily measured. For example, a study of the implementation of a new patient monitoring system [13] found that the system’s real-time alerts reduced response times to critical situations but also may have led to alarm fatigue among nurses, ultimately reducing their effectiveness in responding to urgent alerts. In addition, changes in health care policy or budget constraints can affect the availability of necessary infrastructure or training programs, further complicating the process of understanding the factors that lead to the successful implementation and adoption, or the failure, of DNTs [14].

Although several evaluation frameworks for digital technologies exist [14-18], as well as scoping and systematic reviews that examine different types (eg, monitoring, sensors, and robots); settings (eg, formal and informal care); and outcomes (eg, acceptability, effectiveness, and efficiency) [7,8,19], significant gaps remain in understanding the factors that influence the implementation and adoption of DNTs.

We aimed to explore the factors (barriers and facilitators) that influence the implementation and adoption of DNTs used in nursing care settings from the perspective of nurses.

Our paper contributes by synthesizing existing evidence through an umbrella review approach, providing a comprehensive overview of the key factors influencing DNT implementation and adoption. To our knowledge, no existing review aims to synthesize and map all relevant influencing factors across the spectrum of implementation and adoption for DNTs in the context of formal care.

By identifying these key factors, stakeholders can better address barriers, tailor interventions, and create environments that foster the effective integration of DNTs.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was used to conduct and report our findings [20].

Due to the large number of relevant reviews, we decided to conduct an umbrella review to compile, synthesize, and summarize the results of several systematic reviews [21]. This design allows us to provide a comprehensive overview of the current landscape of DNTs to support nursing care across settings and interventions [21]. In addition, we aimed to identify potential gaps in the existing evidence to guide the direction of future research initiatives. The umbrella review framework is conceptualized as a systematic review in which only reviews are used as the fundamental unit of analysis within the overarching structure [22]. This methodological approach is particularly well suited to broad areas of inquiry, where the aim is to provide a consolidated summary of the most rigorously conducted reviews of advances within a particular field [22]. Using this approach, it is possible to identify gaps in the existing literature and to synthesize and present the most important findings [22]. The review protocol was registered in the Open Science Framework [23]. Minor amendments were made to the study protocol during the peer-review process. These included a revision of the study title and an extension of the literature search period.

A sensitive search was conducted using the PICO (population, intervention, comparison, outcome) scheme to guide the systematic review process [24].

We performed a systematic literature search in 4 databases (PubMed, CINAHL, Cochrane Library, and Business Source Premier) between March 2023 and May 2023. Although no specific number of databases is required for an umbrella review, the selection should be based on the research question and the scope of the review [25]. The four databases used in this review were chosen to ensure coverage of literature relevant to our topic due to their strong thematic relevance. During the preliminary phase, we conducted a pilot search to refine the search strategy (SW and CA). Keywords (including MeSH [Medical Subject Headings] terms and synonyms) were grouped into three overarching categories: (1) DNT, (2) implementation, and (3) formal care. These categories were linked using the logical operator “AND,” while terms within each category were linked using “OR.” The search terms were tailored to the specific criteria of each database.

The results of the pilot search were reviewed for appropriateness, and the search strategy for the main search was iteratively refined. To ensure methodological rigor, the final search strategy was validated in collaboration with a library consultant from the Furtwangen University. The search was updated in December 2024 and January 2025 to include the most recent publications. We also screened the reference lists of the included reviews to reduce the risk of missing relevant articles. The complete search strategy, along with database-specific adjustments, are provided in Multimedia Appendix 2.

The inclusion and exclusion criteria were defined based on the PICO framework [24], focusing on the population (nurses), the intervention (DNTs), and the outcome (factors influencing the implementation and adoption of DNTs). The comparison component was not applicable to this study and was therefore excluded. Refer to Textbox 1 for details. Studies had to meet the following inclusion criteria: reviews where nurses were either the primary focus or where findings on nurses’ perspectives could be meaningfully extracted were included; reviews including mixed professional groups (eg, physicians, therapists, and nurses) were only included if they reported clearly distinguishable results relevant to nurses; only knowledge synthesis publications, such as frameworks and reviews, were considered; and studies written in English or German and published between 2006 and 2024 were included.

The exclusion criteria were applied to studies that did not contain results regarding factors influencing the implementation and adoption of DNTs in the context of nursing care. Primary studies, randomized controlled trials, books, dissertations, and gray literature were also excluded, as these types of publications do not meet the level of knowledge synthesis required for this type of review [21]. In addition, a temporal exclusion criterion was enforced to exclude studies published before 2006. This was done because such articles may not provide relevant evidence, as the technologies are likely to be outdated by that time [26].

During the initial screening phase, which included title and abstract screening, each article was individually assessed by at least 2 reviewers (SW and CA). Disagreements were resolved through constructive dialogue and when necessary, by a third reviewer (CK). The subsequent full-text review followed the same protocol. The articles that met all the inclusion criteria were thoroughly reviewed using a structured data extraction form.

The data extraction form was used to extract relevant details covering study attributes (eg, title, year, authorship, country, review type, and the number of studies included) and details of integrated technologies and any content relevant to implementation aspects, including identifiable barriers and facilitators. Data extraction was performed independently by 2 reviewers (SW and SM). The resulting data extraction was reviewed and refined for each article.

To assess the quality of the included studies, we used the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses [27]. This checklist is a widely accepted and validated tool designed to ensure the methodological rigor and transparency of systematic reviews. It includes 10 criteria that address key aspects of the review process, including the clarity of the review question, the appropriateness of the inclusion and exclusion criteria, the transparency of the study selection process, and the comprehensiveness of the search strategy. Other important dimensions assessed include the standardization of the data extraction process, the thoroughness of the quality assessment of the included studies, the appropriateness of the synthesis methods, the consistency of the conclusions with the findings, and the identification and reporting of potential conflicts of interest.

Each included review was evaluated against these criteria and a score was assigned to reflect its overall methodological quality. The scoring process resulted in an overall score ranging from 0% to 100%, providing a quantitative measure of quality. Higher scores indicated reviews with robust and transparent methodologies, while lower scores highlighted areas of potential methodological weakness. The quality assessment was carried out independently by 2 researchers (SW and SM) to ensure an objective and systematic assessment. Any disagreements in the assessment were resolved by discussion to reach consensus. Multimedia Appendix 3 [9,10,19,27-89] provides a detailed scoring document.

We applied the NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework as a methodological tool to categorize the data (Figure 1) [14]. The NASSS framework was selected due to its ability to capture the multifaceted nature of technology implementation in health and care settings. It considers multiple levels of analysis to predict and evaluate the success of technology implementation and adoption. Failures, partial successes, and unexpected problems with technology are explained by examining complex interactions across 7 domains: condition, technology, value proposition, adopter system, organization, broader context, and changes over time [14].

The coding scheme was developed iteratively and refined by consensus among 3 researchers (SW, CA, and SM). Following the study by Kuckartz and Rädiker [90], we deductively categorized relevant data fragments into 1 of the 7 domains of the NASSS framework. The selected fragments were then inductively categorized into subthemes. Rather than analyzing each technology or care setting separately, we integrated the identified factors into overarching categories to capture broader implementation barriers and facilitators. This approach allowed us to synthesize common themes across diverse technologies and settings while still acknowledging contextual nuances.

By structuring the findings in this way, we aimed to highlight general barriers and facilitators rather than treating each setting or technology in isolation. We systematically mapped each code to the corresponding domain, ensuring a structured categorization of influencing factors. For example, factors categorized under the “technology” domain included usability and integration issues as barriers, whereas intuitive design and interoperability were identified as facilitators. Similarly, the “adopters” domain captured aspects such as technological confidence and workload, highlighting both enabling and inhibiting influences on DNT implementation.

Figure 2 illustrates the selection and screening process, including the primary reasons for exclusion. The initial search identified 4740 articles, from which 965 (20.36%) duplicates were removed. A total of 79.64% (3775/4740) of the articles underwent abstract screening, resulting in 4.03% (152/3775) of full-text assessments. Of these 152 articles, 101 (66.4%) studies were excluded due to various reasons (eg, outcome of interest not reported and wrong study design).

An updated literature screening identified an additional 1110 records, with 82 (7.39%) duplicates removed, leaving 1028 (92.61%) titles and abstracts for screening. After excluding 96.4% (991/1028) of the articles, 3.6% (37/1028) of the full texts were assessed, of which 62% (23/37) of the studies were excluded. Ultimately, 38% (14/37) of the additional articles were included, leading to a total of 65 studies in this review. Across these 65 reviews, a total of 1806 individual studies were synthesized. The number of studies included per review ranged from 5 to 140, with a median of 18.5 studies per review.

A total of 65 studies on DNT published between 2010 and 2024 were analyzed, with 46 (71%) studies published after 2018. The studies were conducted in 24 countries, with most originating from the United States (15/65, 23%), followed by Australia (7/65, 11%), Finland (6/65, 9%), and Germany (4/65, 6%). With regard to study types, systematic reviews dominated (26/65, 40%), followed by integrative reviews (13/65, 20%); scoping reviews (10/65, 15%); and a smaller number (16/65, 25%) of literature, narrative, rapid and mixed methods reviews. The average quality rating was 92% (SD 11.3%), with 65% (42/65) of the studies scoring 100%.

The studies focused on interventions that included technologies from different technology categories (11/65, 17%), decision support systems (10/65, 15%), hospital or care institution information systems (10/65, 15%), telehealth (9/65, 14%), and electronic medical record systems (7/65, 11%). Reviews focusing on clinical decision support systems (10/65, 15%; 376 included studies; mean 37.6 studies per review), hospital information systems (10/65, 15%; 295 studies; mean 29.5 studies per review) and telehealth (9/65, 14%; 227 studies; mean 25.2 studies per review) tended to include a higher number of primary studies. In contrast, assistive devices (5/65, 8%; 69 studies; mean 13.8 studies per review), and tracking technologies (1/65, 2%; 8 studies; mean 8.0 studies per review) included markedly fewer studies. Multimedia Appendix 1 provides more details on categories and definitions of DNTs.

There was variability in the use of implementation-related terminology and the focus of the included studies. In addition, the study settings varied, including inpatient and outpatient settings, such as home visiting programs, intensive care units, and nursing homes. Refer to Table 1 for more details on the characteristics of the included studies.

In this umbrella review, we synthesized evidence from the existing systematic reviews that discuss facilitators and barriers to the implementation and adoption of DNTs. We identified 1031 segments and 52 inductively generated categories within the 6 domains of the NASSS framework, highlighting the key factors influencing implementation. The review shows increasing research interest in DNTs, especially after 2018 (46/65, 71%), with most conducted in Western countries—predominantly the United States (16/65, 25%). The research focused on electronic health records, clinical decision support systems, and telehealth, while robotics and automation received less attention.

Nurses represent nearly 45% of the global health workforce and frequently act as the link between patients, technologies, and organizational structures. Their acceptance and engagement are therefore critical to successful implementation and adoption. While prior reviews take a general or physician-centered approach [91,92], our nursing-specific focus uncovers unique facilitators and barriers—such as professional identity, autonomy, and relational care—that are commonly overlooked. We believe these insights are essential not only for enhancing DNT implementation in nursing practice but also for providing valuable guidance for developers, policy makers, and health care teams working toward sustainable adoption.

We categorized the identified factors into overarching themes instead of focusing on specific technologies or settings, enabling synthesis across contexts while preserving nuance. However, certain technologies (eg, direct patient interaction vs infrastructure tools) pose unique challenges. Nurses’ needs vary by care setting, influencing how often facilitators and barriers appear across NASSS domains. Some factors even act as both facilitators and barriers. This uneven distribution suggests some domains may be more central to implementation than others.

To increase the likelihood of sustainable implementation and adoption of DNTs, it is recommended that the specific needs of the technology and the setting be considered [17-20], as highlighted in the “technology” and “organization” domains, where usability, infrastructure, and contextual factors varied significantly. Abell et al [93], in a recent scoping review, explored the barriers and facilitators to implementing computerized clinical decision support systems in hospitals. Their review included a broad range of health care professionals, such as physicians, physician assistants, nurses, and pharmacists. Although their focus was limited to one type of technology, their findings—structured using the NASSS framework—align with ours. This supports both the applicability of the NASSS framework in analyzing implementation challenges and the presence of generic influencing factors relevant across different DNTs. Tan et al [94], in another scoping review, examined the factors influencing the implementation and adoption of telehealth in nursing home settings. They identified critical factors, such as availability of technical infrastructure, staff training and acceptance, financial considerations, and leadership support. The authors highlight the complexity of implementing telehealth in care settings and the need to address these determinants to ensure successful implementation. In addition, in the context of informal dementia care, the results of a comprehensive review by Bastoni et al [95] on the factors influencing the implementation of eHealth technologies show similar findings to our work. The results of these studies [93-95] show that the factors influencing the implementation and adoption of DNTs found in our study can be applied (to a limited extent) to other health care professions and settings. This perspective is supported by several studies in the literature. For instance, Borges do Nascimento et al [92] identified key barriers, such as inadequate infrastructure, increased workload, insufficient training, and legal-ethical concerns. Conversely, they highlighted robust institutional training, governmental support, and involving health care professionals in technology development as crucial facilitators—especially when technologies are intuitively designed and their benefits are evident.

Most factors (432/1031, 41.9%) identified in the included studies relate to the “adopters” domain, underscoring the importance of addressing these barriers and facilitators. Adequate training and education on DNT use are crucial for the successful implementation. Similar conclusions have been drawn in studies on digital transformation in nursing education [11]. Current research highlights several issues: a lack of objective tools to assess digital competencies [96,97], insufficient training that addresses varying competencies [98,99], and limited implementation knowledge [6,99]. The NASSS framework helped structure these findings across individual, organizational, and systemic levels, enabling a holistic view of training-related challenges. Well-trained nurses can help address these issues—an approach supported by recent reviews as a key to overcoming barriers and fostering DNT adoption [100].

Our review highlighted the importance of structural and resource-related factors within health care organizations in shaping nurses’ experiences with technology implementation. Leadership support was consistently identified as a key facilitator. Nurses emphasized the role of organizational leaders who ensured ongoing education, IT support, and a supportive work environment in fostering a positive culture for adoption. Nursing leadership, in particular, was seen as crucial in addressing challenges, advocating for staff needs, and enabling integration into clinical routines. In contrast, lack of support, poor IT infrastructure, and staffing shortages were frequently cited as major barriers. These findings align with the previous research emphasizing the necessity of organizational commitment for the sustained adoption of DNTs [101].

The value of DNTs largely depends on their impact on the quality of care [59]. Manufacturer promises often do not reflect nurses’ perceptions. Acceptance increases when nurses are involved in the design and implementation. For instance, bed-exit systems aim to prevent falls but may cause alarm fatigue [13], illustrating the need for usability that fits nursing workflows. Misalignment often stems from development driven by biomedical and economic perspectives, overlooking nursing priorities [14]. Nurses appear to prioritize tools and systems that improve patient outcomes, streamline processes, and ultimately contribute to better patient care. Conversely, when technology complicates workflow or detracts from direct patient interaction, its perceived value diminishes, regardless of the other benefits it may provide (eg, improved efficiency). Therefore, the successful implementation and adoption of technology in the care setting depends on its ability to positively impact the quality of care provided [14]. Integrating participatory design approaches (co-design) in the development phase could help ensure that new digital tools meet the practical needs of nurses and enhance their usability [102].

In our study, the “condition” domain yielded little information, which aligns with our nursing-specific focus—most relevant factors were classified under the “adopters” domain. Similarly, few aspects were related to the “wider system” domain, and none were associated with the “embedding over time” domain, consistent with the findings of Bastoni et al [95]. This gap reflects the dominance of short-term, small-scale studies that often lack structured implementation frameworks. However, understanding how DNTs are sustained, adapted, or discontinued over time is essential for assessing their long-term impact. Without longitudinal perspectives, true integration of DNTs into nursing practice remains unclear. This requires targeted funding, stronger academic-practice partnerships, and wider use of frameworks that address sustainability explicitly.

Political and regulatory factors play an important role in shaping the digital transformation of health care. The lack of clear regulatory guidelines, reimbursement policies, and national funding programs can hinder the widespread adoption of DNTs. Policy makers should focus on creating standardized frameworks that facilitate implementation while ensuring data security, liability clarity, and financial incentives for health care institutions [103].

This review highlights several critical factors influencing the successful implementation and adoption of DNTs in health care settings, offering clear directions for both practice and research (Textbox 2).

Using a sensitive search strategy, we synthesized a substantial knowledge base through a comprehensive examination of reviews. Furthermore, the strength of our review lies in the use of the NASSS framework as a deductive categorization system [14]. However, it is imperative to acknowledge specific limitations. Our findings are context-specific to formal care, and their applicability to other implementation contexts may vary. While there is overlap with other professions and settings, it is important to note that different technologies present their own unique challenges that may not have been fully captured in this broader analysis. Although common themes were identified across technologies, each technology may present its own set of barriers and facilitators that were not always addressed in this review, which may affect the applicability of the findings to specific technology contexts.

Another limitation is that although we searched 4 highly relevant databases (PubMed, CINAHL, Cochrane Library, and Business Source Premier), we cannot ensure that we included all existing reviews in our study. The selection of these databases was based on their relevance to the research topic and their coverage of health sciences, systematic reviews, and business literature. However, we acknowledge that the exclusion of broader databases, such as Scopus or Google Scholar, and other discipline-specific databases, such as PsycINFO or Embase, may have limited the scope of our search and resulted in the omission of relevant studies. In addition, we included only German and English manuscripts, which may introduce a potential regional bias by excluding studies published in other languages, such as French, Chinese, or Spanish. Although this decision was based on the linguistic expertise of the research team, we acknowledge that a fully comprehensive picture of the global landscape of DNT adoption and implementation could not be achieved, and it may limit the transferability of our findings to other cultural and linguistic contexts.

The quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses [27]. As most studies were narrative reviews with a qualitative focus, purely quantitative quality metrics were less applicable. Instead, we prioritized methodological transparency, including clear research questions, a rigorous study selection process, and transparent analysis. Given the qualitative nature of these reviews, we focused on coherence, relevance, and clarity in the synthesis of findings rather than statistical measures. After careful consideration, we included all reviews in the synthesis while ensuring transparency in the quality assessment. However, the varying quality of the included reviews may have influenced the strength and reliability of the synthesized findings.

Finally, it is important to acknowledge the potential publication bias, as only published reviews were included in our synthesis. Although we made a high effort (including a search update) to ensure a comprehensive search, the exclusion of unpublished or gray literature may have led to an overrepresentation of certain outcomes and potentially biased the results.

This umbrella review provides a comprehensive synthesis of the facilitators and barriers to the implementation and adoption of DNTs. It highlights the complex interplay of organizational, individual, and systemic factors that influence the successful integration of new technologies into care processes. Leadership support, adequate training, and alignment with care needs emerge as key enablers, while insufficient resources, infrastructure limitations, and workflow incompatibilities remain substantial barriers. The findings underscore the importance of addressing both the specific technology requirements and the unique needs of the health care environment to ensure the successful implementation of DNTs. Future research should focus on long-term studies and the development of practical tools to support hospital stakeholders—such as nurses, management, and IT departments—in effectively adopting DNTs. This will help to sustainably embed DNTs in nursing practice and increase their long-term impact.