Digital technologies encompass a broad range of applications in nursing care, including telehealth services, clinical decision support systems, sensor-based monitoring technologies, and care robots. These technologies are increasingly regarded as an important strategy to improve care delivery, enhance patient safety, and support health care professionals in their daily work [1,2]. A growing body of evidence indicates that many innovations, even when demonstrating positive effects, fail to transition from project-based implementation to sustained routine use [3-7]. The reasons for this are multifactorial and reflect the complexity of implementing digital health technologies in real-world health care settings [8,9].

Successful implementation of digital health technologies requires collaboration among multiple implementation stakeholders. Within this landscape, nurses play a pivotal role. As the largest professional group in health care and primary users of many digital technologies in clinical care, they are central to determining the success or failure of implementation efforts [10]. However, digital technologies are frequently introduced without sufficient consideration of clinical workflows, professional values, care processes, or user needs, which can hinder their adoption and integration into routine practice [8,11]. Moreover, nurses operate at the intersection of patient care, interprofessional collaboration, and organizational processes, making them key stakeholders in adapting technologies to local contexts and everyday clinical routines.

To better understand and address the complexity of technology implementation in health care, several theoretical frameworks have been developed. Among them, the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework [4] provides a comprehensive approach to analyzing implementation processes across 7 interrelated domains. In an overview of evaluation frameworks applicable to digital nursing technologies, NASSS was identified as one of the most comprehensive and broadly applicable approaches [12]. Other frameworks, such as the Consolidated Framework for Implementation Research (CFIR) [3], similarly emphasize the importance of contextual factors and multilevel interactions. Together, these frameworks have substantially advanced implementation science by providing structured approaches to understanding implementation complexity and identifying determinants that influence implementation success.

While these frameworks provide valuable conceptual guidance, practical tools such as the NASSS Complexity Assessment Tools (NASSS-CATs) have been developed to facilitate their application [5]. However, translating implementation theory into routine health care practice remains challenging. Our previous translation and contextual adaptation of the German version of the NASSS-CAT (NASSS-CAT-D) highlighted the need for clearer guidance, greater contextualization, and more practice-oriented support for routine nursing implementation [13]. Existing implementation frameworks often require substantial methodological expertise, making them difficult to operationalize in everyday implementation practice [9,14]. In nursing care, this includes consideration of profession-specific factors such as clinical workflows, professional responsibilities, and care priorities.

As a result, implementation stakeholders often lack accessible, practice-oriented tools that operationalize implementation theory to support structured reflection and implementation planning while accounting for the inherent complexity of implementation processes [5]. This need is particularly evident in nursing care, where digital technologies are frequently implemented in highly complex clinical environments and nurses play a central role in their adoption and integration into routine practice.

To address this gap, the aim of this study was to develop and iteratively evaluate the Nursing Implementation Complexity Tool (NICT), a theory-informed, practice-oriented implementation reflection tool designed to support implementation planning for digital nursing technologies.

The study addresses the following research questions:

This manuscript was guided by the GUIDED (Guidance for Reporting Intervention Development Studies in Health Research) [15], SRQR (Standards for Reporting Qualitative Research) [16], and GRAMMS (Good Reporting of a Mixed Methods Study) recommendations [17].

The development and evaluation of the NICT followed a Design Science Research (DSR) approach [18]. The study was guided by the interplay between the relevance cycle, the rigor cycle, and the design cycle, thereby integrating practice needs, existing scientific knowledge, and iterative artifact development (Figure 1). The relevance cycle drew on empirical insights from nursing practice to identify implementation challenges, user requirements, and contextual factors. The rigor cycle ensured theoretical grounding through the NASSS framework [4].

Within the overall DSR framework, the development and evaluation of the NICT employed a convergent mixed methods approach [19]. Qualitative and quantitative data were collected across the different development phases to generate complementary evidence for the iterative development, refinement, and evaluation of the NICT. Qualitative evidence was given greater interpretive priority, while quantitative data provided complementary descriptive evidence.

Within this overarching DSR framework, the design cycle was operationalized through 4 interrelated phases:

Phases 1 and 2 primarily focused on the conceptualization, development, and refinement of the NICT, whereas phases 3 and 4 aimed to generate insights into its usability, perceived relevance, and contextual requirements across different user groups and application settings.

The study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of Furtwangen University (approval number: 25‐122). Participation in all study components was voluntary, and participants were informed about the study procedures and data protection measures. Workshop-based evaluations were conducted in educational and professional contexts; no identifying data were collected, and participation was considered as implied consent. For the online survey and think-aloud interviews, informed consent was obtained prior to participation. All data were analyzed in an anonymized form. Ethical procedures for the empirical studies informing phase 1 are reported in the respective publications.

Phase 1 aimed to identify and synthesize implementation determinants relevant to the introduction of digital technologies in nursing care and to derive design requirements for NICT.

Findings from the preceding umbrella review, empirical case studies, and the NASSS-CAT-D revealed a range of interrelated determinants operating at the microlevel, mesolevel, and macrolevel. Key barriers consistently identified across studies included misalignments between technology manufacturers and nursing staff regarding perceived challenges and appropriate solutions, difficulties integrating technologies into existing nursing workflows, inadequate training provision, limited organizational readiness, and insufficient consideration of nursing-specific requirements within existing implementation tools.

To operationalize these findings into actionable design principles, the identified determinants were systematically mapped to the domains of the NASSS framework and iteratively discussed within the research team. This synthesis process resulted in 4 preliminary reflection areas: care recipients, health professionals, technology, and organizational context. Ethical and legal considerations were conceptualized as cross-cutting dimensions relevant across all domains.

Together, these integrated findings informed the design requirements for the NICT. Key requirements included the need for a practical, user-centered, and context-sensitive tool that supports structured reflection, facilitates interdisciplinary communication, and enables the consideration of implementation complexity across multiple levels.

The outcome of this phase was a conceptual framework comprising 4 reflection areas and cross-cutting ethical and legal considerations, which served as the conceptual foundation for the iterative development of the initial NICT prototype in phase 2.

Version 1 of the NICT was applied in 3 workshop-based settings involving nursing professionals, prospective nursing leaders, and nursing students.

Across all settings, participants perceived the NICT as a useful and practice-oriented tool for supporting reflection on complex implementation processes. The completed canvas templates, participant feedback, and facilitator field notes consistently indicated that the NICT supported users in identifying and reflecting on relevant implementation determinants and considering interactions between care recipient needs, technology characteristics, professional perspectives, and organizational conditions. Participants particularly valued the tool’s ability to facilitate communication and establish a shared understanding among different stakeholder groups. In leadership-oriented settings, the NICT supported discussions on roles, responsibilities, stakeholder involvement, and resource allocation. In educational contexts, participants reported that the tool fostered systems thinking and helped link theoretical concepts with practical implementation challenges.

Across all workshops, the NICT was described as clear, easy to use, and beneficial for structuring discussions around digital technology implementation in nursing care. At the same time, the testing phase highlighted important prerequisites for the effective use of the NICT in workshop settings. Participants emphasized the need for sufficient time for group work, reflection, and presentation of results, as well as smaller group sizes and appropriate working spaces. Furthermore, the workshops demonstrated that detailed descriptions of the implementation context are essential for meaningful reflection. Participants were better able to engage with the NICT when implementation scenarios included comprehensive information about the care setting, target population, existing workflows, organizational conditions, and the intended use of the technology. More detailed scenarios facilitated perspective-taking and enabled participants to better anticipate potential barriers, facilitators, and implementation requirements.

Overall, the testing phase demonstrated the perceived usefulness, usability, and adaptability of version 1 of the NICT across diverse nursing-related settings. While no substantial modifications to the NICT itself were considered necessary, the integrated findings informed refinements to the workshop design and facilitation process, including adjustments to time allocation, group size, scenario development, and instructional guidance.

This study aimed to develop and evaluate a practice-oriented, theory-informed reflection tool to support the implementation of digital technologies in nursing. Across surveys, free-text responses, and think-aloud interviews, a consistent pattern emerged: the NICT was perceived as conceptually robust and structurally coherent, enabling systematic reflection on implementation processes. Participants particularly valued its ability to structure complexity, foster shared understanding, and support consideration of the interdependencies between care recipient-related, technology-related, user-related, and context-related factors.

Recurring critiques concerned the tool’s length, abstraction, and the need for additional implementation support during early use. These findings informed iterative refinements of the NICT, including clearer guidance and practical examples incorporated into the final version of the tool. At the same time, participants highlighted the potential value of complementary training opportunities, facilitated workshop formats, and digital versions to further support implementation in practice. Rather than indicating a fundamental trade-off between conceptual comprehensiveness and operational usability, these findings suggest that comprehensive implementation tools benefit from being embedded within broader implementation support strategies that combine structured reflection with facilitation, guidance, and context-specific learning opportunities.

This apparent tension also clarifies the role of structured reflection in implementation. The purpose of the NICT is not to reduce implementation complexity. Rather, it aims to make interacting implementation factors, implicit assumptions, competing priorities, and contextual dependencies more visible and discussable among implementation stakeholders. In this sense, the NICT supports shared understanding and context-sensitive implementation planning rather than reducing the inherent complexity of implementation. This interpretation is consistent with recent NASSS-based implementation studies, which similarly describe structured reflection as a mechanism for adaptive implementation rather than complexity reduction [24].

Beyond these practical implications, the findings reinforce the theoretical assumption that successful implementation of digital technologies in nursing requires structured reflection on interacting technical, organizational, and professional factors. This observation aligns with Greenhalgh et al [4], who conceptualize technology implementation in health care as a dynamic process shaped by interactions across multiple levels, ranging from the characteristics of the technology itself to the broader socio-organizational context.

However, implementation in nursing is a profession-specific and context-dependent process in which technologies are interpreted, negotiated, and integrated into everyday clinical practice. In line with the view of implementation as a social process of sense-making and work integration proposed by May et al [28], participants particularly valued the ability of the NICT to facilitate communication, foster shared understanding and support collective reflection among different stakeholder groups.

Importantly, this conceptual understanding was reflected in the empirical data. Participants consistently described implementation as an active, reflective process influenced by professional reasoning, situational judgment, and team-based interactions. The NICT was used to evaluate technologies and reveal implicit assumptions. It also promoted negotiation between different viewpoints and aligned implementation decisions with professional care priorities.

These findings underscore the role of nursing practice as an active mediating mechanism in implementation processes. Rather than passively adopting technologies, nurses actively shape, adapt, and sometimes resist digital innovations based on professional values, established workflows, leadership support, and care priorities [29-32].

These findings align with international implementation research frameworks, such as NASSS [4], CFIR [3], as well as strategy compilations such as Expert Recommendations for Implementing Change [33], which collectively emphasize the multidimensional and context-dependent nature of implementation. Our study confirms and specifies these assumptions for nursing. Existing frameworks map complexity across domains but often underdevelop the role of professional practice. Consistent with prior research, our findings suggest that professional nursing practice should not be viewed as merely adopting change passively, but rather as a core mechanism through which digital transformation is enabled, filtered, or resisted [29,31,32].

Our findings further support understanding of implementation as a complex, adaptive process rather than a linear pathway. Organizational structures and individual engagement are interdependent: openness toward technology remains insufficient without supportive conditions, while structural resources alone do not ensure sustained use when technologies are perceived as clinically misaligned. This relational perspective was also reflected in our empirical data, where participants described implementation as shaped by the dynamic interplay of individual, organizational, and contextual factors. These observations align with prior work highlighting interactions across microlevel, mesolevel, and macrolevel [3,4,34,35].

This study reinforces a persistent challenge in implementation science: translating comprehensive implementation frameworks into practical tools for routine care [5]. Although frameworks such as NASSS provide valuable guidance for understanding implementation complexity, their application in everyday practice remains challenging [9,13]. The NICT was developed to address this gap by operationalizing implementation theory into a structured reflection tool. Our findings suggest that this translation requires balancing conceptual comprehensiveness with practical usability. Rather than reducing implementation complexity itself, structured reflection can help implementation stakeholders recognize and address complexity more systematically during implementation [36].

Key implications are summarized in Textbox 1.

Several limitations should be considered. First, the sample size of the summative evaluation was relatively small and based on voluntary participation, which introduces a potential self-selection bias and may limit generalizability. Second, the evaluation focused primarily on perceived usability and usefulness rather than objective implementation outcomes; therefore, no conclusions can be drawn regarding the effectiveness of the tool in improving implementation success or patient-related outcomes. Consequently, the present study should be understood as an intervention development and evaluation study rather than an effectiveness study. Third, while parts of the empirical foundation—particularly the case studies informing the conceptual development—were conducted in acute care settings, the overall evidence base (including the umbrella review and multicontext evaluation) spans a broader range of care contexts. Accordingly, the tool is not limited to acute care but may require context-specific adaptations to ensure its practical applicability across different health care settings. Finally, qualitative and quantitative data provided complementary perspectives across the development phases, with their relative contribution varying according to the specific purpose of each phase. Quantitative components were primarily descriptive and therefore complemented the more in-depth qualitative findings. An additional limitation concerns the composition of the summative evaluation sample. Among participants who reported their professional role, 14 of 21 (66.7%) were research staff or scientific personnel; similarly, 4 of the 8 interview participants were research associates in nursing science. Their familiarity with implementation concepts, innovation projects, and structured reflection may have shaped how the NICT was understood and assessed, thereby limiting the external validity of the findings for implementation stakeholders working primarily in routine care.

The NICT is a theory-informed implementation reflection tool that supports nursing professionals and other implementation stakeholders in recognizing, discussing, and addressing implementation complexity during the implementation of digital technologies. Rather than reducing implementation complexity itself, the NICT structures reflection to support informed, context-sensitive implementation-related decision-making. The findings suggest that operationalizing implementation theory into practical reflection tools requires balancing conceptual comprehensiveness with usability. While the NICT was perceived as useful and well structured, participants also highlighted the need for practical guidance, examples, and facilitation, indicating that supporting reflection on implementation complexity remains a complex task in itself. Beyond its application in nursing, this study illustrates how conceptual frameworks for understanding implementation complexity can be translated into structured, practice-oriented reflection tools for digital health implementation. Future research should evaluate the application and effectiveness of the NICT across diverse health care settings and explore digital and AI-supported approaches to further support its use.