A literature review was conducted using the online software Covidence following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol [12] shown in Figure 1. The search concepts fell into 3 categories: COVID-19, digital health, and nursing. The concepts and their associated Medical Subject Headings (MeSH) and non-MeSH terms are described in Table 1. Cited and citing sources were double-checked to ensure no relevant items were missed.

The Boolean operator OR was used between the terms in each category, and then the operator AND was applied to combine the results by category. The search was applied to terms occurring in the title, abstract, or body text of full-text publications. The time frame selected was when COVID-19 was announced as a pandemic up to the time we conducted this study from January 2020 to November 2021. Scientific subscription databases searched contained both health and computing and information science databases, including PubMed, Ovid MEDLINE, Scopus, Web of Science, Institute of Electrical and Electronics Engineers (IEEE) Xplore, and Association for Computing Machinery (ACM) Digital Library. Google Scholar’s database was also searched using the same terms.

The search results were imported from Endnote into Covidence. The authors double-screened the titles and abstracts based on the eligibility criteria defined at the screening stage shown in the PRISMA flowchart. In the case of conflicts among the authors on a title or abstract exclusion, discussions were undertaken in regular meetings to reach a consensus. This approach was then applied to the selected abstracts to conduct the full-text review. The papers selected following double full-text review were accepted for the content analysis.

Studies were eligible for review if they presented original research in the English language, discussed digital health initiatives implemented during the COVID-19 pandemic, and addressed nurses’ experience in using digital health during the pandemic. Exclusion criteria were considered at each stage of the PRISMA flowchart to exclude publications not relevant to this study.

A descriptive qualitative approach to content analysis [13] was used to describe the characteristics of the included studies that were relevant to the research questions outlined in the background. This approach is well suited for analyzing the multifaceted use of digital health in nursing practice in various health care contexts. Inductive reasoning was applied to investigate the literature to answer the study questions [14]. Next, the 8D sociotechnical model designed by Sitting and Singh [15] was selected to deductively analyze the selected studies and explore the interaction between digital health tools and technologies, individuals, and activities. This approach was applied to better understand the nurses’ experience of issues inherent in the design, development, implementation, use, and evaluation of digital health solutions during the pandemic. The findings were synthesized based on the 8 themes of the sociotechnical approach, including hardware and software computing infrastructure; clinical content; human-computer interface; people; workflows and communication; internal organizational policies, procedures, and culture; external rules, regulations, and pressures; and system measurement and monitoring. To ensure interrater reliability, 3 researchers undertook the content analysis independently.

A total of 21 studies met the inclusion criteria: 4 (19%) qualitative studies targeted nurses only [16-19], whereas the remaining 17 (81%) studies included nurses and other health care providers and did not differentiate nurses’ responses from others [20-36].

In addition, 13 (62%) studies explored users’ experience with digital health applications for COVID-19 control [16,17,19-22,26-30,35,36]. In comparison, 8 (38%) studies investigated the use of digital health to manage other acute and chronic conditions during the pandemic, including pediatric otolaryngology [23], alcohol management [18], cancer management [24], hemophilia [25], opioids [31], pediatric chronic pain [34], and mental [32], behavioral, and sexual health [33].

In terms of digital health services, 16 (76%) studies used teleconsultations in home care [16-25,30-34,36], 4 (19%) applied tele–intensive care unit (tele-ICU) [27-29,35], and 1 (5%) study focused on electronic medical records (EMRs) [26].

Regarding the type of health care setting, 10 (48%) studies were conducted in hospital settings [16,20,23,25-29,34,35], 8 (38%) studies were conducted in primary care facilities [17,19,21,24,30,31,33,36], 2 (10%) studies included both primary care and hospital organizations [18,32], and 1 (5%) study involved national nonclinical institutes [22].

The characteristics of the selected studies are shown in Table 2. The studies were sorted in alphabetical order.

The selected studies were synthesized according to the sociotechnical approach. Table 3 shows the frequency of the 8 dimensions of the sociotechnical approach for using digital health technology systems in the selected studies.

As shown in Table 3, none of the selected studies addressed all the 8 dimensions of the sociotechnical approach when exploring nurses' use of digital health during the pandemic. Among the 8 dimensions, the people-related aspect was the most frequently discussed item, studied by 17 (81%) papers, whereas system measurement and monitoring were mentioned in only 2 (10%) papers. Details of each dimension are addressed in Table 4.

This literature review identified that the sociotechnical aspects of digital health in nursing practice are not widely investigated by the literature examining the impact on nursing practice due to the digital health transformation driven by COVID-19. Despite their recognized importance for efficient interaction between nurses, the technology and process within the health care environment were largely not addressed. This suggests that there are gaps in how the interaction with digital health innovations contributes to nurses’ practice to provide efficient care and ensure patient safety and the quality of care. The results showed that the clinical participants mainly discussed patient experiences of digital health, not their own experiences. This indicates a lack of emphasis on understanding nurses’ struggles within their workflows.

Of the 21 studies selected, only 4 papers examined the nurses’ views and experiences of digital health during the pandemic. Undoubtedly, implementing digital health innovations requires a multidisciplinary team, which may explain the multidisciplinary approach of many of the papers examined. However, there needs to be a dedicated examination of the issues nurses face in using digital health during their routine practice in different care settings to identify nursing-specific needs.

Teleconsultations were the most used type of digital health during the pandemic, as evidenced in 16 studies. The high demand for social distancing and the reduction in in-person visits shifted clinic appointments to the virtual model. The findings showed that the health care settings that had already implemented telehealth services and needed to expand them during the pandemic were more confident, satisfied, and less challenged than those that implemented them for the first time in the pandemic. Overall, the studies reported positive attitudes among nurses toward applying telehealth consultations, such as satisfaction, improved communication with patients [23,30,33], improved productivity and quality of care [16,32], and enhanced flexibility in the workflow [16].

The other digital health service applied during the pandemic was tele-ICU, explored in 4 studies, to keep the optimal distance between the control team and clinical providers within acute care departments. The studies showed overall satisfaction with the service that improved the workflow, teamworking, and patient-centered care [27-29,35].

Surprisingly, only 1 study investigated the issues related to the EMR system during the pandemic. EMRs are 1 of the tools that might have been implemented by most of the health care settings before the other digital health services in the prepandemic era. The study explored the causes of EMR-related burnout during the pandemic as the workload and documentation suddenly increased. In contrast to the positive outcomes of virtual visits reported in the studies discussed earlier, the burnout of EMR utilization mainly was reported due to a lack of face-to-face interactions [26].

Regarding disease treatment and monitoring, 13 studies used digital health exclusively for COVID-19, while 8 reported transitioning to telehealth to manage other conditions during the pandemic. Considering the opportunities and challenges expressed in the studies, the digital health transformation requires strategies to overcome the barriers and provide ways to sustain the initiatives for integration with routine nursing practice.

The synthesis of the elements of the sociotechnical approach in the literature showed that the rise and acceleration of digital health during the COVID-19 pandemic era has posed challenges regarding usability, functionality, and transformation. The sociotechnical elements were not thoroughly investigated in the literature, whereas the implementation and use of digital health services require interaction between the human, technology, and process-related factors shown via the sociotechnical approach elements to provide efficient and quality care.

The predominant consideration discussed in the literature was the people factor, which highlights the need to focus further on the nursing workforce. As most digital health studies concentrate on the technology, intervention, or outcome, the people factor, people’s needs, and their competencies are usually overlooked. System measurement and monitoring was the least explored element, indicating that despite the massive implementation of digital health services, there is little research on evaluating effectiveness and plans for ongoing use of services and nurses’ roles in these evaluations.

The literature showed that nurses are less likely to adopt the appropriateness of telehealth services [24] and to use secure messaging in providing virtual care [21]. Anxiety was the biggest challenge for nurses transitioning to telehealth, because moving toward telehealth would reduce patients’ and nurses’ engagement to interact with each other [18]. Nurses reported that the nursing care provided face to face cannot be easily replicated in a telehealth setting due to the type of care provided and the patient group’s needs [16]. Telehealth is a barrier to providing basic nursing skills, such as reassuring a patient [18]. Nurses perceived that their exposure to patients stays at a similar level after implementing in-patient telemedicine [28].

Lack of training has been identified as 1 of the core causes hampering the usability of the digital health system. Further, the literature has identified the connection between poor usability and varying levels of trust in using new technology in privacy protection [21,24,30,33-36]. Therefore, the solution lies in ensuring safe implementation training embedded in the routine training of nurses from undergraduate courses to postgraduate training and continuous professional training. Dedicated training in health informatics provides nurses with in-depth knowledge and skills to become comfortable with technological changes. It translates more robust safeguards to health information used in the digital health platform [37].

Although the telehealth services were perceived as an acceptable solution to increase access to care services during the pandemic [17] and were rapidly deployed during the pandemic, insufficient resources to implement telehealth at a large scale lowers the reimbursement and nurses’ motivation to use the services [24]. The prepandemic studies have addressed the reimbursement challenge as the most significant barrier to scaling up pediatric telehealth programs. The participants reported that reimbursement was a major barrier to the widespread use of telemedicine before the pandemic [31]. However, the payer reimbursement rapidly expanded during the pandemic [33]. As telehealth services are increasingly adopted in primary care, funding for general practice nurses needs to continue to facilitate better use of their roles [17].

There was a vast difference among nurses in various specialties in the perceived quality of care delivered via telehealth. This emphasizes the need for training in virtual physical examinations for different diseases [32]. Similarly, Esmaeilzadeh et al [26] found that the leading cause of EMR-related stress is insufficient training in the use of technology. However, receiving education as written instructions only was deemed the equivalent of having no education in using telehealth and did not enhance the adoption of these services [22]. There was insufficient training on how staff should use and support video visits conducted for the first time [36]. Limited telehealth education in health care professional programs might result from a lack of faculty expertise, technology, or opportunities for clinical experience in telehealth [22]. Nurses’ preparedness to use telehealth depends on the availability of technology and the skillset [17]. Moreover, interpretive services need to be embedded in future telehealth implementations to facilitate communication and improve nursing practice [23].

The other most challenging issues were the usability issues of technology and complicated workflows and communication. Clinicians had challenges deciding which infrastructure, logistics, and platforms to use [34]. The technological challenges were often linked to financial barriers [34]. Lack of adequate resources and the need for more time to conduct teleconsultations were the main challenges reported by O'Donovan et al [25].

System-level challenges exist in navigating payment models offered by different insurance companies, licensure, and litigation issues [24]. Nurses raised concerns about poor phone connectivity that hampered communication and jeopardized patient safety [29]. They felt that telehealth consultations increase their responsibility for connectivity and intake, which would severely limit the volume and efficiency of telehealth services [23]. For example, in tele-ICU services, nurses were frustrated about staying away from the bedside to overcome communication barriers. This increased the need for another nurse to fulfil the needs of critically ill patients [29].

A significant drawback of virtual visits is the inability to conduct physical examinations remotely [32]. There are concerns about not getting a holistic picture of the patient’s status in video visits due to technological and connection issues [20,30]. The inability to adequately assess the patient’s situation due to audiovisual issues reduces the quality of care [31]. There was an increased risk of nurses being unable to visually assess the patients and having difficulties assessing risks, such as domestic violence [18]. The findings showed that those with more EMR experience were more likely to be concerned about patients’ increased demand for virtual care, which is not integrated into EMR workflows [21]. Therefore, more investment is required in the internet infrastructure and access [34]. Effective support processes, such as change management strategies for integrating EMRs and virtual care services, will improve nurses’ practices in providing efficient care [21].

These challenges are not surprising. The rapid adoption of new digital health technologies at short notice in complex health care systems is an economically challenging and time-consuming process [2]. However, this justifies the need for more research in this area. Understanding these challenges can help better prepare nurses for using digital health in clinical practice and not stretch already exhausted systems.

Several literature review studies have been published since the pandemic began that explore the use of digital health in this context [5,8,38-40]. However, these studies have discussed digital health in general and have not focused on nursing practice. This study is the first of its kind that reviewed original research conducted during 2020-2021, focusing on nurses’ digital health experience. It used the 8D sociotechnical approach to comprehensively address the challenges related to the design, development, implementation, use, and evaluation of digital health initiatives that nurses confront in their practice in complex, real-world settings.

As the scope of this review was limited to the past 2 years, it did not cover the research conducted before the pandemic on nurses’ experience with digital health. Moreover, it was limited to English papers and original research. Due to the pressure on the health care systems, nursing practice in many regions might not have researched the nurses’ experience and outcomes during the pandemic or their findings might have been published as white papers or industry reports that were excluded from our screening.

This literature review studied the role and engagement of nurses in the digital transformation of health during the first 2 years of the COVID-19 pandemic. Despite the rapid growth and adoption of digital health [41], as the largest group of health care providers, nurses remained passive users of these technologies. The sociotechnical elements showed a lack of assessing nurses' interaction with and use of digital health. Despite overwhelming evidence suggesting digital health care improves efficiency and equity, many of the studies reviewed highlighted concerns about adopting digital health. Examples included disrupted workflows, lack of regulatory support, and ongoing system monitoring. It is well known that the health care industry is always slow in implementing new technology, which is often a safety-driven decision or due to a lack of supportive evidence [42]. Further, it usually takes a long time to validate and integrate digital health into the existing health services due to the complexity of this process. Recognizing the impact of the health service system and policy on digital health, all stakeholders need to be involved so their needs and interests can be incorporated into the digital health policy development and planning. Future work can explore ways in which nurses can be actively engaged in the design, development, implementation, and efficiency assessment of digital health within health care systems.