Facilitating Digital Transformation in Nursing Through Nursing Development Units: Scoping Review

Introduction

Digital transformation is no longer a future scenario in health care but a present reality driven by artificial intelligence, remote monitoring, electronic health records, and data-informed decision-making [1-4]. While these innovations promise improved care quality, efficiency, and patient engagement, their implementation in nursing faces persistent challenges, including digital burnout, workflow disruption, resistance to change, and insufficient staff-centered design [5,6]. These barriers are not merely technical but rooted in organizational culture, leadership, and professional identity. Consequently, digital transformation in nursing often fails due to misalignment between technological innovations and clinical practice [6]. In this review, digital transformation in nursing is understood as a sociotechnical process. It involves technological adoption, changes in professional roles and competencies, and the adaptation of organizational routines and culture.

Nursing Development Units (NDUs) have emerged as a promising model to foster innovation and support digital transformation in nursing. NDUs are nursing-led, practice-based innovation hubs designed to integrate research, education, and clinical practice through reflective, participatory, and evidence-informed development cycles [7-9]. Unlike isolated pilot projects, NDUs are embedded within health care organizations and supported by dedicated leadership, resources, and evaluation systems, enabling long-term iterative learning and continuous improvement [10,11]. Their core mechanisms—structured reflection, participatory decision-making, and embedded evaluation—directly address known barriers to digital transformation by empowering nurses as cocreators of practice change.

Despite this potential, NDUs remain undertheorized in the context of digital health. Systematic mapping of their conceptual features, functional roles, and organizational frameworks—particularly regarding how they enable or constrain digital transformation—is lacking. Moreover, terminological variation (eg, “Clinical Development Unit,” “Practice Development Unit,” and “Nursing Professional Unit”) complicates cross-contextual comparisons and limits the transferability of insights [11-13]. This conceptual and methodological heterogeneity highlights a key research gap: the absence of a coherent, internationally applicable framework to understand how NDUs function as catalysts for digital innovation in nursing.

This scoping review aimed to address this gap by systematically mapping the international literature on NDUs, synthesizing their core conceptual features, functional roles, and organizational frameworks. The review also explored how NDUs engage with digital transformation—not as passive recipients of technology but as active spaces of knowledge translation [14], organizational change [15], and co-design [16]. A scoping review methodology was chosen due to the conceptual complexity, terminological diffusion, and limited existing synthesis of the NDU concept [17,18]. This approach allows for a comprehensive, transparent, and structured mapping of the literature, providing a foundation for future implementation models and strategies for digital innovation in nursing.

Methods

This scoping review followed the Joanna Briggs Institute methodology [17] and the framework by Arksey and O’Malley [18], which encompasses 4 phases: identifying relevant publications, selecting publications, extracting data, and synthesizing findings. Reporting adhered to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist to ensure transparency and reproducibility [19].

Search Strategy

A systematic literature search was conducted in May 2025 in the databases MEDLINE (via PubMed), ScienceDirect, EBSCO, Cochrane Library, and Europe PMC. Supplementary searches in Google Scholar and LIVIVO captured gray literature and publications not indexed in biomedical databases. Results were sorted by relevance, and all retrieved records were screened without a stopping rule to maximize sensitivity.

The primary database search used the exact phrase “Nursing Development Unit” to prioritize conceptual precision. No additional filters (eg, publication year, study design, or language) were applied to capture the complete literature on NDUs. This decision was grounded in the historically established use of the term. In the literature, “NDU” often denotes a defined organizational model rather than a generic practice development activity. We anticipated that broader search strings (eg, including “Practice Development Unit” or “Clinical Development Unit”) would markedly increase retrieval in the main databases. Much of this literature is conceptually adjacent but heterogeneous (eg, general practice development, quality improvement, or clinical education units) and does not necessarily reflect the NDU model targeted in this review.

To reduce the risk of missing relevant publications due to terminological variation, we complemented the core database search with supplementary searches and screened for records that provided structural or process descriptions consistent with NDUs (eg, “Clinical Development Unit,” “Practice Development Unit,” “Nursing Clinical Development Unit,” and “Nursing Professorial Unit”). The full MEDLINE search syntax is provided in Multimedia Appendix 1.

Publications were included if they described structural, functional, or organizational characteristics of NDUs, as well as development processes and implementation strategies. Publications primarily evaluating effectiveness or outcomes (eg, patient metrics and clinical performance) were excluded as the focus was on conceptual mapping rather than outcome assessment. Disease- or population-specific NDUs were included only if they provided insights into NDU structures or processes. Only English- or German-language publications with available full texts were considered. English was used to ensure coverage of the international literature, whereas German-language publications were included for feasibility given the review team’s proficiency. Textbox 1 summarizes the eligibility criteria.

Publication Selection and Data Extraction

Duplicate records were manually removed based on title, author, digital object identifier, journal, and year. Three reviewers (AG, PM, and KG) independently screened titles and abstracts, and any record deemed eligible by at least one reviewer progressed to full-text review. The involvement of 3 reviewers at this stage was chosen to efficiently manage the large number of retrieved records.

Full-text screening was performed independently by 2 reviewers (AG and KG) using predefined inclusion and exclusion criteria, with disagreements resolved through discussion. All included publications were full-text documents (peer-reviewed articles or gray literature reports) that underwent thematic analysis. Data extraction followed a standardized charting framework capturing structural, functional, and organizational characteristics; development and implementation processes; and references to digital transformation where present. Each publication was extracted by a single reviewer, with the framework ensuring consistency. Given the more in-depth nature of full-text assessment, the involvement of 2 reviewers was considered sufficient to ensure consistency and methodological rigor.

A qualitative synthesis was conducted using the structured qualitative content analysis by Kuckartz and Rädiker [20], as recommended by Levac et al [21]. Thematic categories emerged through an iterative process: (1) deductive mapping of initial categories from the research questions (eg, “leadership identity”), (2) inductive coding of all publications to identify recurring patterns, and (3) aggregation of overlapping patterns into the final thematic structure through team consensus. Category definitions, anchor examples, and iterative coding refinement ensured analytical rigor. Figure 1 [20] illustrates the process.

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Ethical Considerations

As this study was a scoping review of published literature, it did not involve human participants, and therefore, ethics approval was not required.

Results

Publication Selection

The database search conducted in May 2025 yielded 1293 records: 106 (8.2%) from MEDLINE (via PubMed), 818 (63.3%) from Google Scholar, 72 (5.6%) from LIVIVO, 89 (6.9%) from ScienceDirect, 1 (0.1%) from the Cochrane Library, 123 (9.5%) from Europe PMC, and 84 (6.5%) from EBSCO. After removing duplicates and screening titles and abstracts, of the 1293 publications, 101 (7.8%) underwent full-text review. Applying the predefined eligibility criteria resulted in 40 publications included for in-depth analysis. No unresolved disagreements occurred during the selection process. The publication selection process is illustrated in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart (Figure 2 [22]).

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Main Characteristics of the Included Publications

The 40 included publications originated from the United Kingdom (n=26, 65%) and Australia (n=14, 35%) and covered the period from 1991 to 2017. Most publications were in English (n=39, 97.5%), with 2.5% (n=1) in German. Study designs comprised qualitative, quantitative, mixed methods, and conceptual approaches. The publications examined how professional roles, leadership, collaborative practices, organizational structures, and reflective processes shape nursing practice. Publication characteristics are summarized in Table 1.

Core Elements of NDUs

Overview

The literature consistently described NDUs as operating across 3 interrelated levels: individual, interpersonal, and organizational (Figure 3). These levels structure descriptions of professional development, collaboration, and organizational learning. This framework emerged inductively from the data through iterative coding of all included publications, reflecting patterns observed in the literature rather than a pre-established theoretical model.

Several characteristics identified at these levels—such as competence development, participatory practices, and embedded learning structures—are discussed in the broader literature on organizational readiness for change and digital transformation. While explicit engagement with digital technologies was seldom reported in the included publications, the identified capacities and practices indicated potential enablers for adopting digital tools and supporting digital innovation in nursing.

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Individual Level: Competence, Identity, and Resilience

NDUs were described as settings in which professional roles, leadership capabilities, and personal resilience are addressed. Activities included reflective practice, integration of ethical and evidence-based principles, and adaptation to evolving clinical demands. Table 2 maps publications contributing to individual-level components.

A clear understanding of professional roles, the integration of personal and shared philosophies of practice, and the development of self-efficacy and professional coherence were described as central elements of role and identity development [23,43]. Several publications highlighted intrinsic motivation and self-awareness in relation to personal growth and competence development [23].

Reflective practice was described as integrating ethical considerations, clinical judgment, and personal values into everyday care [43]. The literature reported structured forms of reflection, including written protocols, workshops, and reflective models, which were used to support critical inquiry into values, roles, and routines and articulate emerging professional identities within NDUs [33,34]. Modular training programs addressing clinical and research competencies were described across several publications and commonly linked to supervision and assessment processes [10].

Leadership identity was addressed in a subset of publications (7/17, 41.2%), which described clinical leaders as taking on facilitative and innovative roles and as supporting team processes. At the same time, challenges such as variable staff motivation and uncertainty regarding the NDU concept were reported [8,23]. Leadership support structures, including mentorship, networking, and formal development programs, were described in relation to team support during periods of change [31].

Several publications (5/17, 29.4%) described NDUs as contexts in which professional resilience is addressed, particularly in relation to iterative development processes and challenges associated with time constraints, emotional labor, and organizational obstacles [23,43]. Staff perceptions reported in the literature included high expectations, impatience for visible progress, and difficulties adjusting to evolving roles [43].

Across the included publications, reflective practice, continuous competence development, and leadership identity were recurrently described at the individual level. While the reviewed publications did not explicitly address digital competencies or digital practices, they outlined professional capacities—such as critical reflection, adaptability, and role clarity—that are frequently discussed in the broader literature in relation to organizational and technological change.

Interpersonal Level: Collaboration and Shared Vision

Across the included publications, NDUs were described as fostering participatory and inclusive cultures, supporting collaborative practices, and facilitating the development of shared visions and unit identities. Several publications reported that team interactions and decision-making processes emphasized principles of patient-centered care. Table 3 summarizes the publications contributing to the interpersonal-level subcategories.

Participatory and inclusive cultures were described as involving collaboration, shared decision-making, and ongoing improvement [32,53]. Publications reported that traditional nursing boundaries were sometimes transcended, enabling staff to engage in collective reflection, articulate unit philosophies, formulate action plans, and evaluate progress. Bottom-up approaches, including staff participation as coresearchers, were described in relation to collective ownership of practice change [32,45].

Collaborative practices and support networks were described as developing through mentorship and interdisciplinary teamwork, supporting staff in addressing challenges and continuing professional growth [23,49]. Strategic planning processes were reported to clarify team needs, anticipate obstacles, and link practice activities to evidence generation. Several publications described collaborative planning as fostering shared ownership and a collective vision for change [54]. Partnerships with academic institutions were reported to support training, research, and innovation [9,49].

Shared vision and unit identity were described as contributing to team coherence. Staff involvement in defining the NDU’s purpose, intended outcomes, and guiding principles was frequently reported [43,45,54]. The literature highlighted that shared philosophies of practice grounded in clinical realities and staff perspectives can reinforce team coherence and collective identity [43]. Exposure to experiences from other NDUs was reported to help manage expectations, facilitate collective problem-solving, and support ongoing development [44].

Patient-centered care was described as emphasizing trust, sensitivity, shared decision-making, and patient autonomy [8,43]. Evidence-based approaches were reported across NDUs, although implementation varied. Some publications reported extensive evaluation frameworks, whereas others focused on routine questioning and evidence-informed decisions [9]. Integration with relational care models such as primary nursing was described as an example of applying patient-centered principles in practice [8,43,53].

Across the reviewed publications, participatory cultures, collaborative planning, and shared decision-making were consistently reported as central interpersonal characteristics of NDUs. Although digital technologies were not explicitly addressed, these interactional patterns reflected approaches commonly discussed in the broader literature for co-designing and implementing complex interventions, including digital tools in health care settings.

Organizational Level: Framework, Change, and Learning

At the organizational level, NDUs were described as involving frameworks and structures that support practice development, change, and learning. Several publications highlighted overarching philosophies of practice, structured role development, and embedded evaluation systems as recurring elements. Table 4 summarizes the publications contributing to the organizational-level subcategories.

Philosophies of practice were described as providing frameworks of values, guiding principles, and standards that inform unit culture and practice [51]. Role development and organizational change were reported in relation to clarifying responsibilities, establishing decision-making processes, and supporting structural adjustments to avoid duplication and facilitate innovation [33,53].

Management of resources and change was described in the literature as including strategies to allocate time and materials, address resistance, and respond to operational pressures [49,53]. Evaluation and learning systems were reported to support reflective processes, facilitate improvements based on evidence, and connect practice to research and learning across disciplines [50,51,53]. Iterative development processes using structured strategies, participatory approaches, and strategic planning were described as approaches to respond to local needs while maintaining growth and improvement [10,11,29,50,51,53,54].

Embedded evaluation systems and iterative learning cycles were frequently reported as integral to NDU development. While these publications did not specifically address digital innovations, the described organizational infrastructures and learning mechanisms were consistent with approaches that are widely considered relevant for implementing and adapting complex interventions, including digital tools in health care settings.

Development and Implementation Process of NDUs

NDU development was reported as a multiyear, iterative process involving alignment of organizational structures, professional identity formation, and collaborative teamwork (Figure 4). Implementation evolves through cycles of reflection, strategic planning, practice-based experimentation, and evidence-informed evaluation grounded in a shared philosophy of practice that incorporates diverse staff perspectives and emphasizes holistic, patient-centered nursing [8,11,43,55].

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Implementation practices reported included client-centered care, nurse empowerment, and evidence-based routines [11,29]. Adaptations to local cultural, staffing, and regional conditions were described as supporting flexibility while maintaining core principles [49]. Staff engagement in data collection and analysis was reported to facilitate learning, support innovation uptake, and foster interdisciplinary thinking [50,51,53].

Challenges reported in the literature included staff turnover, limited acceptance by other health care professionals, high workloads, and gaps between theory and practice. Sustained leadership support and team commitment were described as important factors for maintaining NDU development over time [28].

Discussion

Core Characteristics of NDUs: A Foundation for Innovation

This scoping review mapped the structural and procedural characteristics of NDUs across individual, interpersonal, and organizational levels based on 40 international publications from the United Kingdom and Australia spanning 1991 to 2017. The findings confirm NDUs as multilevel, practice-based innovation spaces that foster professional development, collaborative cultures, and structured learning. These characteristics are not merely descriptive but reflect a coherent framework for supporting continuous improvement and evidence-informed practice.

At the individual level, NDUs are not merely settings for skill development but spaces for professional identity formation. The emphasis on reflective practice, leadership identity, and resilience suggests that NDUs support nurses in navigating complex clinical realities and evolving roles [10,23,33,43]. This process fosters psychological safety and self-efficacy—conditions that are increasingly recognized as essential for adaptive learning and innovation [56,57].

At the interpersonal level, NDUs function as cocreation platforms. The documented practices of shared decision-making, collaborative planning, and peer learning indicate a culture where knowledge is coproduced rather than imposed in a top-down manner [23,32,45,50]. This participatory orientation aligns with contemporary models of human-centered design and may reduce resistance to change—especially when introducing new technologies [16,58].

At the organizational level, NDUs are defined by structured learning cycles and embedded evaluation systems. Their iterative development process—rooted in reflection, experimentation, and feedback—mirrors established frameworks for organizational change [10,11,29,50,51,53]. This suggests that NDUs are not static entities but dynamic systems capable of continuous adaptation, a quality that is critical in rapidly evolving digital health environments [59,60].

Crucially, these characteristics are not isolated features but interconnected processes that reinforce one another. For example, individual reflection is amplified through team dialogue, team collaboration is guided by organizational frameworks, and organizational learning is sustained through individual and team engagement. This synergistic interplay positions NDUs as potential organizational incubators for innovation—although the extent to which they support digital transformation remains to be empirically tested.

Implications for Digital Transformation: A Cautious Interpretive Framework

While the included publications did not explicitly address digital technologies, the identified characteristics of NDUs suggest potential conditions that may support digital transformation in nursing. This section presents these connections as interpretive transfer hypotheses—plausible inferences based on conceptual alignment with known prerequisites for successful technology adoption.

NDUs may support digital transformation by fostering the professional and organizational capacities required for technology integration. For instance, reflective practice and continuous competence development—core to NDUs—can help nurses critically engage with digital tools, align them with ethical and clinical values, and integrate them meaningfully into care routines [33,34,43]. This supports the development of a digital professional identity where technology use is not seen as an external imposition but as an extension of nursing expertise [5,6,61,62].

The participatory culture of NDUs—characterized by shared decision-making, co-design, and peer learning—may reduce resistance to change and improve the fit of digital tools with clinical workflows [16,63-65]. By involving nurses in the design, testing, and evaluation of digital solutions, NDUs could serve as safe spaces for experimentation, where failures are reframed as learning opportunities [15,16]. This aligns with human-centered design principles and may enhance user acceptance and long-term sustainability [58].

At the organizational level, the structured frameworks for change management, iterative evaluation, and evidence-based practice in NDUs mirror the adaptive and learning-oriented processes needed for digital implementation [7,15,50,51]. The emphasis on feedback loops, strategic planning, and continuous improvement provides a robust infrastructure for managing the uncertainties and disruptions associated with digital innovation [60,66].

However, these implications must be interpreted with caution. The evidence base is limited in both temporal and technological scope: most included studies (39/40, 97.5%) were published before 2007, and none explicitly examined digital tools or competencies. Therefore, the claim that NDUs “support digital transformation” should not be understood as a proven causal relationship but rather as a plausible hypothesis that requires empirical validation in contemporary digital contexts.

Strengths and Limitations

This review’s strength lies in its systematic and transparent approach guided by established frameworks (Joanna Briggs Institute and PRISMA-ScR guidelines). The inclusion of diverse study types and international literature provides a broad understanding of NDU development and implementation. The independent screening and iterative data extraction process enhances rigor, transparency, and generalizability.

Several limitations must be acknowledged. First, while this review focused on publications explicitly labeled as “Nursing Development Unit,” it is possible that related concepts or alternative labels (eg, “Clinical Development Unit” and “Practice Development Unit”) exist in more recent (digital) nursing literature and may share similar mechanisms for supporting innovation and technology adoption. Although supplementary searches were conducted, our decision to anchor the database search to the exact phrase “Nursing Development Unit” may have led to missed publications describing comparable models under different terminology. Consequently, our synthesis should be interpreted as mapping the literature that explicitly self-identified as “NDU” rather than exhaustively capturing all international Practice Development Unit models. Second, the age of the included publications (mostly published before 2007) limits the direct applicability of the findings to current digital health landscapes, where technologies such as artificial intelligence, real-time monitoring, and interoperable electronic health records are increasingly central. Third, the lack of outcome evaluations and the heterogeneity of definitions and implementation contexts reduce the comparability of the findings. Fourth, the exclusion of non–English- and non–German-language publications may have introduced language bias. Fifth, the absence of a formal quality appraisal—typical in scoping reviews that prioritize conceptual mapping over effect estimation—limits the comprehensive assessment of the robustness of individual findings.

These limitations underscore the need for future research to explicitly link NDU principles with digital transformation using contemporary case studies, mixed methods designs, and outcome-focused evaluations.

Conclusions: A Foundation for Future Inquiry

This review demonstrates that NDUs are structured environments that promote professionalization, collaboration, and learning through multilevel processes. While the evidence base does not directly support claims about digital transformation, the core characteristics of NDUs—reflective practice, participatory cultures, and iterative learning—may offer enabling conditions for the adoption and integration of digital technologies in nursing.

However, these connections remain theoretical and require empirical testing. Future research should investigate how NDUs can be adapted to support digital innovation, with a focus on digital competencies, workflow integration, ethical considerations, and staff well-being. Only through such research can we determine whether NDUs are indeed a viable foundation for digital transformation in nursing or whether new models are needed to meet the demands of the digital age.