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.

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.

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

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]).

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.

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].

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].

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.

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.

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.

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.