Abstract
Abstract
Background
Implementing digital health technologies is challenging because implementation is shaped by interacting technical, organizational, professional, and contextual factors. Although implementation frameworks such as the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework support understanding this complexity, translating them into practical tools for routine implementation remains difficult.
Objective
This study aimed to develop and evaluate the Nursing Implementation Complexity Tool (NICT), a theory-informed implementation reflection tool designed to operationalize the NASSS framework and support implementation-related reflection and decision-making for digital technology implementation in nursing.
Methods
This Design Science Research study combined 4 iterative development phases with a convergent mixed methods evaluation. The development of the NICT was informed by an umbrella review, 3 mixed methods case studies, and the German adaptation of the NASSS Complexity Assessment Tool (NASSS-CAT-D). Following iterative development and expert review, the NICT was evaluated through workshops with nursing professionals, prospective nursing leaders, and nursing students. A summative evaluation included an online survey (28 participants completed the questionnaire) and think-aloud interviews (8 participants). Quantitative data were analyzed descriptively, qualitative data were analyzed using qualitative content analysis, and findings were integrated during interpretation.
Results
The NICT comprises 3 complementary components: a guideline, a visual canvas, and a pocket card organized around 4 reflection domains. Across the formative and summative evaluations, participants consistently perceived the NICT as a useful and well-structured implementation reflection tool. In the summative evaluation, 24 of 26 (92.3%) participants agreed that the NICT had a logical structure, and 24 of 26 (92.3%) agreed that it supported structured reflection on implementation-related factors. Qualitative findings showed that the NICT facilitated discussion of implementation determinants, stakeholder perspectives, and contextual influences while also highlighting the importance of practical guidance, examples, and facilitation to support its application.
Conclusions
The NICT supports nursing professionals and other implementation stakeholders in recognizing, discussing, and addressing implementation complexity through structured reflection. Rather than reducing complexity itself, it facilitates implementation-related reflection and informed decision-making. 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.