Nineteen CDIFs and needs related to feeling safe and DTs (see Fig. 2) were developed based on 127 main and 222 sub-categories (76.59% of the subcategories were related to emotional safety, and 23.41% were related to psychological safety) (see Additional file 3). Each CDIF was multifaceted in its dimensions and addressed one or several levels: the microlevel (healthcare recipient/provider and DT), mesolevel (community/organizational), and macrolevel (system/society).

Fig. 2

Core dimensions of IFs in the context of perceived safety and DTs in healthcare. Legend: larger black spheres = mostly addressed CDIFs; smaller lighter spheres = rarely addressed CDIF; bottom layer = level of digital technology; left layer = healthcare recipient level; right layer = healthcare provider level; upper layer = system/society level; and rear layer = community-organizational level)

Most of the CDIFs (n = 15) were primarily at the healthcare recipient level, and the DT, community-organizational, and system/society levels were considered nearly equally. Only two CDIFs (‘organizational culture’; and ‘experiences and routines’) were on the healthcare provider and considered the organizational level and individual experiences. Several CDIFs at the healthcare recipient/provider level were directly related to previous experience and user characteristics, as well as to the DT. A large number of CDIFs were related to the community-organizational level, as they represent community-related issues or effects before and after the use of DTs. A few CDIFs could be assigned to the system-society level, which involves fundamental societal uncertainties that may have an impact on the perceived safety before the introduction of DTs.

Most of the CDIFs were also related to needs that were described for both healthcare recipients and providers, e.g., receiving support [52] (see Additional file 4). Not receiving necessary support negatively influences perceived safety [48]. Some CDIFs were not addressed such as ‘trust’, ‘data security’, ‘transparency’, ‘demands on the users’, ‘financial uncertainties’, and ‘organizational culture’. Generally, the needs were categorized into three main areas: needs for the stakeholders themselves (e.g., healthcare recipients expressed the desire for anonymity or autonomy in decision-making [36, 55]); needs for DTs (e.g., DTs should have different features depending on individual needs, better monitoring [48] or special features for emergency situations [54]); and needs for the environment (e.g., creating the right conditions for DT implementation [38, 42, 47], including organizational and political support [42]).

Core dimensions of influencing factors, most frequently addressed by publications

Nineteen CDIFs were identified by publications at varying frequencies. They could be divided into three groups: ‘mostly addressed’ n = 16–24 (50–75%), ‘moderately addressed’ n = 3–14 (9–44%), and ‘rarely addressed’ n = 1–2 (3–6%).

Four of the 19 CDIFs, ‘noticeable changes in care’, ‘digital (health) literacy’, ‘design and appearance’, and ‘need-oriented technology’, were mostly addressed by publications and had both positive and negative influences on feeling safe. The most addressed CDIF, ‘noticeable changes in care’, covered the perception of changes in people’s care and its association with perceived safety on several levels. This reflected perceived health improvements, such as more efficient access to care [6, 7, 40] or resolved communication problems by DTs [3, 41, 56]. In contrast, a fear of deterioration by DTs [36, 38] or expected reduced access for certain patient groups because of an inability to use DTs could lead to a loss of perceived safety [38, 42].

The second most frequently addressed CDIF, ‘digital (health) literacy’, reflected nearly all levels of healthcare recipients and providers and DTs at the community-organizational, system, and society levels. It contained several aspects of DT affinity [39] and knowledge [43], such as the manner in which (needs-based) information is communicated [43] and dealing with DTs are trained [60]. In this context, high DT-related requirements in society seem to be relevant for people who are particularly unfamiliar with technical devices [9, 52], whereas the limited capabilities of healthcare recipients or providers can be a barrier to perceived safety [38, 42].

The third most frequently addressed CDIF, ‘design and appearance’ (DT/organizational level), contained predominantly positive IFs of feeling safe, e.g., the empowerment of healthcare recipients working with DTs [12, 37, 43]. Notably, the human appearance of robots was viewed differently. For some healthcare recipients, a high degree of humanity can lead to increased perceived safety; for others, the opposite is true [3]. Additionally, the visibility or invisibility of the DTs can lead to an opposing perceived safety [3, 6, 44]. Different views on feeling safe were also found regarding the fourth most often addressed CDIF, ‘need-oriented technology’, which stresses the importance of DTs that are adapted to the needs, expectations, and values of users [6, 9, 54]. It was emphasized that it is essential to involve the users of DTs as co-designers [3] to ensure user-specific DTs [2, 43]. The relevance of adapting DTs to an individual’s disease needs was stressed to avoid reduced safety feeling [46].

Core dimensions of influencing factors focusing on the healthcare recipient and other levels

The CDIF ‘control’ (recipient and organizational level) played a crucial role from healthcare recipients’ point of view, as the opportunity to control the DT to stop it [55], the control over one’s own data [3, 7, 45] or the supervision of the DT by healthcare professionals [3] are mentioned positively. Restrictions on data access rights for healthcare providers resulted in minor control of health data and hence lower perceived safety at the recipient and system levels [45]. Similarly, the CDIFs’ ‘transparency’ (e.g., data processing [3, 9] and data transparency [7, 45, 46]) and ‘degree of privacy’ (e.g., protection of privacy [48] and a risk–benefit analysis [54]) were associated with the healthcare recipient and organizational levels. ‘Transparency’ was found to hinder perceived safety, mainly because unclear data transfer processes caused confusion [7, 40]. The ‘degree of privacy’ was important for healthcare recipients and for social debates [47]. The CDIFs ‘data security’ and ‘demands on the users’ were both identified as inhibiting perceived safety since fundamental societal concerns about data security were expressed [9, 41, 45]. Users experience high political and societal demands because they are expected to know how to use DTs [9]. Overall, from the point of view of healthcare recipients, DT develops rapidly, which can lead to a fear of anticipated excessive demands and negative feelings such as stress or anxiety about using new DTs [52], especially among older people [9].

Core dimensions of influencing factors, emphasizing healthcare provider, and other levels

Four CDIFs at the healthcare provider level have rarely been addressed in publications but have had an impact on the perceived safety. ‘Financial uncertainties’ are uncertainties about the financial remuneration of digital services via ‘providers’ [36, 42]; ‘status of scientific knowledge’ is related to unresolved scientific questions that can create ambiguity for healthcare recipients in therapies [52, 60] addressed at the system/society level; ‘organizational culture’ refers to healthcare providers feeling safer and testing new DTs in a positive organizational culture where initial mistakes regarding DT use are tolerated [53]; and ‘experiences and routines’, make healthcare providers feel more confident in using DTs at an individual level and allow them to develop a safety feeling due to exercises and routines [38, 43].

Relationships among the core dimensions of influencing factors

Although only a few relationships among the CDIFs were explicitly mentioned, this did not necessarily mean that none existed. For example, ‘need-oriented technology’ is related to ‘health and psychosocial conditions’. The physical conditions and illnesses of healthcare recipients were described as having an impact on perceived safety regarding DT use [3, 43, 50] for both healthcare recipients and providers [42]. Hence, considering needs is also related to considering health status and the appropriate selection of DTs [2, 43]. ‘Support’ and ‘trust’ could both be similar ‘digital (health) literacy’ considering the healthcare recipient and provider levels nearly evenly. ‘Support’ (e.g., the presence of healthcare providers during DT use) [3, 43] and the opportunity to receive efficient support if required [6, 9, 44] were more directed to the healthcare provider level, suggesting that a lack of support for technical problems can restrict the perceived safety [48]. The CDIF ‘trust’ included, for example, increased trust by DTs [3, 40], the perception of DTs as ‘cold and distant’ [2], and limited general openness of healthcare recipients towards DTs [38].

‘Noticeable changes in social life’ and ‘noticeable changes in care’ both focus on perceived changes due to DT use. Healthcare recipients often perceive a change in their social life and environment due to the use of DTs positively affects their feeling of safety [6] because DTs enable individuals to stay at home [40, 47, 60] or create a safe space at home [40, 55, 57]. This point was made only by the healthcare recipients and their relatives. In contrast, the CDIF ‘noticeable changes in care’ were also mentioned by healthcare providers, such as improved or faster care via DTs [6, 41, 42]. Inhibiting factors were also noted by healthcare providers and recipients, such as anxiety about the loss of human interaction [39, 43, 60]. This can be interpreted as a perceived deterioration of care and could lead to an inhibited safety feeling [43].

Core dimensions of influencing factors related to DTs

All CDIFs covered by needs were related to one or more of the eleven types of DTs, and none were addressed by all types, such as robotics in healthcare (n = 3) [3, 39, 59]; telehealth (remote healthcare by telecommunication, e.g., telemedicine, telenursing, telecare) (n = 10) [12, 38, 40, 42,43,44,