How Digital Stress and eHealth Literacy Relate to Missed Nursing Care and Willingness to Use AI Decision Support

Background: Digitalization and artificial intelligence-supported clinical decision support systems (AI-DSS), defined here as tools that generate patient-specific alerts, risk estimates, prioritization prompts, documentation suggestions, or related recommendation outputs intended to support rather than replace professional nursing judgment, can improve clinical decision-making, yet they may also amplify technostress and burnout, with downstream effects on missed nursing care and implementation readiness. Methods: We surveyed 239 registered nurses from a tertiary-care hospital in Timișoara, Romania (January-March 2025), including critical care (n = 60) and general wards (n = 179). Measures included a 15-item technostress scale, eHEALS, Maslach Burnout Inventory-Human Services Survey (MBI-HSS), Safety Attitudes Questionnaire (SAQ) teamwork and safety climate subscales, a 10-item missed nursing care inventory, and a six-item AI-DSS acceptance scale reflecting perceived usefulness, trust, and stated willingness to use such tools if available as an attitudinal readiness outcome rather than as routine observed use. Multivariable regression, exploratory mediation models, cluster analysis, and exploratory ROC analysis were performed. Results: Higher technostress was associated with higher emotional exhaustion (r = 0.52) and more missed care (r = 0.41), whereas eHealth literacy correlated with higher AI-DSS acceptance (r = 0.35) and lower technostress (r = -0.34). In adjusted models, technostress (per 10 points) was associated with higher missed care (β = 0.28, p < 0.001) (equivalent to 0.14 points per 5-point increase) and higher odds of low AI-DSS acceptance (OR = 1.38, p = 0.001), while eHealth literacy was associated with lower odds of low acceptance (OR = 0.71 per 5 points, p < 0.001). Burnout and the safety climate statistically accounted for approximately 35% of the technostress-missed care association. Three workflow phenotypes were identified, with the high-strain/low-literacy cluster showing the most missed care (3.5 ± 1.8) and the lowest AI acceptance (19.7 ± 5.2). An exploratory in-sample ROC model for intention to leave achieved an AUC of 0.82. Conclusions: Higher technostress clustered with worse nurse well-being, more care omissions, and lower AI-DSS acceptance, whereas eHealth literacy appeared protective. Interventions combining digital skills support, usability-focused redesign, and a stronger safety climate may reduce missed care and support safer AI implementation.