Legal Literacy in Clinical Nursing Practice: A Walker and Avant Concept Analysis

Comments 1: The introduction addresses a relevant topic for the study. However, the reference support in this section should be revised more carefully, because some citations do not appear to match the statements they are intended to support. In particular, the methodological grounding of the concept analysis should be strengthened: the key Walker and Avant source is cited as reference 10, but its accessibility and bibliographic presentation should be checked. References 18 and 19 do not clearly justify the methodological approach described in the manuscript. Reference 19, for example, appears to report an online survey rather than to provide methodological support for concept analysis. The authors are encouraged to align citations more precisely with the text, especially in the introduction and methods sections, and to cite appropriate methodological sources for both Walker and Avant’s concept analysis and the content analysis procedure.

Response 1: Thank you for this important comment. We agree that the citation support in the Introduction and Methods required more precise alignment with the statements being made. In the revised manuscript, we checked the citation logic in the Introduction and Methods and clarified the function of each methodological reference. Walker and Avant’s book is now used as the principal source supporting the concept analysis method and is presented with a complete bibliographic entry. Other concept-analysis papers are no longer used to justify the methodological framework itself; instead, they are used only to demonstrate that concept analysis has been applied to complex and context-dependent nursing concepts. We also strengthened the description of the content analysis procedure in the Methods section and added appropriate methodological support for the analytic process, including the unit of analysis, coding procedure, category development, coding consistency, and analytic trustworthiness. These revisions can be found in the Introduction and in Sections 2.1 and 2.4 of the revised manuscript.

Examples of revised text:

“Concept analysis provides a systematic approach for addressing such conceptual ambiguity by examining how a concept is used across the literature, identifying defining attributes, constructing illustrative cases, and delineating antecedents, consequences, and empirical referents [21]. This approach has been applied to clarify complex and context-dependent nursing concepts [19,20].”

“Qualitative content analysis was used to identify conceptual meanings and defining attributes. The unit of analysis was a meaning unit related to the definition, use, attribute, antecedent, consequence, or empirical referent of legal literacy and adjacent concepts.”

Comment 2: The selected design is appropriate in principle, but its methodological presentation is not sufficiently clear. The Walker and Avant eight-step approach should be described more explicitly, and the citations used to support the design should be revised for accuracy and relevance.

Response 2: Thank you for this helpful suggestion. We retained Walker and Avant’s concept analysis method because it is appropriate for clarifying a concept that is widely used but insufficiently defined in clinical nursing practice. To improve methodological clarity, we revised Section 2.1 to explicitly describe Walker and Avant’s eight steps and to explain how each step was applied in the present study. We also revised the citations supporting the design so that Walker and Avant’s original methodological source is the main reference for the framework. The revised text is located in Section 2.1, Study design.

Examples of revised text:

“The analysis followed the eight steps proposed by Walker and Avant: selecting the concept, determining the aims of the analysis, identifying uses of the concept, determining defining attributes, constructing a model case, identifying additional cases, identifying antecedents and consequences, and defining empirical referents.”

“In the present study, ‘legal literacy in clinical nurses’ was selected as the target concept. The purpose of the analysis was to clarify its conceptual boundaries and to distinguish it from adjacent concepts, including legal knowledge, legal awareness, legal cognition, and medical ethics.”

Comment 3: Methods: methodological transparency remains insufficient in several important respects. In particular, the manuscript should report the exact search syntax, database-specific search strategies, and the screening process for the 56 included sources in greater detail. In addition, although the authors state that content analysis was used, the methodology of this analysis is not described clearly enough. The manuscript does not adequately explain the unit of analysis, the coding procedure, the development of categories, or how analytic trustworthiness and coding consistency were ensured, all of which are expected elements in qualitative content analysis reporting. It would also be helpful to clarify whether any formal quality appraisal of included sources was undertaken or, if not, why this was considered not applicable in the context of concept analysis. The use of independent dual-reviewer coding is a strength, but the process for resolving disagreements should be described more explicitly.

Response 3: We appreciate this detailed methodological comment and have substantially revised the Methods section in response. First, we revised Section 2.2 to describe the two-stage literature search and the rationale for distinguishing the primary search from the supplementary conceptual search. We reported the representative search syntax in the main text and provided complete database-specific search strategies in Supplementary File 1. Second, we revised Section 2.4 to report the full screening process for the 56 included sources, including the number of records initially identified, duplicates removed, title/abstract screening, full-text assessment, exclusion reasons, and final inclusion. Third, we clarified the content analysis process by specifying the unit of analysis, data extraction items, independent dual-reviewer coding, code grouping, category development, mapping to Walker and Avant’s components, and procedures used to ensure analytic trustworthiness. Fourth, we added a dedicated section explaining why formal methodological quality appraisal was not undertaken and why conceptual relevance assessment was more appropriate for this concept analysis. Finally, we clarified that disagreements in screening, coding, or category development were resolved through discussion and, when necessary, adjudicated by a third reviewer. These revisions can be found in Sections 2.2, 2.3, 2.4, 2.5, and Supplementary File 1.

Examples of revised text:

“The database search initially identified 1,768 records, including records from Wanfang (n = 276), VIP (n = 401), CNKI (n = 243), CINAHL (n = 285), Cochrane Library (n = 7), Embase (n = 234), PubMed (n = 159), and Web of Science (n = 163). After removing 801 duplicate records, 967 records remained for title and abstract screening.”

“Two reviewers independently coded the extracted meaning units. Similar codes were compared and grouped into preliminary categories, which were refined through constant comparison across theoretical, empirical, and measurement-based sources. The final categories were then mapped onto Walker and Avant’s analytical components, including defining attributes, antecedents, consequences, and empirical referents.”

“A formal methodological quality appraisal was not conducted because this study was a concept analysis rather than an evidence synthesis.”

Comment 4: The results are structured and generally consistent with Walker and Avant concept analysis. However, their transparency is weakened by the limited methodological description of how the categories were generated through content analysis.

Response 4: Thank you for this comment. We agree that the Results section could only be fully transparent if the Methods clearly explained how the final categories were generated. Accordingly, we expanded Section 2.4 to describe the content analysis procedure in detail. We also clarified that meaning units were extracted from definitions, conceptual descriptions, measurement dimensions, and practice-related descriptions; that these meaning units were independently coded; that similar codes were grouped into preliminary categories; and that the final categories were mapped to Walker and Avant’s analytical components. In addition, we added a supplementary table illustrating the pathway from meaning units to initial codes, preliminary categories, and final defining attributes. This was done to make the generation of the three defining attributes more transparent to readers.

Examples of revised text:

“The unit of analysis was a meaning unit related to the definition, use, attribute, antecedent, consequence, or empirical referent of legal literacy and adjacent concepts.”

Comment 5: The conclusions are broadly aligned with the reported results, and the proposed operational definition is potentially useful. However, their strength is limited by the insufficient methodological explanation of how the final conceptual synthesis was derived through content analysis.

Response 5: Thank you for this helpful observation. We agree that the strength of the conclusion depends on a transparent explanation of how the conceptual synthesis was derived. As described in our response to Comments 3 and 4, we revised the Methods section to explain the data extraction and content analysis process in greater detail. These changes clarify how the three defining attributes, antecedents, consequences, empirical referents, and operational definition were derived from the included sources. We also reviewed the Conclusion to ensure that it does not overstate the findings and remains aligned with the results of the concept analysis. The revisions strengthen the methodological basis for the final operational definition.

Examples of revised text:

“Based on an analysis of 56 papers, the study clarified the conceptual boundaries of legal literacy in clinical nurses, identified its defining attributes, and articulated an internal structure that moves from cognitive foundation, to value orientation, and then to situational practice.”

“The findings provide a conceptual and structural foundation for subsequent measurement development, targeted legal education, and evidence-based nursing management.”

Comment 6: Figure 1 is useful for summarizing the study selection process, although the text within the flow diagram could be slightly enlarged to improve readability in the final publication version.

Response 6: Thank you for this practical suggestion. We revised Figure 1 to improve readability. The text within the flow diagram was enlarged, and the figure was checked to ensure that all numbers correspond exactly to the screening process reported in Section 2.4. We also corrected minor layout issues in the figure, including removal of the duplicated final inclusion box and removal of repeated database text in the top box. The revised Figure 1 is now clearer and more suitable for publication.

Examples of revised text:

“Figure 1. Literature screening process and results for the concept analysis.”

Comment 7: A table or figure illustrating the content analysis process would strengthen transparency and help readers understand how the final attributes were derived.

Response 7: Thank you for this valuable suggestion. We agree that a table illustrating the content analysis process would improve transparency. We have added a supplementary table showing the analytic pathway from representative meaning units to initial codes, preliminary categories, and final defining attributes. This table is intended to help readers understand how the final attributes—normative understanding, value internalization oriented toward rights and responsibilities, and law-based situational practice—were derived through content analysis. We also added a cross-reference to this supplementary table in Section 2.4.

Examples of revised text:

“A table illustrating the content analysis process from meaning units to initial codes, preliminary categories, and final defining attributes is provided in Supplementary File 3.”

3. Response to Comments on the Quality of English Language

Point 1: The English could be improved. Minor copyediting may still be useful during production for consistency, hyphenation, and a few long sentences.

Response 1: Thank you for this comment. We have carefully edited the manuscript to improve readability, consistency, punctuation, hyphenation, and sentence structure. We shortened several long sentences, removed unnecessary repetition, and revised the Introduction and Discussion sections to improve flow and clarity. We also checked terminology for consistency, including the use of “legal literacy,” “legal awareness,” “legal cognition,” “legal consciousness,” and “law-based situational practice.”

4. Additional Clarifications

In addition to the revisions described above, we checked the consistency between the flow diagram and the numerical reporting in the Methods section, standardized the reference format, translated Chinese-language references into English while retaining the indication “[in Chinese]”, and updated the Supplementary Materials statement to reflect the supplementary files cited

Comments 1: This is definitely publishable as something which will be valuable to the nursing profession. However, I think it could do with some attention to structure in the sense that the links between sections are almost non-existent so it is difficult to follow where we are in the article and what is coming next.

Response 1: Thank you for this encouraging and helpful comment. We agree that the manuscript needed clearer structural signposting. We revised the Introduction, the beginning of the Results section, and the opening of the Discussion to make the logic of the paper easier to follow. In particular, the revised manuscript now explicitly moves from the practical problem of legal accountability in nursing, to conceptual ambiguity, to the need for concept analysis, and then to the Results and Discussion structure.

In the Results section, we added a bridging explanation before distinguishing the related concepts, clarifying that these concepts are not entirely separate but are positioned along a continuum from factual knowledge, to subjective interpretation and value orientation, and finally to situated professional action. In the Discussion, we also revised the opening paragraph and Sections 4.1 and 4.2 so that they focus on interpretation and implications rather than repeating the Results.

“In this analysis, these concepts are not treated as entirely unrelated constructs. Rather, they are positioned along a conceptual continuum from factual knowledge, to subjective interpretation and value orientation, and finally to situated professional action.”

“The results represent a systematic conceptual structure that moves from cognitive foundation through professional value orientation to situational action capacity.”

Location in revised manuscript: Introduction; Results, Section 3.1; Discussion, Sections 4.1 and 4.2.

Comments 2: I was also wondering where the socio-legal literature referred to in line 234 was - there were no references and I did not see much of it or any of the legal writing on legal literacy in law cited. There is in fact a substantial literature both in the fields of access to justice and clinical legal education and the article might have profited from a comparison between nursing/medical understandings of legal literacy and those from within the legal field.

Response 2: Thank you for identifying this important issue. We agree that the earlier version did not sufficiently show where the socio-legal literature was being used. In the revised manuscript, we clarified the role of socio-legal literature in two ways. First, we added a supplementary conceptual search using “legal consciousness” to clarify the boundary between legal awareness and legal consciousness. This supplementary search was used for conceptual clarification and did not change the 56 sources included in the primary concept analysis. Second, we added and clarified legal-field sources on legal literacy to support the comparison between legal literacy as understood in law-related scholarship and legal literacy in the clinical nursing context.

We revised Section 3.1.2 to clarify that legal consciousness is a broader socio-legal construct, whereas legal awareness in this manuscript is used in a narrower professional healthcare sense. We also clarified that legal literacy in the legal field generally emphasizes understanding law, legal rights, procedures, and access to legal resources, while legal literacy in clinical nursing additionally requires role-specific translation of legal norms into legally accountable clinical action. This distinction is reflected in the revised discussion of legal awareness, legal consciousness, and the defining attribute of law-based situational practice.

“Legal awareness is closely related to, but should not be used interchangeably with, legal consciousness. In socio-legal scholarship, legal consciousness is a broader concept that concerns how individuals understand, experience, interpret, and position law in everyday social life. By contrast, legal awareness in the healthcare context is used here in a narrower professional sense, referring to nurses’ awareness of legal norms and their subjective endorsement of lawful practice, patient rights, professional responsibility, and procedural compliance.”

“Legal literacy additionally requires systematic normative understanding and the capacity to translate legal and professional norms into contextually appropriate clinical action.”

Location in revised manuscript: Methods, Section 2.2.2; Results, Sections 3.1.2 and 3.2.3; Discussion, Sections4.1 and 4.3; References related to legal literacy and socio-legal scholarship. Supplementary File 2 also summarizes how included sources contributed to conceptual boundaries, defining attributes, antecedents, consequences, and empirical referents.

Comments 3: More could also have been said on debates about how to integrate issues like law and ethics into nursing, drawing on analogous debates over the teaching of legal ethics.

Response 3: We appreciate this suggestion. In response, we strengthened the distinction and relationship between legal literacy and medical ethics and expanded the practical implications for nursing education. In Section 3.1.4, we clarified that law and ethics overlap in clinical practice but differ in their normative source, reasoning logic, and accountability mechanism. In Section 4.2, we revised the educational implications to emphasize that legal education should not be limited to didactic teaching of legal knowledge, but should include case-based ethical-legal discussion, reflective learning, and scenario-based training.

We also clarified that legal literacy and ethics are mutually reinforcing but not interchangeable: legal literacy emphasizes legally accountable practice, while medical ethics emphasizes morally justified practice. This directly addresses how law and ethics should be integrated into nursing education without conflating the two.

“Law establishes formally accountable normative boundaries and emphasizes rights, duties, procedures, evidence, and responsibility. Ethics provides moral justification and value-based reasoning and emphasizes broader aspirational standards, such as beneficence, dignity, compassion, fairness, and respect for persons. The two domains often overlap in clinical practice, but they differ in normative source, reasoning logic, and accountability mechanism.”

“Educational strategies should therefore include case-based ethical-legal discussion, reflective learning, and integration of legal obligations into professional value formation, rather than didactic teaching alone.”

Location in revised manuscript: Results, Section 3.1.4; Discussion, Section 4.2.

Comments 1: Methodology, Section 2.2.1 Databases and Search Terms: The reviewer noted that the search terms did not include ‘legal consciousness’, although this term was referred to under Legal Awareness as a closely related term in socio-legal scholarship. Given the broad view of the concept across law, public health and social sciences, the reviewer asked why this term was excluded from the search criteria.

Response 1: Thank you for this important observation. We agree that the relationship between legal awareness and legal consciousness needed to be addressed more transparently in both the search strategy and the conceptual analysis. In response, we revised the Methods section to add a supplementary conceptual search using the term “legal consciousness.” We clarified that this supplementary search was conducted to examine whether additional socio-legal literature was needed to support the conceptual boundary between legal awareness and legal consciousness. The search did not identify any additional sources that met the formal eligibility criteria for inclusion in the primary concept analysis; therefore, the final number of included sources remained 56.

We also clarified this point in the database-specific search strategy note in Supplementary File 1. The revised manuscript explains that the supplementary search was used for conceptual clarification rather than to redefine the scope of the primary empirical source pool.

“In addition to the primary search, a supplementary conceptual search was conducted using the term “legal consciousness.” This was added because legal consciousness is a broader socio-legal construct closely related to legal awareness, and it was relevant to clarifying the conceptual boundary between legal awareness and legal consciousness.”

“The supplementary search did not identify any additional sources that met the formal eligibility criteria for inclusion in the primary concept analysis. Therefore, the number of sources included in the primary analysis remained unchanged at 56.”

Location in revised manuscript: Methods, Sections 2.2.2 and 2.4; Supplementary File 1.

Comments 2: Section 3.1 Distinguishing Related Concepts: Line #214 needs citation.

Response 2: Thank you for noting this. We added and aligned citations in Section 3.1 to support the need to distinguish the target concept from adjacent and overlapping concepts. We also clarified that distinguishing related concepts is part of the Walker and Avant analytical process and that, in the present manuscript, legal knowledge, legal awareness, legal cognition, and medical ethics are positioned along a conceptual continuum rather than treated as completely unrelated constructs.

“Within Walker and Avant’s framework, distinguishing a target concept from adjacent and potentially overlapping concepts is an essential preliminary step, because it clarifies the conceptual boundaries that the defining attributes must subsequently delimit [21].”

Location in revised manuscript: Results, Section 3.1.

Comments 3: Section 3.1.2 Legal Awareness: The reviewer raised conceptual and citation-related concerns about the definition of legal awareness. In particular, the reviewer noted that one cited source appeared to discuss legal consciousness rather than legal awareness, and that the cited sources did not clearly support the multidimensional definition involving cognition, attitudes, evaluations, and affective orientation. The reviewer requested clarification of whether the source was being interpreted as addressing legal awareness specifically and suggested additional citation or justification.

Response 3: We appreciate this detailed comment. We revised Section 3.1.2 substantially to avoid using literature on the origin of legal consciousness as direct definitional support for legal awareness. In the revised manuscript, legal awareness is defined in a narrower healthcare-professional sense, and the discussion explicitly distinguishes it from legal consciousness as a broader socio-legal construct. We also clarified that the four elements—cognition, attitude, evaluation, and affective orientation—are used to explain how legal awareness extends beyond factual legal knowledge in the clinical nursing context.

Specifically, we now explain that the cognitive dimension concerns recognition of the relevance of law to clinical practice; the attitudinal dimension concerns acceptance of legal rules and procedures as professionally important; the evaluative dimension concerns judgments about the legitimacy and practical significance of legal requirements; and the affective orientation concerns respect for, trust in, or concern about law and legal accountability in care situations. This revision directly addresses the reviewer’s concern regarding the relationship between the theoretical description of legal awareness and its practice-oriented meaning in nursing.

“Legal awareness refers to healthcare professionals’ cognition, attitudes, evaluations, and affective orientation toward medical law, health regulations, institutional rules, and the normative order governing clinical practice. This construct extends beyond factual knowledge. Its cognitive dimension concerns whether nurses recognize the relevance of law to clinical practice; its attitudinal dimension concerns whether they accept legal rules and procedures as professionally important; its evaluative dimension concerns how they judge the legitimacy, necessity, and practical significance of legal requirements; and its affective orientation concerns their respect for, trust in, or concern about law and legal accountability in care situations.”

Location in revised manuscript: Results, Section 3.1.2.

Comments 4: The reviewer requested clearer distinction between legal awareness and legal consciousness, supported by relevant literature, and suggested citation for the sentence referring to the close relationship between these concepts.

Response 4: Thank you. We revised the relevant paragraph to explicitly distinguish legal consciousness from legal awareness. In the revised manuscript, legal consciousness is treated as a broader socio-legal construct concerning how individuals understand, experience, interpret, and position law in everyday social life. Legal awareness, by contrast, is used in a narrower professional healthcare sense, referring to nurses’ awareness of legal norms and their subjective endorsement of lawful practice, patient rights, professional responsibility, and procedural compliance. We added citations to support this distinction and explained why the distinction matters for the present concept analysis.

“Legal awareness is closely related to, but should not be used interchangeably with, legal consciousness. In socio-legal scholarship, legal consciousness is a broader concept that concerns how individuals understand, experience, interpret, and position law in everyday social life [26]. By contrast, legal awareness in the healthcare context is used here in a narrower professional sense, referring to nurses’ awareness of legal norms and their subjective endorsement of lawful practice, patient rights, professional responsibility, and procedural compliance [27].”

Location in revised manuscript: Methods, Section 2.2.2; Results, Section 3.1.2; Supplementary File 1.

Comments 5: The reviewer noted ambiguity in the manuscript’s internal use of legal awareness: the term was first theoretically framed as cognition, attitudes, evaluations, and affective orientation, but later described as nurses’ subjective endorsement of lawful practice, protection of patient rights, assumption of professional responsibility, and compliance with procedures. The reviewer asked how these elements align.

Response 5: We agree that the relationship between these two descriptions needed to be articulated more explicitly. We revised the section to clarify that the practice-oriented description is the clinical nursing application of the broader multidimensional structure of legal awareness. In other words, nurses’ endorsement of lawful practice, patient-rights protection, professional responsibility, and procedural compliance operationalizes the attitudinal, evaluative, and affective-orientational aspects of legal awareness in clinical nursing. We also clarified that legal awareness is one value-attitudinal component of legal literacy, but that legal literacy is broader because it also requires systematic normative understanding and law-based situational practice.

“For the present concept analysis, legal awareness is therefore understood as nurses’ subjective recognition and endorsement of lawful practice, protection of patient rights, assumption of professional responsibility, and compliance with clinical procedures, rather than as legal knowledge per se. Compared with legal literacy, legal awareness constitutes an important value-attitudinal component, but it remains insufficient on its own. Legal literacy additionally requires systematic normative understanding and the capacity to translate legal and professional norms into contextually appropriate clinical action.”

Location in revised manuscript: Results, Section 3.1.2; Abstract and Results wording revised to avoid implying that related concepts are entirely separate and unrelated.

Comments 6: The reviewer noted that the sentence stating “Compared with legal literacy, legal awareness constitutes one important component...” might lead readers to assume ambiguity between subcomponent and adjacent construct. The reviewer recommended explicitly clarifying whether the related concepts are components of legal literacy or adjacent but separate constructs.

Response 6: Thank you for pointing out this important conceptual issue. We revised Section 3.1 to make clear that the related concepts are not treated as completely unrelated constructs; rather, they are positioned along a conceptual continuum. Legal awareness is considered an important value-attitudinal component within the broader construct of legal literacy, but the term “legal awareness” as used in the literature is also an adjacent construct that requires conceptual distinction. To avoid the impression of complete separation, we revised the opening of Section 3.1 and the concluding paragraph of Section 3.1.2.

“In this analysis, these concepts are not treated as entirely unrelated constructs. Rather, they are positioned along a conceptual continuum from factual knowledge, to subjective interpretation and value orientation, and finally to situated professional action.”

Location in revised manuscript: Results, Sections 3.1 and 3.1.2.

Comments 7: Section 3.1.3 Legal Cognition: The reviewer noted that the section lacked citations to support statements and definitions of the concept. The reviewer also asked whether “subjective recognition of the meaning and significance of legal norms” overlapped with cognition, attitudes, evaluation, or affective orientation in the section on legal awareness. The reviewer further requested clarification of the claim that legal cognition occupies an “intermediate position.”

Response 7: We agree that this section needed stronger citation support and clearer conceptual positioning. We revised Section 3.1.3 by adding citations and by clarifying that legal cognition emphasizes understanding and interpretation, whereas legal awareness places greater emphasis on subjective endorsement, attitudes, evaluations, and affective orientation toward law. We also clarified that legal cognition occupies an intermediate position between legal knowledge and legal literacy because it is broader than factual knowledge but does not necessarily include stable value internalization or practical enactment in clinical situations.

“Legal cognition refers to nurses’ understanding and subjective interpretation of the meaning, relevance, and significance of legal norms in clinical practice [12,28]. It is broader than legal knowledge because it not only involves knowing legal provisions, but also involves interpreting why those provisions matter and how they relate to professional responsibility. At the same time, it is narrower than legal literacy because it does not necessarily include stable value internalization or the ability to enact lawful practice in complex clinical situations.”

“Legal cognition also differs from legal awareness. Legal cognition emphasizes understanding and interpretation, whereas legal awareness places greater emphasis on subjective endorsement, attitudes, evaluations, and affective orientation toward law.”

Location in revised manuscript: Results, Section 3.1.3.

Comments 8: Section 3.1.4 Medical Ethics: The reviewer requested citation for the definition of medical ethics and noted that, although a distinction between legal knowledge and ethical application was offered, the distinction between legal literacy and medical ethics remained unclear. The reviewer suggested clarifying legal literacy using the refined concept developed in the manuscript.

Response 8: Thank you for this helpful suggestion. We revised Section 3.1.4 by adding citations for the definition and principles of medical ethics and by clarifying the conceptual distinction between legal literacy and medical ethics. In the revised manuscript, medical ethics is described as value principles and moral norms governing healthcare relationships, while legal literacy is described as a professional competency centered on understanding legal norms, recognizing rights and responsibilities, and enacting lawful practice. We also used informed consent as an example to show that ethical concern for autonomy does not automatically ensure knowledge of legal procedures, documentation requirements, or institutional accountability.

“Medical ethics refers to the value principles and moral norms that govern relationships among persons, professions, and society in healthcare [29,30]. In its classic formulation, the four-principles framework proposed by Beauchamp and Childress, namely respect for autonomy, non-maleficence, beneficence, and justice [31], is widely applied to clinical ethical reasoning and the analysis of moral dilemmas.”

“Legal literacy in clinical nurses is more centrally concerned with understanding legal norms, recognizing rights and responsibilities, and enacting lawful practice in clinical situations. Medical ethics is more centrally concerned with moral judgment, value-based reasoning, and the resolution of ethical dilemmas in care. Although both are necessary for professional nursing practice, legal literacy emphasizes legally accountable practice, whereas medical ethics emphasizes morally justified practice.”

Location in revised manuscript: Results, Section 3.1.4.

3. Additional clarifications

The revised submission includes only two supplementary files: Supplementary File 1, which provides database-specific search strategies for the primary search and notes the supplementary conceptual search using “legal consciousness”; and Supplementary File 2, which summarizes the included sources and their relevance to the concept analysis. No additional supplementary file is used in this response.

We thank the reviewer again for the detailed comments, which helped us strengthen the conceptual precision of the manuscript, especially the distinctions among legal awareness, legal consciousness, legal cognition, legal literacy, and medical ethics.

Comments 1: Adjust the references' numbering system. The first references you cite are 5 and 38. Numbering of the references should be sequential starting from n. 1 and ongoing.

Response 1: Thank you for identifying this problem. We agree that the previous reference numbering was not sequential and could create confusion for readers. We have revised the in-text citations and the reference list throughout the manuscript so that references now appear sequentially from [1] onward according to their first citation in the text. We also checked the correspondence between all in-text citations and the reference list to ensure consistency. This revision can be found throughout the manuscript, particularly in the Introduction, Methods, Results, Discussion, and References sections.

Comments 2: Shorten the introduction section and the paragraphs 4.1 and 4.2. Even though well written, these sections should be shortened, especially paragraphs 4.1 and 4.2, which for the most part are a repetition of the results.

Response 2: Thank you for this helpful suggestion. We agree that the earlier version contained unnecessary repetition between the Results and Discussion sections. We have shortened the Introduction by removing repeated background statements and retaining only the main rationale: the increasing legal complexity of nursing practice, the practical consequences of insufficient legal knowledge and law-based practice, the conceptual ambiguity surrounding legal literacy, and the need for concept analysis. The revised Introduction now presents the study rationale more directly and concisely.

We also substantially shortened Sections 4.1 and 4.2. Section 4.1 now focuses on the theoretical meaning of the three-attribute structure rather than restating each defining attribute in detail. Section 4.2 now emphasizes the implications of the antecedent-consequence framework for nursing education, organizational management, and policy development without repeating the Results section. These revisions can be found in the revised Introduction and in Sections 4.1 and 4.2 of the Discussion.

Representative revised text from Section 4.1:

“The three defining attributes identified in this analysis—normative understanding, value internalization oriented toward rights and responsibilities, and law-based situational practice—should not be interpreted as a simple list of competencies. Rather, they form an internal developmental structure through which legal norms are first understood, then internalized as professional obligations, and finally translated into lawful action in clinical situations.”

Representative revised text from Section 4.2:

“The antecedent-consequence framework identified in this analysis has practical implications for nursing education and training, organizational risk management, quality governance, and policy development. It suggests that legal literacy in clinical nurses should not be addressed merely as an individual knowledge deficit, but as a multidimensional professional competency shaped by educational preparation, organizational conditions, and regulatory expectations.”