Conceptual Framework of Health-Literate Nursing System: A Proceduralized Grounded Theory Approach

Aim: To develop and define a conceptual framework for a system-level nursing approach that addresses patients' health literacy needs. Background: Health literacy has evolved beyond individual-level concerns to system-level responsibilities. While several frameworks, such as the Health Literate Healthcare Organization and Organizational Health Literacy, have guided institutional reforms, they often neglect the unique functions and contributions of the nursing system. Hence, a need exists for clear, structured guidance to integrate health literacy into nursing practice and management. Methods: A proceduralized grounded theory approach was employed. In-depth interviews were conducted with 23 healthcare professionals from diverse institutions between August 2021 and May 2022. Field observations were performed in one tertiary and one secondary hospital from December 2021 to March 2022. Data were analyzed through open, axial, and selective coding. Theoretical saturation was confirmed with additional interviews conducted between July and September 2024. Results: A conceptual framework, designated the Health-Literate Nursing System (HLNS), was developed. HLNS centers on health literacy-oriented nursing support, comprising five interrelated elements: (1) nurses who lead health literacy promotion, (2) patients who participate in health literacy initiatives with nursing support, (3) a health-literate nursing material environment, (4) a health-literate nursing management system, and (5) a health-literate external system. These components synergistically facilitate clear communication, equitable access to nursing services, and health information dissemination. Conclusions: This study proposes a conceptual framework for the HLNS, offering a system-level approach to enhancing healthy literacy in patients and nursing systems. It emphasizes nurse leadership, patient engagement, supportive material environments, effective management structures, and cross-sector collaboration. Implications for Nursing Management: The HLNS framework offers practical guidance for nursing leaders to advance system-level health literacy. It underscores the importance of resource allocation, workforce development, interdepartmental collaboration, and standardized tools to assess and improve nursing system performance.