The hidden cost of patient advocacy: moral courage mediating clinical advocacy behaviors and workplace ostracism among Chinese nurses.

Background: Patient advocacy is a central ethical responsibility of nurses and is generally associated with patient protection, safety, and care quality. However, most existing studies have emphasized the benefits of advocacy for patients, whereas relatively little is known about whether advocacy may create interpersonal costs for nurses themselves. This issue is particularly relevant in Chinese tertiary hospital settings, where nurses work within high-demand, team-based, and hierarchical clinical environments. Yet, empirical evidence on how clinical advocacy behaviors are associated with workplace ostracism, and through which psychological and organizational mechanisms this association may occur, remains limited. Methods: This study investigated the relationship between clinical advocacy behaviors (CAB) and workplace ostracism (WO) among Chinese nurses, and further examined the mediating role of moral courage (MC) and the moderating role of perceived organizational support (POS). A cross-sectional study was conducted with 350 nurses from tertiary hospitals in Xi'an, China. Participants completed validated measures of clinical advocacy behaviors, moral courage, workplace ostracism, and perceived organizational support. Internal consistency was acceptable to excellent for all instruments (Cronbach's Results: CAB was significantly and positively associated with WO ( Conclusion: Nurses' clinical advocacy behaviors are associated with greater workplace ostracism, suggesting that patient advocacy may carry interpersonal costs in clinical environments. Moral courage serves as a partial explanatory mechanism, whereas perceived organizational support does not significantly attenuate this relationship. Interventions are needed to foster organizational climates in which nurses can advocate for patients without incurring social exclusion.