Abstract
Background: By focusing in prioritizing patients and their rights, occasional limitations may arise and prevent nurses from doing their work according to their social and professional commitment. This may culminate in Moral Distress, resulting from the incoherence between the nurses' actions and their personal convictions.
 Research question: Is there any relationship between healthcare advocacy and moral distress in the practice of nurses working in hospitals?
 Objective: Analyzing the relation between healthcare advocacy and moral distress in the practice of nurses working in hospitals.
 Research design: Quantitative, analytical cross-sectional study. The data collection instruments comprise the Moral Distress Scale Revised – Brazilian version and the Protective Nursing Advocacy Scale – Brazilian version. Data analysis was carried out with elements of descriptive statistics, Pearson's correlation and linear regression analysis.
 Participants and research context: The participants comprised 157 nurses working in two hospitals located in a city in southern Brazil. One of the institutions is a public university hospital and the other is a philanthropic institution.
 Ethical considerations: All the international directives for research with human beings were observed.
 Findings: The constructs barriers to the advocacy practice and negative implications to the advocacy practice were pointed out as predictors of moral distress. 
 Discussion: The situations approached in this study illustrate that certain organizational and cultural contexts have negative impacts on nurses, who are in constant contact with the necessity of promoting patient well being and increasing access to healthcare, especially under the perception of vulnerability in risk situations, or when the quality of the services provided decreases and patients are not given adequate assistance.
 Conclusion: We hope that this study encourages the reflection about the relationship between patient advocacy and moral distress, and the search for resources that may contribute to the quality of the assistance provided by nurses.
Highlights
In healthcare environments, the nurse is responsible for coordinating the work of the other nursing professionals, planning and organizing healthcare activities in order to ensure adequate conditions for the assistance given to patients, as they are in constant need of the knowledge of healthcare professionals, the respect for their rights and the acknowledgement of their human condition
We hope that this study encourages the reflection about the relationship between patient advocacy and moral distress, and the search for resources that may contribute to the quality of the assistance provided by nurses
According to the results presented, the construct facilitators to the advocacy practice obtained the highest average in the instrument, which evinces that personal values, characteristics and competences of the nurses are identified as the main sources of support to advocacy actions in healthcare
Summary
The nurse is responsible for coordinating the work of the other nursing professionals, planning and organizing healthcare activities in order to ensure adequate conditions for the assistance given to patients, as they are in constant need of the knowledge of healthcare professionals, the respect for their rights and the acknowledgement of their human condition. By focusing in prioritizing patients and their rights, occasional limitations may arise and prevent nurses from doing their work according to their social and professional commitment This may culminate in Moral Distress, resulting from the incoherence between the nurses' actions and their personal convictions. Concerning nursing philosophy, nursing education and position in the health system, defending patient rights and interests is becoming more and more important as an integral part of the nurse's work It has been described as an ethical and legal obligation, and more recently, as an ideal for the practice of the profession, which characterizes the term "advocacy in healthcare" [3]. Advocacy is considered an important part in the guarantee of patient rights and safety, to achieve the results expected by the professionals, and to act in favor of those who are not able to defend themselves [3]
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