The citation arrived on my last day.

Waiting for me on my kitchen counter.

I had already cleared out the office. The notice came through formally, addressed to me personally, as Pharmacist-in-Charge. Two years earlier, our pharmacy had flooded again, creating yet another emergency. I made the clinical call to move chemotherapy compounding operations to a contracted infusion pharmacy so that patient care would not be disrupted. We cooperated fully with the Board of Pharmacy investigation that followed. I accepted the accountability that came with my role. And on the day I walked out for the last time, the regulatory consequence landed on my personal license, while the institution absorbed its own citation at the organizational level.

I felt anger first. Then indignation and disbelief.

Then something I didn’t expect: clarity.

Because in that moment, a pattern I had been inside of for years became impossible to misread.

And underneath everything, one thing remained unmoved.
I had made the right call for patient care.
That never changed.

What changed was my ability to name what had been happening all along.

HERE'S WHAT I KNOW ABOUT THE PEOPLE READING THIS

You’ve sat in root cause analysis (RCA) meetings. You’ve probably run sentinel event reviews. You’ve stood in rooms and established that the goal of any adverse event investigation is not to assign blame, but to identify what conditions in the system produced this outcome.

You’ve done this work carefully. You’ve protected people under your leadership from punitive responses to errors that the system itself helped create.

You followed the process.
You reported up the chain.
You did what you were trained to do.

And the system responded the way systems do: by protecting itself.

There’s a framework many healthcare organizations have adopted called Just Culture. Its central premise:

• most adverse outcomes are produced by system conditions, not solely individual failure

• accountability should be proportionate to the nature of the behavior, not the severity of the outcome (was it human error, at-risk behavior, or reckless and willful misconduct?)

Healthcare leaders have implemented it to protect clinical staff from punitive blame cultures, to foster safe and transparent environments where reporting of problems could lead to continuous learning, improved systems, and increased trust.

Most leaders, however, have never applied it to their own experience inside those same organizations.

This isn’t an accident. It’s a feature of how institutional environments maintain their own stability. When the people most capable of identifying systemic harm are also the most invested in the institution's survival, the analysis stops.

Not from dishonesty.
From proximity.

The more evolved conversation in healthcare is Restorative Just Culture, a framework developed by safety scientist Sidney Dekker. Where traditional Just Culture asks what type of behavior occurred and what accountability is proportionate, Restorative Just Culture asks three different questions:

• who is harmed,

• what are their needs,

• and whose obligation is it to meet them?

When that framework is applied, the circle of harm is wider than institutions typically acknowledge. It includes the leaders who absorbed the weight of decisions made inside under-resourced systems, cooperated with every investigation, and were never once asked what they needed in return.

That’s not a complaint. It’s an incomplete restoration.

THE WOUND THAT FORMS WHEN NO ONE ASKS

You know the feeling...

The moment you swallowed a concern because the timing wasn't right.

The meeting where you reframed what was actually happening into something more palatable before you said it out loud.

The decision you implemented that you knew wasn't the right one, because the right one wasn't available to you.

That accumulates. And the research has a name for what it becomes.

Moral injury was first defined in military medicine as the damage done when someone experiences a betrayal of what is right, by someone with legitimate authority, in a high-stakes situation. Brett Litz broadens the definition to include the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. This includes acts of commission and omission.

In 2018, Drs. Wendy Dean and Simon Talbot extended the framework to healthcare, naming the specific wound that forms when clinicians simultaneously know what care or action is right and are prevented from delivering it by institutional constraints. Leaders face a version of this that rarely gets named. The role comes with accountability for outcomes– outcomes that often require resources, structural changes, or decisions that live above their authority level. Accepting the weight of a leadership role is not the same as accepting unlimited accountability for conditions you didn’t design and cannot unilaterally change.

That conflation doesn’t serve you. But it serves the institution.

Leaders are responsible for fixing the problem, yet when they are also prevented by institutional constraints (denied staffing requests, aging and failing facilities, etc.), they are not immune to moral injury. But no one asks. Because healthcare leaders are trained to project competence, absorb pressure without complaint, and never be the one in the room who doesn't have it together.

In Moral Injury: Healing the Healers, Dr. Jennie Byrne, MD, PhD, describes moral injury as progressing through stages of wounding, analogous to a pressure wound. An acute wound is one the body knows how to respond to. Address it directly, give it the right conditions and a healthy environment, and healing is the expected outcome. But a wound that goes unaddressed doesn’t just go away. It progresses.

And here is what makes it dangerous: you eventually stop feeling it.

Sensation diminishes. The tissue starts to die. By the time a wound reaches late-stage, there is most certainly tissue loss and exposed bone, muscle and tendon. The body is no longer certain what to do with it. Debridement is required. Sometimes surgery. The intervention that would’ve been straightforward at stage one has become a procedure.

Moral injury in healthcare leaders follows the same arc. The early wounds are manageable. The problem is that the institutions producing them are also the institutions determining whether they ever get named. If you’ve ever softened a concern before raising it, reframed a complaint as a question, or decided a battle wasn't worth the political cost– that is the mechanism working exactly as designed.

The data is sobering. Across large healthcare systems, surveys have found that 45% of healthcare workers reported feeling betrayed by leaders they once trusted. Feelings of institutional betrayal increased the odds of measurable psychological distress by nearly three times. In 2023, Weisleder found that among clinicians, the incidence of moral distress, moral injury and burnout exceeds 50%.

These are not outlier experiences. They are the operating condition.

SO HERE'S WHAT THE ANALYSIS LOOKS LIKE WHEN YOU RUN IT ON YOURSELF

Just Culture asks: What conditions in the system produced this outcome? And then: is the accountability being applied to me proportionate to my behavior, or is it proportionate to the exposure the institution needs to manage?

Restorative Just Culture asks something different, and something most healthcare leaders have never been asked in return: Who is harmed, what do they need, and whose obligation is it to meet those needs?

When you apply both frameworks honestly, two things become clear.

The accountability has not always been proportionate. Some leadership roles carry personal regulatory exposure that institutional structure doesn’t share equally. The individual absorbs the professional weight. The organization absorbs its liability at the entity level.

And the circle of harm is wider than the institution has acknowledged. It includes the patients and staff, yes. It also includes the leaders who made sound decisions inside broken systems, cooperated with every process, and were never once asked what they needed in return.

Naming that asymmetry is not blame.

It is diagnosis.

The framework doesn't excuse or diminish the outcome.

It just stops misplacing the blame.

THIS IS WHAT CLARITY ACTUALLY DOES

It doesn't require you to leave. It doesn't ask you to stop leading. It recalibrates the instrument you use to make every consequential decision in your role.

Leaders with distorted situational awareness– about their environment, their capacity, and the actual source of systemic dysfunction– make decisions from incomplete data. That’s a patient safety issue as much as it is a leadership one.

And this is the insight other leadership frameworks are not saying out loud: organizations can be pathological environments. The body responds to chronic exposure the same way it responds to any other sustained stressor. It adapts. It compensates. It signals. And when those signals go unaddressed long enough, the adaptation itself becomes the problem.

You cannot out-supplement a toxic system.
You cannot meditate your way through moral injury and institutional betrayal.

At some point, the most regulated thing you can do is name what is actually happening.

Naming changes what is possible within your environment– which battles are worth the physiological cost, which ones were decided above your level before you ever entered the room, which accountability you’ve been carrying that was never structurally yours to carry alone. What you do with that clarity belongs to you.

But you cannot get there from inside the story that this is a personal failure of resilience or leadership. That story is not an honest systems analysis. It is what the institution needs you to believe to maintain its own equilibrium.

YOU ALREADY KNOW HOW TO DO THIS WORK

You’ve done it in every RCA, every adverse event review, every performance improvement cycle.

It seems like the smallest possible move.

It is not. Naming is the first act of agency.

Not because it resolves anything immediately, but because it stops the misdiagnosis that has been driving every decision.

And naming, for most leaders, doesn’t happen alone. It happens in a conversation with someone who speaks both the clinical and the leadership language, and who has no stake in the story the institution needs you to tell about yourself.

If what you just read is naming something you've been living without language for, I want to talk with you directly. A 55-minute conversation where we run the actual analysis on your situation and you leave with a clear picture of what you are working with.

I work with a small number of healthcare leaders at a time. If this is where you are, this is the right next step.

May is Mental Health Awareness Month. The irony is not lost that the people least likely to use that language to describe their own experience are the ones who most need this conversation. If someone came to mind while you read this, send it to them. You don't need to say anything. The email will say enough.

Grace