Navigating the “Moral Maze”: A Flourishing-Centered Reflective Inquiry for Healthcare Leadership

Abstract

This paper aims to address the limited availability of reflective approaches designed for healthcare leaders to consider ethically consequential decision-making by introducing a flourishing-centered reflective inquiry into a single temporally structured process. To inform the development of this approach, we conducted a scoping literature review of peer-reviewed articles and scholarly book chapters published in English between 2015 and 2025. Because healthcare is often situated in academic medical centers influenced by higher education concerns, the search was conducted across both healthcare and higher education. Relevant literature set in a military context was retained when it illuminated leadership in settings where hierarchy or moral injury are relevant. Publications were screened for relevance to ethical leadership and were categorized and synthesized by setting, participant group, timing of reflection, and type of ethical tension addressed. The final corpus included 40 publications: 27 in healthcare, 11 in higher education, and 2 in military contexts. The review found that reflection is widely used in professional learning, clinical practice, and team-based settings, but is less often structured as a discipline for leaders’ own ethical reasoning in operational and executive decision-making. Across the corpus, reflection appeared in retrospective, ongoing, and multi-phase forms, and ethical tensions repeatedly spanned individual, institutional, and societal goods. These findings informed the development of a reflective cycle in three phases: reflection-for-action, reflection-in-action, and reflection-on-action. Each phase is guided by an inquiry guide developed using the KNN Framework for Flourishing’s elements of character, caring, and practical wisdom toward flourishing across socio-ecological systems. This paper contributes a conceptually integrated and practically oriented reflective inquiry for healthcare leadership that offers structured guidance for ethical discernment before, during, and after consequential leadership decisions.

Introduction

Over the past decade, leaders in American healthcare have been required to make difficult decisions in response to a decline in public trust, a global pandemic, and, most recently, rapid changes in healthcare policy and governmental priorities. The decisions required of leaders are often morally consequential because they shape whose needs are prioritized and which institutional values are upheld or compromised.

Across healthcare organizations, leaders may be required to respond immediately to policy shifts, funding threats, staffing shortages, public controversy, or legal uncertainty while also protecting institutional mission and professional integrity. A leader, for example, may need to decide whether and how to preserve a program that supports workforce development, inclusion, community partnership, or patient access when doing so appears to place financial stability, regulatory compliance, or institutional reputation at risk. Such decisions are not merely administrative. They raise questions about which values will be protected under pressure, whose opportunities or care may be diminished, and what kind of healthcare organization is being sustained. When decisions of this kind must be made quickly, with limited opportunity for consultation or reflection, leaders may have fewer resources for ethical discernment and greater pressure to act reactively or primarily in response to perceived compliance demands.

Recent scholarship focused on academic medicine underscores the immediacy of this challenge and describes the present moment as one of abrupt and destabilizing change in which political and policy pressures are disrupting normative processes, straining research and clinical funding, weakening public trust, and producing uncertainty about what can be taught, said, or defended without jeopardizing institutional standing or professional integrity.^1–3

Evidence suggests that the pressures reverberate across healthcare more broadly by shaping access to care. For example, Russell and Wallace⁴ discuss how immigration policy changes may deter vulnerable patients from seeking emergency services, underscoring that healthcare leadership decisions unfold within a broad ethical landscape.

Carroll et al⁵ sharpens significance of this moment for leaders by foregrounding how university leaders describe such situations. Their analysis suggests that leadership under pressure involves public ethical positioning: naming institutional goods, narrating deliberative process, and making visible the relationship between character, commitment, and institutional action.

Under such conditions, leadership can be morally disorienting, which is why Jackall’s⁶ language of the “moral maze” is useful here. His sociological account of corporate managers suggests that the institutional structures that produce ethical tensions often resemble a moral maze, where shifting expectations and pressures can sometimes place moral principles in tension with institutional priorities, career considerations, and personal values. The need to navigate the moral maze makes reflective leadership necessary for preserving healthcare’s ethical commitments under pressure.

Reflection is widely endorsed in professional formation and team learning, yet existing approaches offer limited guidance for healthcare leaders reflecting on their consequential decisions in ways that hold together personal character (expressing their values and character), relational care (attending to the needs of specific people in specific circumstances), and structural responsibility (shaping the conditions under which others live and work).

Prevailing approaches to ethical leadership tend to address these dimensions separately.⁷ Character development programs focus on the individual leader’s virtue; relational or team-based approaches focus on caring practices in the immediate clinical or institutional encounter; systems thinking focuses on structural and policy conditions. Each tradition has genuine value, but leaders in the moral maze rarely face decisions that belong cleanly to one dimension. The same decision that tests a leader’s personal character also shapes the institutional culture that will constrain or enable the ethical choices of others and also reflects or resists broader patterns of power and care in the healthcare system.

This leaves both a practical and theoretical gap. Healthcare leaders need a reflective process that can help them examine experiences, emotions, and actions in relationship to the interconnectedness of individual good, institutional good, and societal good. Applying the KNN Framework for Flourishing,⁸ including its elements of character, caring, practical wisdom, and flourishing across socio-ecological systems, we offer an approach that brings these dimensions together within practice. We argue that this approach supports leadership driven by practical wisdom and moral responsiveness by creating space to surface ethical tensions that might otherwise be obscured by pressure, compliance, or fear, even when decisions remain unchanged.

To ground our approach, we begin by detailing the KNN Framework for Flourishing that serves as the conceptual foundation for the flourishing-guided reflective inquiry we outline. We continue with a review of relevant literature on reflective practices amid tensions that put pressure on character and reasoning before sharing the cyclical approach and related inquiry guides. We conclude with a brief description of a qualitative study still in the planning stages that will explore what, if any, effects it has on reflective habits, relational awareness, and decision-making.

Theoretical Framework

The KNN Framework for Flourishing addresses this challenge by integrating three theoretical traditions: virtue ethics, ethics of care, and socio-ecological theory as mutually constitutive dimensions of ethical practice. The Framework defines flourishing as the aspirational aim of health professions and relies on Su’s framing of the concept: “a wholeness—of being and doing, of realizing one’s potential and helping others do the same”.⁹ Flourishing is seen as achievable not through character formation alone, or caring practice alone, or practical wisdom alone. Rather, it requires all three, enacted together, across every level at which leaders act. Character, caring, and practical wisdom are elements of the same moment of moral action, each incomplete without the others.

Virtue ethics grounds the framework’s understanding of character not as a fixed set of traits a leader either has or lacks, but as “a constellation of characteristics—moral, civic, intellectual, and performance—formed over time and manifest in dispositions and practices” influenced by and valued according to context.^8,10 Character, by this account, is what a leader brings to a decision: the accumulated dispositions, commitments, and responses that shape how they perceive a situation and what kinds of responses feel possible. Without attention to character, ethical practice risks becoming procedural Character development is therefore not a prerequisite to ethical leadership that is accomplished before the need for difficult decisions is upon leaders. Rather, character is cultivated through those decisions, and reflection is one of its primary disciplines.

Where virtue ethics attends to who the leader is becoming, ethics of care, particularly as developed by Tronto^11,12 attends to who is being affected and how. Tronto identifies caring as a practice with specific moral dimensions: attentiveness to the needs of others, responsibility to respond, competency to do so, responsiveness to how that care is received, and a civic engagement that asks who is included and systematically excluded.^11,12 For healthcare leaders, this tradition is already central to ethical decision-making. Decisions about staffing, institutional priorities, leadership transitions, and responses to policy change are not only institutional questions. They determine whose needs are seen, whose vulnerabilities are protected, and whose interests are minimized when pressures are high and resources are limited. An ethics of care insists that these power-laden relational realities are recognized. A leader who acts from strong personal character but without the attentiveness and relational responsiveness Tronto^11,12 describes may still cause harm and may be unable to recognize that harm from within a virtue ethics framework alone.

Socio-ecological theory^13,14 provides the framework’s contextual structure and highlights that individuals, institutions, and societies are interconnected systems that shape and are shaped by one another. For healthcare leaders, this matters because it prevents ethical analysis from consistently defaulting to the individual level when the real leverage is elsewhere. A leader who asks only “What should I do?” when facing a morally distressing situation may be accepting as fixed a structural constraint that reflection at the institutional or societal level could reveal as changeable. Conversely, a focus on systemic change without attention to the character and caring practices of individuals risks advocating for change in the absence of ethical formation. The socio-ecological dimension therefore specifies the levels at which both character and caring must be examined, and at which practical wisdom must be exercised.

Practical wisdom (phronesis) is the activity that unifies the framework in practice. It is the form that ethical action takes when leaders use “acquired experience to discern the right way to do the right thing in a particular circumstance, with a particular person, at a particular time”.^8,15 A leader exercising practical wisdom is not applying character first and then checking it against ethics of care (or vice versa). The practically wise leader notices what is ethically salient because their character has shaped what registers as significant, attends to whose needs and perspectives are present or absent because relational responsibility is already woven into how they perceive, and discerns a response that is neither entirely self-expressive nor other-directed but shaped by both simultaneously.

The flourishing-centered reflective inquiry approach we propose operationalizes this integrated practice. It is designed to help leaders, consistently and longitudinally, engage character, caring, and practical wisdom together as elements of a single moral responsiveness toward flourishing across socio-ecological levels. Before presenting the approach and guidelines for its application, we review the relevant literature on reflective practice and ethical leadership.

Methods

To explore how reflection supports ethical leadership, particularly in navigating tensions between individual, institutional, and societal goods, we conducted a scoping review of the literature, focusing on ethical leadership and reflection in healthcare and higher education settings. Because leadership development in healthcare frequently occurs within academic health centers situated in higher education institutions, the review included scholarship from both healthcare and higher education contexts. Though we recognize they are not equivalent contexts, literature situated in higher education offers transferable conceptual insights into reflective leadership under institutional pressure. These insights were interpreted through a healthcare-specific lens.

The review was guided by the following question: How does reflection function as a resource for ethical discernment in complex healthcare leadership contexts operating across multiple socio-ecological systems?

Search Strategy and Eligibility Criteria

An initial search was conducted in October 2025 – February 2026 in Scopus, Web of Science, ERIC, and PubMed databases using the search string “ethical leadership AND reflection AND (higher education OR healthcare)”. We included peer reviewed articles and scholarly book chapters published in English between 2015 and 2025. Eligible sources examine reflection as a process, intervention, or analytical lens and address ethical leadership, judgment, or ethical decision making among students, trainees, faculty, clinicians, or individuals in formal leadership roles.

Given the limited number of sources situated explicitly in healthcare contexts identified in the initial search, a targeted follow-up search was conducted in April - May 2026 using the same databases and publication frame. The revised search string was ethic* AND leader* AND reflection AND healthcare. The initial search and targeted follow-up were subjected to the same process of manual deduplication, title and keyword screening, abstract review, and full-text assessment described below and reflected cumulatively in Figure 1.

Figure 1.

PRISMA-style Flow Diagram. Source: Page MJ et al BMJ 2021;372:n71. doi: 10.1136/bmj.n71. This work is licensed under CC BY 4.0. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/.

Across the two search phases, a total of 261 records were identified. Duplicate records (n = 84) were removed prior to screening, resulting in 178 records screened by title and keywords. During title and keyword screening, 34 records were excluded due to clear irrelevance to ethical leadership, reflective practice, or the publication frame (language and time). The remaining 144 records proceeded to abstract screening. Abstracts were assessed for alignment with the guiding research question, resulting in the exclusion of 80 records that did not substantively engage reflection in relation to ethical leadership or ethical discernment.

Full texts of 64 records were then assessed for eligibility. Of these, 24 sources were excluded because reflection was tangential or leadership was not ethically framed. Ultimately, 40 publications met inclusion criteria and were incorporated into the final analytic corpus. These sources collectively informed an integrative analysis of how reflection is conceptualized, enacted, and mobilized to support ethical leadership within complex healthcare and academic leadership environments. See Figure 1 for a PRISMA-style schematic of the process.

Results

The 40 included publications spanned healthcare (n = 27), higher education (n = 11), and military settings (n = 2). Though we did not set out to locate publications on military leadership, the two we found were retained because one generalized to “high-risk occupations” where moral injury is prevalent¹⁶ and another was concerned more broadly with hierarchical organizations.¹⁷

The corpus addresses learners at undergraduate, graduate and professional levels (n = 8), healthcare professionals and clinical care leaders (n = 12), academic leaders and faculty (n = 11), institutional leaders (n = 7), and military leaders (n = 2). See Table 1 for a categorization of publications by subject population. The majority employed qualitative design such as semi-structured interviews, focus groups, reflective writing analysis, participatory action research, case studies, narrative inquiry, and autoethnography. A smaller number included mixed methods designs, scoping reviews, and conceptual pieces.

Table 1.

Literature Review Publications by Population

Population	Healthcare Settings	Academic or Military Settings
Learners (undergraduate, graduate and professional)	McDaniel et al18 Nadarajan et al19 Orr and Romem20 Wald and Monteverde21	Alvidrez et al22 Chunoo23 Haritas and Harini24 Harris25 Yamagata-Lynch et al26
Healthcare Professionals and Clinical Care Leaders	Ahokas and Hemberg27 Devik et al28 Donkers et al29 Eide et al30 Koskinen et al31 Jensen et al32 Jakobsen and Olsen33 Munkeby et al34 Semler35 Soderhamn et al36 Spowart et al37 Van den Bulcke et al38
Academic Leaders and Faculty	Baser et al39 Maritz40 Rider et al41	Forsyth et al42 GuramatunhuCooper and Headrick43 Hailu and Cox44 Hedberg45 Lumby46 Lvina47 Schrier et al48
Organizational Leaders	Alsio et al49 Falkenstrom and Hoglund50 Gabriele51 Kröger et al52 Ilse53 Pergert et al54 Spanos et al55
Military Leaders		Ohlsson et al17 Williamson et al16

Timing of reflection varied considerably across the corpus. In some studies, reflection was represented primarily as retrospective sensemaking following ethically salient events, most clearly through end-of-course written reflections, final evaluations, or post-experience narrative synthesis (n = 8). A substantial subset of studies positioned reflection as ongoing and embedded within practice, coursework, or organizational routines, such as repeated small-group dialogue, digital ethics reporting tied to daily work, routine ethical discussion in meetings, and curriculum-integrated reflective exercises sustained over time (n = 11). A smaller group of studies explicitly structured reflection across more than one temporal point, including preparation before action, reflection during implementation, and integrative follow-up after the event or intervention (n = 6). Several studies emphasized ethical climate or the importance of reflection without specifying a clear sequence for how reflective activity should be applied in practice (n = 17). Table 2 organizes the corpus by the temporal mode of reflective practice.

Table 2.

Literature Review Publications by Temporal Mode

Temporal Mode	Healthcare Settings	Academic or Military Settings
Retrospective Reflection	Orr and Romem20 Semler35	Alvidrez et al22 Forsyth et al42 Haritas and Harini24 Lvina47 Schrier et al48 Yamagata-Lynch et al26
Ongoing Reflection	Alsiö et al49 Devik et al28 Jakobsen and Olsen33 Koskinen et al31 Kröger et al52 Munkeby et al34 Pergert et al54 Rider et al41 Söderhamn et al36	Chunoo23 Hedberg45
Multi-Phase Reflection	Başer et al39 Eide et al30 Maritz40 McDaniel et a.,18 Nadarajan et al19 Spowart et al37
Temporally Unspecified	Ahokas and Hemberg27 Donkers et al29 Falkenström and Höglund50 Gabriele..51 Ilse53 Jensen et al32 Spanos et al55 Van den Bulcke et al38 Wald and Monteverde21	GuramatunhuCooper and Headrick43 Hailu and Cox44 Harris25 Lumby46 Ohlsson et al17 Williamson et al16

Discussion

This corpus of literature portrays ethical leadership less as a matter of selecting the “right” principle and more as the ongoing work of maintaining moral responsiveness while balancing personal values with institutional demands, negotiating power, and responding to societal pressures. The ethical tensions leaders navigate often surface not only among types of goods (individual, institutional, and societal) but also within them. While reflection is most often described in relation to professional learning, clinical practice, and team-based sensemaking, there is comparatively less attention to reflection as a structured practice oriented to leaders’ ethical reasoning embedded in operational and executive decision-making,^33,50,53,55 suggesting a potential gap in reflective practice across levels of leadership. Examination of leaders reflecting on the ethics of their own power and institutional shaping appears inconsistently and often indirectly or as critique of inconsistency or absence. This gap can position leadership more as an enabling condition for others’ reflection than as a reflective practice in its own right.

Individual Goods: Integrity, Ambition, and Sustaining Moral Agency

In the corpus, reflection often appears at the individual level as a protective infrastructure for moral agency under chronic constraint, especially in ethically complex care contexts. Studies of intensive care moral distress and ethical climate highlight how ethical strain intensifies under systemic constraints, and the benefit of reflective debriefing to improving conditions.^29,32 For example, Eide et al³⁰ describe nurse managers experiencing reflection as strengthening and clarifying in busy periods. Nurses did not experience reflection as “extra work” but as a way to stay attentive to ethical issues and to what matters as leaders. One nurse manager noted that reflection, “kept me aware of ethical issues in a busy period. I got greater insight into what is important to me, as a leader”.³⁰

Devik et al²⁸ similarly show nurse managers describing ethical reflection as helping them think and feel differently, justify decisions, and remain morally oriented despite time pressure and unclear responsibility. Ahokas and Hemberg²⁷ extend this by depicting reflection as a resource for moral judgment, resilience, and integrity among care leaders working within system-level constraint, often introduced by “top management”, that conflict with clinical leaders’ ethical values. In these articles, the need to reflect often stems from the need to work within or otherwise respond to decisions made by leaders higher in the organization rather than one’s own decision-making process.

However, leaders at all levels often face tensions that arise from the internal conflict between personal integrity and professional ambition. Illustrating this tension clearly, Hailu and Cox⁴⁴ describe the difficult choice between acting with integrity and pursuing disciplinary status: “One of the most difficult choices I had to make as a department chair was to decide between being a leader of integrity regardless of what came my way or to focus on disciplinary status and my future.”⁴⁴ This candid reflection reveals the importance of self-awareness and willingness to confront uncomfortable trade-offs and is notable as one of the clearer instances in the corpus where ethics is not merely supported by leaders but narrated as a lived, reflective struggle in the leader’s own moral formation.

Institutional Goods: Power, Participation, and Ethical Climate

At the institutional level, reflective practice is most often treated as an organizational condition leaders enable through time, routines, facilitation, and ethical climate rather than a practice focused on leaders’ own power and trade-offs. The most consequential tensions often include struggles of power, participation, and the ethical climate that determines whether ethical concerns can be raised and addressed. Lumby’s⁴⁶ analysis of leadership and power emphasizes that disavowing power may be socially adaptive, but ethical choices cannot be made without self-awareness of how influence is being exercised. She argues, The often unconscious process of disavowal or blurring of power is entirely understandable and, in many ways, adaptive to the requirements of leading in higher education. However, working in the dark, without self-awareness, has obvious disadvantages. Without self-awareness, ethical choices cannot be made.⁴⁶ Similarly, Ohlsson et al¹⁷ emphasize that navigating Jackall’s⁶ “moral maze” of ethical tensions requires deliberate reflection of how leaders move between formal and informal institutional structures. Without it, leaders may misjudge the ethical dimensions of their influence, allowing structural pressures to override integrity despite good intentions.

Several studies deepen this conceptual argument by suggesting that ethical culture is sustained by routines and structures that make ethical reflection possible. Söderhamn et al³⁶ describe short, structured ethical reflection embedded into daily meetings, with reported outcomes including increased moral awareness, mutual respect, courage to speak up, and critical self-evaluation. These outcomes align with institutional goods such as psychological safety and respectful deliberation. Koskinen et al³¹ similarly frame interprofessional ethical competence as dependent on regular, systematic reflection and ethical culture, with leaders functioning as role models and facilitators who make “time for talk” possible. Alsiö et al⁴⁹ add that leaders have responsibility for promoting reflective practice at both meso (team) and macro (institutional) levels as part of professionalism and well-being in organizations.

In these studies, leaders are often presented as enabling reflection through tools, routines, and facilitation rather than as participants in collective ethical reflection about leadership-level trade-offs, resource constraints, and voice. Jakobsen et al³³ for example, captures nurse leaders’ expectations of digital ethical reflection primarily as a mechanism for staff ethical awareness and accountability, highlighting a support role more than leaders’ own reflective interrogation of managerial ethics. Falkenström and Höglund⁵⁰ describe “total silence” and limited, inconsistent ethical reflection among high-level healthcare leaders, suggesting that ethical leadership does not automatically deepen with seniority and that institutions lack forums where leaders can engage in shared moral learning.

Societal Goods: The Moral Accountability of Institutions

Societal-level ethical tensions are frequently articulated as critique of institutional logics or as educational sense-making, with comparatively less direct operationalization of leader reflection for executive healthcare decisions affecting equity and public accountability. Leaders encounter tensions between institutional preservation and broader societal obligations when institutional demands for efficiency, stability, or political viability compete with commitments to professional training, care, and equity. Harris²⁵ critiques the influence of neoliberalism on educational leadership, arguing that leaders must move beyond managerial efficiency and engage in administrative action that serves the broader societal good. Gabriele⁵¹ similarly frames reflection as a way to surface ethical and cultural challenges introduced by business and market-driven models in healthcare and research, implicitly challenging leaders to consider what is lost when institutional efficiency becomes the overriding good.

Schrier et al⁴⁸ sharpen this tension through simulation-based reflection. Students grappled with equity and equality in public programs and discovered that ethical decision-making often collides with advocacy pressures and incentives tied to maintaining authority, illustrating how societal goods can be compromised when institutional or individual survival dominates deliberation. Together, these studies underscore that leaders’ moral work is not only to make defensible decisions, but to keep societal commitments in view when institutional logics reward narrower measures of success. Spanos et al⁵⁵ echo this, arguing that ethical formation is under-supported in complex healthcare environments and that when reflection is informal or absent organizations default toward compliance-oriented approaches that can further widen the gap between institutional priorities and broader ethical accountability.

Across these three domains of goods, a consistent pattern emerges. Reflection is widely endorsed and often structured for clinical ethics support, team learning, and professional formation, but far less consistently operationalized as a practice for healthcare leaders reflecting on the ethical tensions within their own operational and executive decisions, especially decisions involving power, participation, and allocation under constraint. This asymmetry positions leaders more as enablers of others’ reflection than as reflectors on the ethics of their own decision-making. This gap matters because reflection is not inherently benign. Without explicit attention to power, resources, and psychological safety, reflection can become moral laundering, burden shifting, or a compliance ritual

Theoretical Implications

Building on critiques of competency-based and rule-oriented approaches to professional ethics,⁴⁰ we propose a flourishing-centered reflective inquiry for ethical leadership in healthcare that brings character, caring, practical wisdom, and socio-ecological responsibility into a single temporally structured reflection process. Such reflection makes ethical tensions discussable within real constraints, surfaces competing goods across individual, institutional, and societal domains, and supports disciplined inquiry. It offers a question-based reflection cycle organized to support ethical reflection before, during, and after consequential leadership decisions in healthcare, thereby positioning leaders not only as facilitators of others’ reflection but as reflective decision-makers accountable for how their choices shape flourishing across systems.

Flourishing-Centered Reflective Inquiry

We offer a flourishing-centered reflective inquiry as a question-guided and temporally structured reflective practice for healthcare leadership that brings individual, institutional, and societal goods into one reflective process. The literature review presented above clarifies why such practice is needed. First, the literature shows that reflection is often structured for learners, clinicians, or staff teams, while leaders are more frequently positioned as facilitators or enablers of others’ reflection than as reflective subjects of their own ethical reasoning, power, and decision making. Alsiö et al⁴⁹ sharpen this point by showing that the healthcare leaders who participated in their study recognized the value of reflective practice but implemented it primarily at lower hierarchical levels. The pattern supports the need for reflective inquiry directed explicitly at leaders’ own ethical reasoning, use of power, and responsibility within healthcare systems.

Second, the temporal variation in the literature suggests that reflection performs different kinds of ethical work depending on when it occurs. Reflection that takes place following ethically significant events appears to function primarily as a mode of interpretation, enabling participants to process experience, weigh competing perspectives, and clarify what was morally at stake once the immediacy of action has passed.^22,26,42,48 By contrast, when reflection is embedded within routines of practice, professional development, or curriculum, it seems to keep ethical and relational concerns visible within the flow of work and resist their reduction to technical or purely operational problems.^28,31,33,41 Explicitly multi-phase designs point to the possibility that reflection can accompany the full arc of a decision, supporting ethical preparation beforehand, recalibration while action unfolds, and accountable learning afterward.^{18,19,30,35,39} Flourishing-centered reflective inquiry builds on these multi-phase approaches by organizing reflection across the full arc of a decision, and, in doing so, foregrounding the ethical tensions that leaders must navigate.

Third, the review repeatedly shows that the ethical tensions healthcare leaders face span across individual, institutional, and societal goods. Ethical concerns outlined in the literature are not limited to leaders’ personal intentions or integrity, but also appear in organizational routines, cultures, power relations, and broader systems that shape participation, inclusion, and accountability. This means that ethically salient tensions may lie as much in policies, hierarchies, and institutional logics as in leaders’ own motives or choices. A flourishing-centered reflective inquiry, therefore, adopts a multi-level approach so that reflection does not default to the individual decision-maker alone.

We focus on an inquiry-based reflection design following Ghaye’s⁵⁶ position that the questions we ask have a chance to change the conversations we have. This guiding design principle underscores that reflective practice for flourishing in healthcare depends not only on whether healthcare leaders reflect, but on what their questions make visible, askable, and discussable. The questions we outline aim to shape the ethical quality of leadership conversation by surfacing questions of power, goods, assumptions, and consequences within decision-making. Across all phases of the cycle, the guiding questions are designed to keep the telos of healthcare in view: not merely organizational compliance or efficiency, but the advancement of health, care, dignity, and flourishing for those who depend on and work within the system.

Established reflective approaches in healthcare provide useful starting points for positioning flourishing-centered reflective inquiry within familiar practice traditions. For example, After-Action-Review (AAR) and clinical debriefing are widely used to help teams revisit events through simple questions (What was expected? What happened? Why the difference? What will change?) aimed at understanding what happened, why it happened, and what can be learned.⁵⁷ Similarly, the Driscoll cycle offers a three-step arc (What? So what? What now?) as a memorable, simple, set of questions for moving from experience to action.⁵⁸ Both approaches are valuable because they provide time efficient structures for post-event learning, but they do not in themselves ensure reflection on the assumptions, power relations, or institutional conditions that shape what could be noticed, decided, or acted on.⁵⁹ For healthcare leaders, that limitation matters. Without more targeted prompts, reflection risks bypassing the deeper ethical and structural dynamics of consequential decision-making.

Flourishing-centered reflective inquiry extends these familiar reflective approaches by directing attention to leaders’ ethical reasoning, by spanning the temporal arc of consequential decisions, and by surfacing tensions beyond the individual and team levels. These extensions can be further understood through distinctions between learning loops. Argyris and Schön’s⁶⁰ account of single-loop learning is useful for describing reflection that improves actions within existing assumptions, whereas double-loop learning involves questioning the values, goals, and interpretive frames that shape action. Later descriptions to triple-loop learning emphasize focus on how decisions themselves are structured, including the broader systems of meaning, power, and institutional context that shape what can be perceived and decided.⁶¹

These distinction matter for the design of flourishing-centered reflective inquiry because a focus on flourishing in health is intended to support more than single-loop adjustments. Some questions in the inquiry guides for healthcare leaders shared in the next section help leaders clarify action within their immediate circumstances, but others invite examination of the assumptions and values shaping those circumstances, and still others direct attention to the contours of power and institutional conditions. In this sense, the questions are designed not merely to improve decisions within existing frames, but to help leaders interrogate the frames themselves.

Additionally, we draw on the influential work of Killion and Todnem,⁶² who introduced a widely adopted typology of reflection that includes three interrelated temporal modes: reflection-in-action (reflecting during decision-making), reflection-on-action (reflecting on past experiences), and reflection-for-action (ongoing reflection to guide future decision-making). This typology has shaped decades of scholarship on reflective practice, particularly in education, where reflection is seen as a pathway to developing professional agency. It is intended to be engaged as an integrated and iterative reflective practice where understanding of past actions informs present judgement and future understandings. Applying this process to healthcare leader reflection extends its relevance and offers a cycle through which leaders can learn to regularly and continuously consider their agency, the values that guide them, and the virtues and dispositions upon which they rely. Through this habituation, reflection becomes more than a reactive tool; it becomes a discipline. See Figure 2 for a visual representation of flourishing-centered inquiry and its temporal phases.

Figure 2.

A representation of flourishing-centered inquiry that engages the ethical demands of character, caring, and practical wisdom, attends to socio-ecological levels of impact, and spans the temporal arc of decision-making. Phases of reflection are adapted from Killion and Todnem (1991).

Inquiry Guides for Healthcare Leaders

The inquiry guides described in this section are the operational expression of flourishing-centered ethical inquiry. They translate the KNN Framework for Flourishing into a set of healthcare leadership questions that support reflection across time, socio-ecological levels of impact, and the ethical demands of character, caring, and practical wisdom. They were developed through the first authors’ (C.A.M.) insights from her experience serving as provost at a health sciences university in the United States, where she needed to make frequent time-pressured decisions under conditions of uncertainty and institutional strain. The questions’ attention to needs, responsibility, responsiveness, and structural impact resonates with previous care-informed reflective work in the literature, including Maritz’s⁴⁰ use of ethics of care to engage phases of care through structured reflexive inquiry. The questions are organized around what a healthcare leader must be able to do well to navigate the moral maze in service of healthcare’s telos: perceive the ethical dimensions of a situation before acting on it, including whose needs and what stakes are present or absent; recognize the relational obligations and structural conditions that shape who gives and receives care; and exercise practical wisdom about the available actions when values, obligations, and competing goods are in tension.

During the reflection-for-action phase, leaders engage guiding questions (See Table 3) designed for reflection during times of relative calm, when decisions are not immediately necessary and pressures are neutral or low. This phase supports leaders’ attentiveness to needs and the assumption of responsibility as leaders cultivate a personal understanding of flourishing while also considering how their values shape institutional culture and societal outcomes.

Table 3.

Reflection-for-Action Inquiry Guide for Healthcare Leaders

	Individual	Institutional	Societal
What am I noticing about myself, about those affected, and about what is shaping this situation?	What values and assumptions am I carrying and might they be causing me to miss something important about those most affected?	Whose voices are already shaping how we see this challenge and does that reflect the kind of healthcare organization we aim to become?	What does this moment reveal about power and inequity and what does that ask of me and of us as a healthcare organization?
What do my values and my responsibilities to those affected require of me?	What does character require of me toward the people whose flourishing depends on how I lead and am I willing to honor that even when it costs something?	Do our systems and policies distribute care, trust and responsibility in ways that advance flourishing in health or are they protecting forms of compliance we have not yet had the courage to examine?	Who has historically been left out of decisions like this and what would genuine inclusion require of me and of this healthcare system?
What are the possible responses?	What does the wise path forward look like, and does it account for my responsibilities to those whom my decisions will affect?	How can I act in ways that strengthen both who we are as a healthcare institution and the conditions that allow the people within it to flourish?	What do I still need to understand about the needs and experiences of those this decision will reach?

During the reflection-in-action phase, leaders consider a smaller set of guiding questions appropriate to the time constraints and high pressure of immediate decision-making.⁶³ (See Table 4). Therefore, this phase promotes real-time awareness of one’s actions and how they will potentially resonate personally, within institutional culture, and in broader societal contexts. The questions guide leaders to assess alignment with personal and institutional values as well as potential ripple effects beyond the institution with particular attention to impact on vulnerable groups. By fostering this multi-level awareness, the temporal phase helps leaders find grounding in their moral commitments even when time is limited. While it may seem difficult to engage in reflection under pressure, we posit that the guiding questions supports skill building and habit development through repeated use. Over time and with practice leaders will be able to activate it quickly.

Table 4.

Reflection-in-Action Inquiry Guide for Healthcare Leaders

	Questions
Individual	What is this moment asking of me as a healthcare leader, and whose care, safety, or dignity is most at stake?
Institutional	If we respond only in compliance to immediate demands, what kind of healthcare organization are we becoming?
Societal	How will this decision affect those who have the least power to shape it, including patients, families, staff, or communities already disadvantaged by the system?

While reflection-in-action supports moral responsiveness in the moment, reflection-on-action allows leaders to critically evaluate their decisions and make sense of past choices with the goal of preparing themselves to act ethically in future situations. The questions in this temporal phase (See Table 5) deepen awareness and strengthen leadership accountability by providing opportunities for evaluative reflection in which leaders can look back on their actions and decisions to retrospectively assess their impact and meaning. The questions encourage leaders to consider not just outcomes but also the processes that were used and the relationships that were involved.

Table 5.

Reflection-on-Action Inquiry Guide for Healthcare Leaders

	Individual	Institutional	Societal
What did I notice about myself, about those affected, and about what was shaping this situation?	What assumptions shaped what I saw, and what does what I missed tell me about my own blind spots?	Whose perspectives shaped how we understood this situation and what does that tell us about whose needs were prioritized?	What structural realities did I name and what does that naming tell me about where my sense of responsibility to others still needs to grow?
How well did my values hold in how I acted?	Where did I act with character and care, and where did habit, self-interest, or fear get in the way?	How well did dialogue shape how care was given and received, and did our institutional practices support character-centered responses or undermine them?	How genuinely did I account for those most affected and does my answer reflect the public and moral responsibilities of a healthcare organization beyond its internal priorities?
Did I discern wisely?	How did this decision account for my responsibilities to others and for how care and responsibility were distributed?	How did this decision strengthen both who we are as a healthcare institution and the conditions that allow the people within it to flourish?	What trade-offs did I make, and do they reflect wise judgment or accommodation I need to name and learn from?

Across these interrelated phases, the inquiry guides function as part of one cyclical process of ethical leadership toward flourishing. The questions on the reflection-for-action guide invite leaders to engage in intentional planning, aligning their values, goals, and anticipated impact with the needs of those they serve. They are most useful before high-impact choices such as restructuring, staffing changes, policy implementation, or quality and safety initiatives. Reflection-in-action questions support responsiveness in the moment, enabling leaders to adapt with practical wisdom and relational attunement as situations unfold. They are designed for use when time is limited but ethical stakes are high. The questions for reflection-on-action, in turn, offer space for retrospective evaluation, allowing leaders to assess the outcomes, processes, and relational dynamics of their decisions. They help leaders assess not only outcomes but also whether care, trust, inclusion, and flourishing were strengthened or diminished.

Across all three phases, the inquiry remains oriented to sustaining the conditions for flourishing in health by cultivating a deeper awareness of how leadership practices contribute to or hinder that aim. It also reinforces the reciprocal nature of flourishing as both shaped by and shaping the contexts in which people live and work and offers a scaffold for understanding how leaders engage with ethical complexity. Future research can build on this foundation by exploring how these reflective processes can be operationalized, how they intersect with power and positionality, and how they contribute to transformational change and flourishing cultures.

Practical Implications: Applying Flourishing-Centered Reflective Inquiry

Flourishing-centered reflective inquiry is intended for healthcare leaders making consequential decisions under conditions of uncertainty, competing goods, and institutional constraint. Use of the guides begins with the temporal phase of the decision. Though rigorous reflection requires movement across the full cycle, it can also begin midstream. In this sense, the guides function as a navigational map, orienting leaders across a decision arc while preserving enough flexibility to meet the realities of healthcare leadership.

The guides can be used individually or relationally. Individual use may be sufficient when leaders need a brief pause for ethical orientation. In such cases, a small number of questions may provide enough structure to clarify what is at stake. Fuller use supports deeper inquiry by helping leaders trace patterns, tensions, and trade-offs across time. The guides can also be used in pairs or small groups, where participants share responses, invite questions, and surface assumptions that may otherwise remain implicit. Relational use aligns with the reviewed literature which repeatedly shows that ethical reflection becomes more generative when multiple perspectives can surface assumptions, deepen ethical awareness, and strengthen a shared culture.^28,31,36,41

Importantly, the process is not meant to produce consensus on difficult decisions or to eliminate reasonable disagreement among ethical leaders. Rather, they create space for more thoughtful, values-explicit deliberation that considers individual character development, institutional mission alignment, and societal responsibility in concert. The flexibility of the inquiry guides is, therefore, not permission for selective or self-confirming reflection. Instead, the process is structured to interrupt those tendencies by directing attention beyond immediate preference or convenience toward questions of power, resource constraints, and the distribution of consequences across individual, institutional, and societal levels. By making ethical reasoning visible and routine rather than implicit or reserved for crisis moments, flourishing-centered reflective inquiry supports leadership cultures where moral responsiveness becomes habitual, accountable, and open to challenge.

At the same time, we acknowledge that what the literature collectively reveals is a gap that reflection alone cannot close. Knowing what character and caring requires and being able to articulate the “right” path, is not the same as being willing to act on that knowledge when doing so carries personal or institutional cost, Hedberg’s⁴⁵ finding that faculty default to compliance despite valuing virtue-based pedagogy, Devik et al’s.²⁸ nurse managers who recognized the value of ethical reflection but could not find institutional support for it, and Lumby’s⁴⁶ warning that leaders distance themselves from their own power without the self-awareness to recognize the ethical consequences each describes such challenges. What bridges the gap between knowing and doing is moral courage, the willingness to act on ethical convictions even in the face of fear, opposition, or personal cost. Reflection, regardless of how well designed, cannot supply this courage, but can cultivate the clarity and conviction that make it more available.

Future Directions: A Call for Reflective Practice and Research

We are considering a qualitative pilot study examining how healthcare leaders reflect both on a routine basis and when facing difficult institutional decisions. Participants from various levels of leadership, including executive leaders, medical and nursing directors, department chairs, health system administrators, and clinical service directors, could be invited to participate and share evaluative feedback on the overall cyclical approach and the specific questions within the inquiry guides. Their formative evaluation would be examined for themes to support iterative improvement.

To be clear, we do not advocate for a utilitarian assessment of this reflection process or judging the ethical value or moral underpinnings of leadership actions or consequences. In recognition that ethical, moral leaders will have reasonable disagreements, we propose instead that flourishing-centered reflective inquiry be examined for its impact on leader meta-awareness of the decision-making process and their agency within that process. Examples of useful research questions that prioritize leaders experience and reflective process include

• Adoption and Integration: Under what conditions do leaders reflect? What challenges do leaders encounter when attempting to integrate use of the inquiry guides into their routines?

• Experience and Impact: How do leaders describe the experience and impact of reflecting while using the inquiry guides to underpin each temporal phase? In what ways do leaders perceive the questions as influencing their decision-making or leadership practices?

• Influence on Reasoning: How do leaders see the guiding questions shaping their ethical reasoning, relational awareness, and/or leadership identity? To what extent do leaders attribute changes in their reflective practices to the flourishing-centered reflective inquiry cycle or the inquiry guides?

Data sources such as recorded discussions, written reflections, and interviews could be analyzed to explore how leaders engage with the temporal cycle and its related guides as well as how they describe any influence of these tools on their reflective practices, their relational awareness, or their decision-making processes. An exploratory design would allow for a nuanced understanding of how participants experience the reflection process and how it can be habituated over time. Insights from a pilot study could inform design principles for embedding reflective practices into healthcare leadership routines and developing a more robust research agenda.

Although further research is needed, the theoretical grounding of flourishing-centered reflective inquiry suggests that it holds promise for fostering reflection on character and relational obligations to navigate complex tensions. Grounded in the KNN Framework for Flourishing, it encourages leaders to regularly and consistently consider the role of character, caring, and practical wisdom in the promotion of flourishing across socio-ecological systems. Ultimately, the KNN Framework supports the cultivation of healthcare leaders who are morally responsive decision-makers. Future research will build understanding of if and how this approach shape reflective habits, character development, and moral reasoning. By advancing this work, we can move toward healthcare leadership cultures that promote self-awareness and prioritize thoughtful discernment in decisions that affect individuals, institutions, and society.

Conclusion

US healthcare leaders have been increasingly called to make morally consequential decisions under conditions of uncertainty, constraint, and limited time for reflection. This paper responds to that challenge by proposing flourishing-centered reflective inquiry as a question-guided and temporally structured approach to reflection in ethical leadership. Grounded in the KNN Framework for Flourishing, the inquiry guides are intended to help leaders engage character, caring, practical wisdom, and flourishing as integrated elements of a single moral responsiveness across individual, institutional, and societal levels.

The value of this approach lies not in prescribing a single correct outcome, but in creating space for more disciplined ethical discernment about what is at stake, whose needs are being shaped, and what kind of healthcare organization is being sustained through leadership decisions. In this sense, flourishing-centered reflective inquiry invites leaders to move beyond compliance, convenience, or reactivity toward more thoughtful and relationally grounded judgment. Although further empirical work is needed, this approach offers a promising conceptual and practical contribution to scholarship on ethical leadership in healthcare.

Funding Statement

This work is supported by the Kern Family Foundation.

Disclosure

The authors report no conflicts of interest in this work.