Florence Nightingale on Hospital Reform: Understanding Florence Then and Now

Understanding what Florence Nightingale stood for and fought for is integral to understanding what she would stand and fight for today. In today's healthcare environment, many of the same issues exist. While we have made advances in many areas, there are still blocks to a healthy holistic healthcare environment, not only for patients, but nurses and healthcare workers too. Providing physical safety for patients and staff, especially during Pandemic times is crucial. However, we must give Psychological Safety the same priority.


  • Specializes in Critical Care. Has 29 years experience.
Florence Nightingale on Hospital Reform: Understanding Florence Then and Now

Understanding Florence

Coming from privilege, determined and passionate about helping those in need, she used her influence and intellectual voice to bring about change. At times that voice was pointed and harsh, her will strong. A study of Florence shows so many examples of this (McDonald, 2020b, para. 2-4). One such example can be seen when she circumvented commanding officers to order and obtain much needed medical supplies, The Chief British Officer, John Hall wrote in anger, “Miss Nightingale shows an ambitious struggling after power inimical to the true interests of the medical department” (Hammer, 2020, para. 8).

Although Florence Nightingale was a practicing nurse during the Crimean War, who started one of the world’s first nursing schools, the vast majority of her career was devoted to research and hospital reform. She did this through years of collaborative efforts with government and private organizations, associations, and individuals at the top of their field. Working alone and with others, she compiled data and statistics to convince bureaucrats and the medical community of desperately needed change (McDonald, 2020a, para. 2-4). She used her station in life and her connections to help influence decision-makers and fund those changes (McDonald, 2020a, para. 21).

Her ideas and observations were not always received well by bureaucrats and superiors. Some were inaccurate, however when shown the evidence she did change her recommendations (McDonald, 2020a, para. 19). Through hard work and relentless drive, she was able to contribute so much to her profession and humanity. Her hope was to improve healthcare for all, not just the elitist class she was born into.

Even though her own health was poor she was a tireless staunch advocator, opening the eyes of many who were resistant (Hammer, 2020, para. 16 & 20). The scope of her work regarding Hospital Reform covered multiple topics and subtopics. She was so much more than “The Lady with the Lamp.” She was a forward futuristic thinker, and although not all of her advice proved relevant, much of her work remains the basis of nursing, hospital and healthcare reform today (McDonald, 2020b, para. 23-24).

What Would Florence Advocate for Today?

Historical writings through publications, correspondence and notes by Florence show us what she fought for. These findings would lead us to believe in modern-day, she would continue to advocate for best practice in:

  • infection prevention
  • disease prevention
  • hospital architectural design to enhance healing and nursing efficiency
  • supportive research and data collection to justify changes
  • remediating patient safety issues to avoid errors
  • questioning hospital expenditures
  • allocating healthcare funds
  • access to healthcare for all
  • stress reduction (both physical and psychological)

But besides these broad areas listed she also fought for equality and the protection of not only patients, but nurses as well, inside and outside of hospital walls. Much of today’s terminology, with regards to the treatment of nurses on the job was not commonly used in her time. It was even thought that she alluded to protecting nurses and nursing students from “sexual harassment” and “sexual abuse” when she advised against “holes and corners” with regards to hospital design (McDonald, 2020b, para. 5). Florence also expressed that nurses and student nurses should have a safe environment to work in, and they should have a comfortable work environment (McDonald, 2020b, para. 5-6).

What Constitutes a Safe Work Environment?

Certainly, a safe work environment includes Physical and Psychological Safety. Physical and Psychological Safety have always been of great concern for Nurses and Healthcare Worker’s and has been unbelievably magnified since the COVID-19 pandemic (Mann, 2020). While Physical Safety must be considered first, Psychological Safety can no longer be ignored. Yes, the lack of Physical Safety can lead to injury, contracting disease of all kinds, short and long-term disability, and even death. The absence of Psychological Safety can and does have the same implications, but many times gets ignored within our healthcare institutions and healthcare culture.

Hospital Reform Through Internal Culture Change

Now more than ever healthcare organizations need to understand the importance of assuring, to the best of their ability, healthcare workers are psychologically safe on the job. There is no more denying the problem exists. When organizations private and public publish articles and a call to action on Harassment, Bullying, Bystander Effect, and Microaggressions (which stretch beyond gender and racism) we know how pervasive the problem is. Awareness is all around us through peer reviewed articles and books, and leading speakers touring and training on these subjects. Let’s take a look at some of these organizations and what they are publishing:

  • American Nurses Association, (2015, July 22)
  • American Medical Association (AMA), (Murphy, 2020)
  • The Robert Wood Johnson (RWJF), (Fountain, 2014)
  • National Institutes of Health (NIH), (Edmonson & Zelonka, 2019)  
  • Occupational Safety and Health Administration (OSHA), (OSHA, 2015)
  • The Joint Commission (The Joint Commission, 2016)

With all we know of Florence, today she would be an advocate for Hospital Reform through “Internal Cultural Change” to promote Psychological Safety for nurses and healthcare workers. She would ask, “Given all the attention issues surrounding the lack of Psychological Safety in recent times have had, why is it still so prevalent within healthcare settings”, “Why are we all talk, and despite attempts to mitigate the problems, having little success?” She would undoubtedly let the statistics speak for themselves.

Our Modern Day Nightingales: Solutions Offered

Researching who Florence Nightingale was and what she stood for reveals an individual that was: always looking; always leading; always problem-solving; never accepting that this is all we have; that this is all we can do; never giving up on finding solutions. She is a voice from the past that resonates with us today on current issues. If she were alive today, we know this driving force would continue doing the same, utilizing modern-day research and listening to frontline staff that brings to light problems that need to be addressed. So, what are our modern-day Nightingales doing? Collaboratively, nurses and non-nurses are doing the same, working towards Hospital Reform through creative solutions such as:

  • Training on Harassment and Bullying
  • Training on Microaggression
  • Training on Bystander Effect
  • Training on Psychological Safety
  • Working Around Obstacles to Protect Staff Physically and Psychologically  
  • Books and Journal Articles Calling Out Issues
  • Foundations and Professional Organizations Giving Voice and Solution to Issues
  • Promoting Psychological Safety
  • Software and Apps Created to Track Internal Issues Giving Staff Anonymity When Reporting

Listing resources for the above list would be exhaustive. A simple Google search opens our eyes to the ubiquity of these problems, and the attempt to bring awareness and solutions to them. However, three individuals worth mentioning here are Amy Edmondson, Toni Howard Lowe, and Pamela M. Tripp. Amy Edmondson is a Harvard Business School professor who coined the term Psychological Safety and defines it as: “a sense of confidence that the team will not embarrass, reject, or punish someone for speaking up with ideas, questions, concerns, or mistakes. It is a shared belief that the team is safe for interpersonal risk-taking.” (Andreatta, 2020). Toni Howard Lowe is, “a global diversity and inclusion strategist and consultant” and founder and CEO of  TCT Consultant Group. She consults corporations, engages in speaking tours across the country, and gives trainings on “Microaggression” in the workplace (Lowe, 2021). Those interested in her trainings can view her on LinkedIn free. Pamela M. Tripp is President and Founder of “Corporate Transcendence” and author of “The Culture Cure: Transforming the Modern Healthcare System” (Tripp, n.d.).

These three women, non-nurses, are working inside and outside of healthcare. Their aim is to change our toxic cultural workplace practices, from employees on up to CEO’s. Wouldn’t Florence be so proud of these women, wouldn’t she collaborate with them?


While honoring and acknowledging frontline healthcare workers through media, billboards and such is welcomed and appreciated, it should never take the place of protecting, supporting and compensating those workers both Physically and Psychologically in an effort to “cause no harm.”  It takes a village of like minds, working for a common cause to bring about change. It is so important to “Critically Think.” There may not be a best practice in the moment. The best practice at the time may be standing up, speaking out and doing the right thing. Isn’t that what Florence would do?


American Nurses Association (ANA). (2015, July 22). Incivility, bullying, and workplace violence. ANA Position Statement. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/

Andreatta, B. (2020, October 26). Work shouldn’t hurt: Resources for workplace bullying and psychological safety. Retrieved from https://www.brittandreatta.com/about-britt-andreatta/

Edmonson, C., Zelonka, C. (2019, June 4). Our own worst enemies: The nurse bullying epidemic. Nursing Administration Quarterly. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716575/

Fountain, D. M. (2014, April 27). How to address disparities? End bullying of nurses in the workplace. Culture of Health Blog: Robert Wood Johnson Foundation. Retrieved from https://www.rwjf.org/en/blog/2014/04/how_to_address_dispa2.html

Hammer, J. (2020, March). The defiance of florence nightingale. Smithsonian Magazine. Retrieved from

Lowe, T. (2021). Dealing with microaggression as an employee. LinkedIn Learning. Retrieved from https://www.lynda.com/Toni-Lowe/20544000-1.html

Mann, B. (2020, May 2). Nurses left vulnerable to COVID-19: 'We're not martyrs sacrificing our lives'. Retrieved from

McDonald, L. (2020a, May 4). Florence nightingale: The making of a hospital reformer. HERD: Health Environments Research & Design Journal.

McDonald, L. (2020b, June 8). Florence nightingale’s influence on hospital design, hospitalism, hospital diseases, and hospital architects. HERD: Health Environments Research & Design Journal. Retrieved from https://journals.sagepub.com/doi/full/10.1177/1937586720931058

Murphy, B. (2020, November 17). Workplace bullying must have absolutely no place in medicine. American Medical Association. Retrieved from

Occupational Safety and Health Administration (OSHA). (2015, December). Caring for our caregivers: Preventing workplace violence: A road map for healthcare facilities. Retrieved from https://www.osha.gov/sites/default/files/OSHA3827.pdf

The Joint Commission. (2016, June). Bullying has no place in health care. Quick Safety Issue 24: The Joint Commission. Retrieved from https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/joint-commission-online/quick_safety_issue_24_june_2016pdf.pdf?db=web&hash=84E4112AB428AD3CA1D5B9F868A1AD10

Tripp, P. (n.d.). Transformational change in healthcare Speaker profile. Retrieved from http://www.sahalliance.org/files/Pamela Tripp - Speaker Profile.pdf

Additional Resources & Reading

Duma, Maingi, Tap, Weekes, Thomas Jr. (2019, May). Establishing a mutually respectful environment in the workplace: A toolbox for performance excellence. American Society of Clinical Oncology. Retrieved from

Edmondson, A. (n.d.). Why is psychological safety so important in health care? Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Amy-Edmondson-Why-Is-Psychological-Safety-So-Important-in-Health-Care.aspx

Hughes-Reese, M. (2017, April). Magnet tip: Cultivating psychological safety at the unit level. American Nurses Association. Retrieved from

Institute for Healthcare Improvement. (2021). Why is psychological safety so important in health care? Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Amy-Edmondson-Why-Is-Psychological-Safety-So-Important-in-Health-Care.aspx

Redford, G. (2019, November 12). Amy Edmondson: Psychological safety is critically important in medicine. Association of American Medical Colleges. Retrieved from

Tripp, P. (n.d.). The fix the healthcare industry yearns for. [Web log post]. Retrieved from https://pamelatripp.com/culture-fix-healthcare/

Christie Dungey MSN RN Advocating for Psychological Safety in Healthcare

2 Articles   10 Posts

Share this post


3 Articles; 18 Posts

Has 42 years experience.

Very well written. Hospital reform is critical for the future of nurses and patients.



2 Articles; 10 Posts

Specializes in Critical Care. Has 29 years experience.
On 8/3/2021 at 4:43 PM, cherylrenee said:

Very well written. Hospital reform is critical for the future of nurses and patients.


Thank You Cheryl! Nurses cannot be divided, we must support each other to survive in these times.