1. Davidson, Sue B. PhD, RN, CNS

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CNSs, NACNS, and the Tipping Point

All the arrangements were complete, the supplies and conference materials received, and the registration area set up, and then we launched what was to my somewhat biased view, our best-ever annual conference in Atlanta this year. We had the largest number of abstracts for posters and podium presentations submitted and accepted so far, attendance by the greatest number to date, and the launching of the CNS of the Year award, an initiative that was a dream of Dr Rhonda Scott, one of NACNS's recent presidents. By all accounts, these external indicators suggest that we are close to reaching our strategic goals for CNS practice in nursing and in the healthcare system. What more must we do?


The answer to this question unexpectedly emerged as I recently read a book titled The Tipping Point: How Little Things Can Make a Big Difference.1 This book describes a theory of change that shows how little things can cumulatively lead to really big changes. The theory also offers an intriguing way of evaluating where we are relative to our goals. To illustrate how the theory works, the author tells a story about hush puppies, suede shoes with crepe soles that were popular in the 1960s. However, their popularity dropped as styles and types of men's shoes changed, and, by the mid-1990s, the company was only selling about 30,000 pairs a year. Then, two company executives began to hear that hush puppies were being worn by people in clubs and bars in Manhattan and by a well-known New York fashion designer. In 1995, the company sold more than 400,000 pairs and in 1996, more than 1.5 million pairs. No one tried to make hush puppies a trend, but due to accumulated small changes that "tipped" hush puppies, they became a trend in two years. Unlike changes that unfold in a predictable, incremental, and linear way, "tipping" point change describes when the unexpected becomes expected. The book explores how some trends lead to epidemics and others don't. Reading the book made me think about how we can deliberatively start and control an "epidemic" of our own whose purpose is to enhance and increase the recognition and valuing of CNS practice.


Tipping trends and changes depend on 3 things:


* Three types of people


* Stickiness of the message


* Context



The 3 people types that are needed for small changes to accumulate are connectors, people who occupy niches in one world but who also are uniquely gifted in connecting people to other worlds; mavens, people whom Gladwell calls "knowledge vigilantes"-people who know everything there is to know about a particular product and action and who convincingly articulate that value everywhere they go; and salespeople, the persuaders of innovation or of change. Having sufficient numbers of these 3 types of people talking about and supporting a particular trend, product, or action is one of the factors that is critical to tipping.


The second requisite for tipping point change is the stickiness of the message. This component relates to the unforgettable features of a message that stay with the recipient long after the interaction in which the message was received. Stickiness can be enhanced in the message by making changes to the presentation or the structure of the information that result in the desired impact.


The third aspect of tipping point change is attention to context, particular aspects of the context (eg, setting in which you work), which may not be perceived but that has great meaning. An example of this might be seen in the effect of broken windows or clutter in a neighborhood where illegal drug activity is being established. These changes in the context signal almost at an imperceptible level that the community is not able to hold together. The effect of small interventions, replacing broken windows and adequate street lighting, are perceived as positive change even though they are indirect. In summary, the tipping theory of change explains the gap that can occur between the early response of some to an innovation and when the change becomes widespread throughout the culture.


So, how does this apply to CNS practice and NACNS? In my view, CNS practice fits into the category of a new idea or a change. My reasons for saying this are that for a nearly 15-year period (1980-1995), there was no national presence or organization that focused solely on the practice of CNSs while, at the same time, there were at least 4 major national organizations for nurse practitioners (NP) who were able to obtain many legislative and regulatory changes to support NP practice. The message of the 1980s to the public and to nurses about CNS practice was unclear, unheard, and, in some ways, nonexistent. Through this same time period there were multiple and differing voices within nursing articulating one solution or another about who was needed to respond to the needs for nursing care of the nation.


Since the emergence of NACNS in 1995, we have continuously articulated 4 simple messages about CNSs and their practice. The messages are:


1. NACNS is the only nursing organization at the national level that represents nurses who practice as CNSs


2. CNS practice is a requisite for quality healthcare


3. CNSs have a unique practice that differs from that of other advanced practice nurses


4. When CNS practice is viewed with that of other advanced practice nurses, it provides the diversity needed to meet the multiplicity of nursing and healthcare needs of individuals and families and advances the practice of nursing within organizations and systems.



Are there connectors, mavens and salesmen and saleswomen among the CNSs in NACNS and those who presently practice in this country? By definition, CNSs are mavens, they are knowledge vigilantes (in the best sense of the word ) whose grasp of the best- and evidenced-based practices to address gaps and problems in the provision of nursing care make them extremely valuable to the systems in which they practice. By definition, CNSs would not have survived the last 20-year period if they haven't been good salespeople related to the outcomes of their practice. What I think we have not yet fully discovered is all of the strategic partners whose interests and strengths intersect with ours in ways that are mutually beneficial. For example, my relationship with Kinkos, the 24-hour 7-days a week, quick printing services in most cities, is roughly equivalent to an essential vitamin. Given my use and support of this valued business, what would happen if we approached Kinkos and asked them to underwrite via a grant, our conference syllabus for the next several years? What other creative partnerships exist that link us to others who can advance our interests through this mechanism?


It is my belief that CNS practice and NACNS as its spokespeople are close to tipping. What we need to do is continue to refine our message, enlarge our connectors, mavens and salespeople, work on increasing the stickiness of our message, and finally, intervene directly to improve those elements of nursing practice which staff nurses are concerned about, an example of sensitivity to perception of context. So, here's to tipping and thank you, Malcolm Gladwell!


NACNS Statement on Clinical Nurse Specialist Practice and Education

This document articulates the competencies requisite to CNS practice, outlines the necessary outcomes of nursing, and provides direction to schools of nursing regarding the preparation of CNSs. You can purchase your copy of this landmark document through the NACNS Office. The cost is $15 per copy for members of NACNS and $25 per copy for nonmembers. Discounts are offered on purchases of 15 copies or more. Contact the NACNS Office today to order your copy of the Statement.




1. Gladwell M. The Tipping Point: How Little Things Can Make A Big Difference. Boston: Little, Brown & Co; 2002. [Context Link]