In 2000, Malcolm Gladwell's1 book, it The Tipping Point, hit the bestseller list. The book was about change and how it happens. At last, an explanation of how change spreads, how ideas are adopted, and who is most instrumental in making change happen. Gladwell asserted that changes in any market or organization were driven largely by "connectors," those special individuals whose early adoption of a product, service, or idea is a near guarantee of success because of their extensive social networks and their knack for "spreading the word."
Gladwell referred to this phenomenon as the "law of the few," that is, get your message to those few influentials in your world and watch change tip, even explode. An explicit premise in The Tipping Point is that some people matter more than others when it comes to driving change.
Nurses often struggle with the perception that they are not major players in the game of change in healthcare. There is much to be done to inject more caring into healthcare; to design healthcare from the vantage point of patients, families, and communities; to include a menu of holistic modalities to complement and soften the edge of traditional interventions; to pay more attention to patient teaching and primary prevention; and to humanize clinical environments.
Every single nurse practicing today can tip a trend in the most positive of directions because there is now ample evidence that in our world of social complexity anyone can tip or trigger a trend, spread an idea, or initiate change. The notion of "connectors or influentials" is obsolete. Ideas and trends spread randomly in any network until, like a virus, their load explodes into significant change. In fact, Duncan Watts, a network theory scientist from Columbia University, has offered strong evidence that if a society or organization is ready to embrace a trend, almost anyone can start one and if it is not ready, then almost no one can.2 It just might be that the special few are not that special when it comes to making change. Watt's work heralds the end of the special few and opens the door for every nurse to test and assess environments for the changes that desperately need to be made to improve healthcare delivery. In Watts' view, there is a viral quality to the spread of change and that virus is extremely sensitive to the conditions of the environment. If the environment is right, the virus spreads like wildfire; however, certain conditions can restrict or even stop viral change cold.
So, what is the significance of Watt's theory to nursing practice? Nurses everywhere, in every setting, have the ideas and the power to make significant change. All nurses need to determine is what changes the environment can bear or embrace. For example, is your workplace ready to embrace the use of clinical aromatherapy in the patient room, in the newborn nursery, or in the MRI tube for the purpose of soothing and comforting patients? How will you know unless you test the readiness of the environment?
For nurses, Watts' message is one of empowerment. Any nurse can start a trend in any setting. All that is needed is one good idea to plant in a ready environment. Nurses can spread ideas on how to improve patient safety or patient satisfaction, how to educate future nurses more effectively, or how to redesign a room to enhance healing-the list endless. What changes are needed and to what degree is the environment ready to embark on change.Better yet, what changes are desperately needed and how can nurses prime the environment to accept change. In other words, the change process works from both ends; either assess that the environment is ready or tweak the environment to embrace your change.
Let us take one moment to remember Florence Nightingale and how she worked change. Clearly she was not the typical upper-class Victorian woman, hoping for a good marriage and a sedate life, doing needlepoint and entertaining the local gentry. She wanted to "work," to make a difference-an idea that was so alien in her era and to her family, yet she was determined. Work was not an option for proper Victorian women, let alone the kind of work that nursing presumed. So she scanned the environment and took advantage of the Crimean War, through which to drive her idea about the efficacy of nursing care.
All she had was hygiene to make her point-remember there was not even a wide acceptance of the germ theory when she began her Crimean quest-so she cleaned up the war hospital environment and lowered the mortality by more than 80%. Then she paraded around her statistical charts to bring home the point. She had enemies that she largely ignored or worked around-because she was "viral" about creating change, about legitimizing work for women, and about proving that good nursing care makes an enormous difference in the lives and health of people-whether in the hospital, home, or community. And her ideas spread to the United States and other parts of the world even without the Internet-amazing.
Each nurse reading this journal has much more opportunity than Nightingale to make significant change because of technologies that enable rapid communication and social networking. Today's currency is ideas, and the profession of nursing will either be richer or poorer as function of its idea production. I am standing before a reservoir of ideas that could revolutionize practice because as Watts is telling us, "anyone can start a trend," there are no "influentials," there is no "special few." It is about the democratization of ideas and information to improve nursing practice, and every day in every healthcare arena, nurses are improvising to improve care. Think about the last time you initiated something new at work, even if it was one simple change for only one patient. Did you share the outcome of your intervention with another nurse or with your nurse manager?
Now I need to caution you-ideas are dangerous. They will get you into conflict, require that you defend your notions, produce data, and offer evidence that your change produced some desired effect. But because you do not need to be "influential" to create change, you will find many allies along the way. If the environment is ready, your change will take hold, and if it is not ready, you will tweak it until it is. I am reminded of a nurse by the name of Jane Elinor Lester, who noticed when she put jaundiced babies near the sunlit nursery window that their jaundice cleared up faster, and a nurse by the name of Hildegard Peplau, who hung her shingle and practiced as an independent psychotherapist and was accused of practicing medicine without a license. There are so many stories of nurses who have made and are making a difference-the difference for this generation is that you can disseminate your ideas so widely, you can network with nurses all over the world, and you can and will change healthcare because there is just no one else to do it. So as my mother used to say, "If you want something done right, do it yourself." I challenge the readership of Holistic Nursing Practice to forget about tipping points and the special few. All nurses need to do is step up to the plate with an idea, spread the word, and believe in the power of viral change.
Gloria Ferraro Donnelly, PhD, RN, FAAN
Editor-in-Chief
REFERENCES