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Influence has long been a grounding principle of clinical nurse specialist (CNS) practice. Clinical nurse specialists were conceived of as expert advanced nurses with ability to influence practice without administrative authority. The Spheres of Influence Framework, developed by the National Association of Clinical Nurse Specialists, describes CNS practice as 3 distinct yet overlapping and interacting domains aptly called spheres of influence.1 Thus, throughout our history and culminating in the current framework, it is clear that CNS practice outcomes are based on the power of influence.


The enormity of the idea that influence is the power behind practice outcomes has been underappreciated, or so it seemed to me when I discovered How, a book by Dov Seidman, the full title being How: Why How We Do Anything Means Everything[horizontal ellipsis] in Business (and in Life).2 Seidman2 noted that having specialized knowledge and skill differentiates an individual for a moment in time, but it will likely not support an entire career. Continuing to achieve desired outcomes depends on adapting knowledge and skill to new conditions. Given this, Siedman2 argued that success is not related to what you do, but how you do it. How, he explained, exists in the space between us.


A simple analogy to the nervous system served as Seidman's starting point for explaining how. The nervous system is a network of excitable membranes wherein action potentials move along nerve fibers and pass on messages by crossing synapses. It is the transmission of the message across the synapse, the space between nerves, that allows for human behavior. He compared nervous system message transmission to a wave created by football fans in a stadium. It starts with several fans initiating a behavior, the behavior conveys a message, and other fans receive the message and respond in a kind of behavior producing a recognizable pattern of a wave passing through the stadium. The success of the wave depends on a message passing from person to person in the space between them. As the simple example of wave demonstrates, achieving success in influencing human behavior is tied to how the message is communicated in the space between us.


Influence, as described in the Spheres of Influence CNS practice framework, is similar to Seidman's notion of how. Influence is what occurs in the space between the CNS and patients, nurses, hospital administrators, other healthcare providers, and policy makers. Success occurs in the transmission of a message of desired behavior traversing the space between us. How reflects core values-Seidman offers integrity, passion, humility, and truth as core values. The core values are actualized through leadership attributes such as vision, optimism, and the ability to confront complexity, tolerate ambiguity, take responsibility, and pursue significance to name a few. In contrast, when how reflects attributes such as blind determination, lack of awareness, complacency, short-term gains, and lack of transparency, the messages that are communicated do not lead to long-term success.


Influencing patient and health-related outcomes by communicating in the space between us is the work of the CNS. As we continue to grapple with educational standards, practice competencies, and legislative issues, it is important and timely that CNSs also address the notion of influence as central to our role and practice. Seidman makes it clear that how does not just happen; it takes initiative, planning, and reinforcement. To further explore how as it applies to the notion of CNS influence, the journal invites manuscripts describing theory and research that further our understanding of how we do our work in the space between us.




1. Baldwin KM, Lyon BL, Clark AP, Fulton J, Dayhoff N. Developing clinical nurse specialist practice competencies. Clin Nurse Spec. 2007;21(6):297-303. [Context Link]


2. Seidman D. How: Why HOW We Do Anything Means Everything[horizontal ellipsis] in Business (and in Life). Hoboken, NJ: John Wiley & Sons Inc; 2007. [Context Link]