Le nursing, dans son évolution, est considéré soit comme un prolongement dans le domaine de la médecine, c.-à.-d. comme assurant un rôle d'assistant ou de substitut du médecin, ou encore comme un é1argissement dans un domaine des services de santé pour faire le pont avec les divers services. Ici, il s'agit d'un rôle complémentaire par rapport à celui des autres professionnels de la santé. La première approche demande des connaissances et des compétences médicales supplémentaires, alors que la seconde favorise une amplification de la fonction essentielle du nursing. Ces deux perspectives caractéristiques quant aux nouveaux rôles du nursing se distinguent d'après les dimensions suivantes : type de problème, envergure de la difficulté, perspective, moyens d'évaluation de la situation, base de la planification des soins, délais, et modalité d'évaluation. L'étude considère que la pratique du nursing peut être distinguée selon ces dimensions et l'hypothèse suppose que ces deux approches du nursing provoquent des résultats différents pour les sujets et pour les familles; de plus, chaque approche, pour être viable, requiert des relations d'équipe différentes. L'hypothèse est à l'étude dans le cadre d'une recherche comparative dans trois milieux de soins primaires.

During recent years in the development of health services in Canada and the United States, much emphasis has been placed on the “expanding role” of the nurse. The nature of this expansion seems to take on different characteristics depending upon which health professionals instigate the role innovation and what their views of nursing are.

The Research Unit in Nursing and Health Care at McGill is studying nursing as it is carried out in several settings where different perceptions of an expanded nursing role are being implemented. A basic assumption, developed in the paper that follows, is that this expansion is perceived in one of two ways - as a replacement function or as a complemental function, relative to the knowledge and skills of other health professionals, e.g. the physician. For each approach, characteristic notions of health and nursing practice are described. The research is directed towards demonstrating that differing approaches to nursing yield differing outcomes for individuals/families. This working paper presents the theoretical underpinnings of our ongoing research project.

Approaches to an Expanded Nursing Role
Physicians concerned with the diagnosis and treatment of illness and the prevention of disease perceive the development of nursing as an expansion into the field of medicine, that is, incorporating a portion of the doctor's knowledge and skills. This role is termed the assistant-to-the-physician function; in outlying areas it approaches a complete replacement function. Building on either diploma or baccalaureate basic preparation, the doctor assumes, at least initially, a major share of the instruction in preparing nurses for this type of expanded role. Nurse practitioner practice in primary care settings most closely approximates this version of the expanded function of nursing.

Nurses, on the other hand, particularly those in university settings where philosophies of nursing are being rationalized, tend to perceive the expansion of nursing in one of two ways.

First, the expansion is within the realm of medical knowledge and associated skills are required for the treatment and care of those who are ill, both acute and chronic. This role shares most of the characteristics of the replacement function, as the expansion is based on increasing the medical knowledge and skills of the nurse so that her understanding of the pathological processes, diagnosis, and treatment closely parallels that of the medical person. Although the medical aspects are favoured in expanding the role in the direction of replacement, nursing has attempted to attend also to the psychological and social components which prevail in each particular illness situation. This role is played by persons with baccalaureate or master's preparation where the program emphasis has been on specialized preparation in nursing, that is, medical, psychiatric, community health, geriatrics. It can be found in acute care settings as well as in settings outside the hospital, such as solo practice or group practice with physicians.

Second, the expanded role for nursing is being enacted in primary care settings where emphasis is on the development and maintenance of family health. Here nursing is concerned over time with the family unit, with everyday health practices at the levels of both the individual and the family, with healthy ways of dealing or coping with life situations and problems, with family health given a long-term health problem of a family member, and with follow-up when family members are involved with other health professionals. This expansion of the nurse's role is viewed as complemental in that it does not replace that of other health professionals, but adds another dimension to health care service. It is an expansion of nursing into areas of need which are unmet and unfulfilled at this time; it is also an expansion of the core of what nursing basically is. Knowledge for the complemental function is found, in particular, in the study of the humanities and social sciences. Skills to perform this function are derived from the ability to be responsive to the individual/family both in perception and assessment and in planning and practice. Generic programs in nursing at the baccalaureate level which include a science base, both biological and social, can prepare the individual for this type of expanded function. Preparation at the master's level is required if the nurse is to acquire greater expertise.

The following paper describes the theoretical base for each type of expanded function, replacement and complemental, one an expansion into medicine, the other an expansion of the substance of nursing. These variations in perception of nursing were noted in earlier writings of the author (Allen, 1977; Allen & Reidy, 1971).

Views of Health and Implications for Nursing Practice
Health and the Replacement Function

Health is freedom from superimposed or unnatural influences. Health is seen as the pristine state pre-existing disorder or disease, or as the newly achieved state resulting from the eradication of the superimposed disorder. (Blum, 1974, p. 78)

This notion of health has provided the basis for developing a medical science and is, therefore, evident in nursing activities serving the replacement function. It requires a form of health care in which the goal is to keep people free from disease. The identifying features of a plan to achieve this goal are:

1. screening procedures and checkups to rule out disease;
2. prophylactic measures, such as immunization to prevent specific illnesses;
3. “good” health habits to increase resistance to disease, for example: nutrition, elimination, personal hygiene, rest and exercise, work and recreation; and
4. early diagnosis, treatment, and rehabilitation.

The individual who implements a health care regime contingent on Blum's (1974) definition of health may be identified by the following behaviours. The person practises “good” health habits and institutes reliable measures to prevent disease. He is concerned with illness and looks for reassurance that he is not ill. He is informed and knowledgeable about disease. If sickness does arise he seeks treatment and follows the regime with care and precision. He is a “heavy” utilizer of health services. He views health professionals as having the knowledge to keep him well and he looks for direction to these sources. He tends to adhere to learned ways - health habits and knowledge - and, therefore, experiences difficulty in modifying his behaviour to meet changing health concepts as well as his own needs.

In the assistant-to-the-physician role, the physician has a decisive part in determining the tasks nurses will perform in preventive, curative, and rehabilitative care. To date, nurses in this role have functioned by screening patients and performing the initial workup of physical examination and medical history. In some situations, this focus is extended to include the standard medical treatment regime for the specific problem as well as the subsequent follow-up.

The function of nursing expands as it moves from the assistant-to-the-physician role to replacement of a major part of the physician's work - assessment, treatment, prevention, rehabilitation, follow-up. For this reason, the replacement function tends to follow the medical approach, dealing with common problems about which there is a relatively large body of knowledge and for which there are accepted approaches and solutions. To this end, the nurse accumulates a large body of knowledge; she knows what to look for, what to observe, and what information to gather; she is skilled at attaching meaning to evidence; and she arrives, once the data are amassed, at a reasonable assessment. The treatment plan follows logically, and long-term evaluation relates to the expected outcomes as indicated by the diagnosis.

Health and the Complemental Function

Health is a continuing property, potentially measurable by the individual's ability to rally from insults, whether chemical, physical, infectious, psychological or social. Rallying is measured by completeness and speed. Any insult may have a “training function” and recovery will often be to a slightly higher level of health. The person or body learns something. (Audy, 1971)

An exploratory, responsive approach to health care is adopted by those who see health as a characteristic of a functioning life system, including nurses whose practice is described as complemental. Health care in this framework concentrates on assisting the individual/family to develop ways of dealing with everyday situations in a health-promoting fashion. It assumes that developing abilities of this nature builds and augments the potential for health of the individual/family. The family gains some control over the minor and major events in their lives. The individual/family learns a way of being healthy which is responsive to situations over time.

This notion of health is identified with the following behaviours in the individual/family. They discuss and share information on common problems, they seek out relevant sources of information and knowledge, and they work out plans of action. Each individual has some input into the situation if it is relevant to him. The family plan ahead and make long-term approaches to situations; there are few crises. They use health professionals judiciously, learning to rely on their own judgement and resources in most situations. They approach the professional with relevant and organized information and with some assessment and plan, which they seek to discuss and work out with the professional. They look for outcomes from the plan as feedback and make use of it in further planning. They wish to be healthy and pursue this goal by fashioning their approach to the needs of the situation, thereby learning more about how to achieve health as they go along.

The expanded role of the nurse in this context derives from a complemental function, a function in addition to that provided by other professionals. It is an expansion of the core attributes and tasks of nursing into problem areas where health services remain in an inchoate state. A major gap is to be filled in services directed towards family health: assistance in developing individual/family practices which have a positive benefit for health at the levels of both the individual and the family; guidance in the growth and development of children so that they learn constructive health practices; and assistance to families in coping with chronic illness and other long-term problems in a healthful fashion. To these ends, nursing practice develops an exploratory and developmental approach. Emphasis is placed on the assessment phase with the individual/family as a primary source of information, on strengthening individual/family potential as the major component of a plan of action, and on gathering evidence of individual/family responses as a basis for further planning and development.

Two Characteristic Approaches to Nursing
The above conceptions of nursing practice underscore a study of the performance of nurses in primary care settings. Initial investigation identified certain aspects of practice as critical to the approach taken by the nurse. These distinctions between replacement and complemental were particularly marked at seven points:

	Replacement Function		Complemental Function
1.	Problem: What is the focus of the nurse in a particular individual/ family situation?
	Problem is perceived as illness - basically medical conditions involved in the individual or family, that is, any disease, including diagnosed psychiatric illness, and the etiology, pathology, symptomatology, diagnosis, treatment, prevention, etc.		Focus is on the health aspect, that is, situations related to the individual/ family's coping either with a medical condition of the individual/ family or with their accommodation to the events of daily living, including both customary situations and unusual ones (crises).
2.	Size of concern: What is the size of the unit (persons involved) within which the nurse perceives the problem to be?
	Problem is described as a phenomenon of the individual; it may be assessed at this level and/or as it affects the family and individuals therein.		Problem is described as a phenomenon of the family; it may be assessed at this level and/or as it affects individuals or groups of individuals therein.
3.	Perspective: What is the extent and complexity of the problem as perceived by the nurse?
	Problem is viewed as a closed system, with a beginning and an end, isolated from other happenings and limited in time, that is, episodic.		Problem is viewed as an open system, which develops, changes, influences and is influenced by other life events; it is seen over time (long term).
4.	Assessment: What sources of information and knowledge does the nurse draw upon to identify the problem of the individual/family?
	Nurse uses existing knowledge and experience to define the situation for her; relying on the logical structure of diagnosis to guide her a priori notions of what information and evidence to obtain and factors to relate.		Nurse observes and gathers information from the individual/family, seeks other sources for related information (library, other professionals, etc.), and brings her own knowledge and experience to bear on the problem; working in an exploratory fashion, she seeks to rationalize the evidence from these sources within the most probable explanatory framework.
5.	Plan of care: Upon which attributes within the individual/family does the nurse establish the plan of care?
	Nurse bases her plan on the lacks and failures which underlie the person's problem.		Nurse recognizes and utilizes strengths and positive forces (potential) in the individual/family situation as a basis for action.
	Replacement Function		Complemental Function
6.	Time frame: How are interventions for the individual/family timed?
	Nurse “zooms in” with the concrete aspects of the plan in a precise and orderly fashion.		Implementation of the plan is characterized by a “wait” period directed towards achieving the best “fit” of action to the individual/ family situation.
7.	Evaluation: What is the nurse's approach in identifying outcomes of the plan as feedback for further assessment and planning?
	Nurse assesses the extent to which the objectives of the plan have been achieved, noting discrepancies between the individual's behaviour and expected outcomes. Further planning to remedy deviations is based upon strengthening the plan and reinforcing its methods.		Nurse notes the individual/family responses to the plan of care and fashions the plan further on these outcomes. Objectives and purpose are achieved as outcomes become visible.

In summary, we have described some dimensions of nursing practice. Preliminary investigation of data garnered from observations and nursing records indicates that nurses implementing the complemental type of expanded function of nursing differ on these dimensions from nurses implementing the replacement type of expanded function. In addition, our present hypothesis suggests that these two approaches to nursing have differential outcomes for individuals and families and require differing sets of team relationships to be viable. This hypothesis is being tested in a comparative study involving three primary care settings each located within a large hospital in one urban setting.

References
Allen, M. (1977). Design for evaluation: Applied educational programs in nursing. Geneva: World Health Organization.

Allen, M., & Reidy, M. (1971). Learning to nurse: The first five years of the Ryerson nursing program. Toronto: Registered Nurses Association of Ontario.

Audy, J.R. (1971). Measurement and diagnosis of health. In Shepard & McKinley (Eds.), Environmental essays on the planet as a home. Boston: Houghton Mifflin.

Blum, H. (1974). Planning for health. New York: Human Science Press.


* Originally published in Nursing Papers, 1977, Vol. 9, No. 2, 38-45.