Introduction

In recent years, providing quality care has been a priority issue for the health system, managers and health professionals.¹ Therefore, comprehensive care is the concept most widely used, with the aim of describing health care as a complete service, technically correct, humanised and individual-friendly.² However, the concept lacks defining criteria in healthcare in general and in nursing in particular, as our profession is very broad and has competencies in all healthcare areas. Caring has been strictly linked to nursing since the beginning of the profession and has been perfected and professionalised as nursing models have evolved. These are the basis of the general guidelines for clinical practice together with the nursing work method (the Nursing Care Process and its implementing tool- The Care Plan). In the research field, nursing models allow knowledge to be organised and direct researchers towards those health problems that need to be known in greater depth.^3,4

According to the American Nursing Association, the nursing process is considered as a standard for nursing practice; its importance has demanded substantial changes in its stages, favouring the development of the profession as a scientific discipline, which in turn has increased the quality of care.^5,6) The nursing process consists of five stages, which are closely related- assessment, diagnosis, planning, implementation and evaluation. For this study, we will refer only to the first two stages. The nursing process is designed to respond to the needs of the people we care for and to restore the patient's health and autonomy. It has become the nurses' most valuable tool. Today, the Nursing Care Plan provides the necessary support for the implementation of nursing care. On this basis, nursing care must be applied to all persons needing it and in all its aspects, both in the family and in the patient’s social and environmental settings. Therefore, the nursing model is based on care, both in theory and in practice, which has been enriched and completed over time. It is noteworthy that by identifying the concept of comprehensive care “foundations are laid to achieve optimal results in care, favouring comprehensive care for the individual in all areas- biophysiological, psychological, social and spiritual.^7-9

Under this premise, this study answers the following research question: What is the best scientific evidence available on the concept of "comprehensive health care" in Nursing care from the point of view of nursing care, its domains, and its characteristics? The definition of the concept starts from an analogy between concepts with the purpose of clarifying logical points and establishing relevant concepts of the domain that unite them, for which the exhaustive analysis of the information is used as a research technique, with the intention that this definition serves as a new line of research and that has a greater level of depth. In order to have arguments to support this assessment, the specific objective of this review is to systematize the available knowledge on the "comprehensive health care" concept in nursing from standpoint of the point of view of nursing care, its domains, and its characteristics.

Methods

A systematic review was conducted as a scientific method for the identification, collection, evaluation and synthesis of existing scientific evidence.⁹ However, an integrative review method was also used, as it provides a systematic and rigorous process designed to enable a comprehensive understanding of the context.¹⁰ The search was standardised and systematised to obtain the most relevant information about the concept of "Comprehensive Care". It is worthy to mention the significance of defining the concept in the nursing care framework through the care plan, to measure the quality of service in nursing, and to detect improvement areas.

Eligibility Criteria. All works were considered eligible, both qualitative and quantitative, of type retrospective, prospective, and cross-sectional studies, in addition, these studies should have been conducted by Nursing and with free access. To ensure that documents were only reviewed in the context of Nursing, exclusion criteria were required to further refine the search and the publications found during the database search. Thus, all studies that do not contain the concept of comprehensive health care in the title or the abstract, as well as studies that do not refer to comprehensive health care oriented to nursing practice, were excluded.

Search Strategy. To search for information, only observational scientific articles were included, whether transversal or longitudinal, published from January 2013 to 2020, available in open access, published in English, Spanish, Romanian and Portuguese.

The databases consulted were Web of Science, Scopus, Medline, PubMed, Cochrane, and Dialnet. The keywords used were comprehensive health care, health. and nursing, following the criteria established in Prisma.¹¹ The Boolean operators used were the intersection: AND to establish the logical operations between concepts, OR to retrieve documents containing at least one of the specified arguments, and NOT to indicate that the keyword before the operator must appear, but not the one after it: Comprehensive health care AND health care AND Nursing NOT holistic care.

Screening Process. All publications included were reviewed in full by the authors. Data extraction included country identification, study design, and key findings. Moreover, a review of publication type was conducted. If it was a research publication, then the type of study, sample, and purpose of the publication was recorded. For the selection process, duplicates were removed, followed by a check of the titles and abstracts by selecting documents that could be relevant to the study successively in the first screening. The presence of the ''comprehensive care'' concept and a subsequent reference to Nursing were sought in the title and abstract of each article. The evaluation of the methodological quality of the articles included was carried out through a tool for the evaluation of studies resulting from qualitative research.¹²⁾ For the quantitative studies, the STROBE ^14,15 report on observational studies in epidemiology was used.

This review has been registered in PROSPERO with reference number 170327.

Figure 1 Flow-chart of Prisma diagram 

Results

After removing duplicates, the primary search reviewed 452 scientific articles from databases such as Web of Science, Scopus, Medline, PubMed, Cochrane and Dialnet. These were selected according to the title, abstract and full text, thereby limiting in each stage. The main reasons for rejection were that the studies did not provide a description of comprehensive care within the title and abstract, and that the concept was not found within clinical practice. The final analysis of the studies included in the qualitative synthesis showed 14 articles (Figure 1).

In accordance with the inclusion criteria established in the first screening of this search in the aforementioned databases, 72 references were found and 380 were excluded due to the type of methodological design, and because they did not meet the inclusion criteria related to the review’s objective, therefore, as a result of this process, 72 results meeting the defined criteria were selected. It was decided to carry out a second screening in order to select those articles that were available in full text and included the concept of comprehensive care specifically through nursing care plans or nursing interventions, and which were not literature reviews.

After this second screening, 18 potentially relevant references were selected to assess the methodological design in terms of the inclusion criteria established in the second screening. Eight different countries were identified from the 14 documents to be jointly evaluated (Table 1). The country with the highest scientific output in this context is Brazil with 8 documents (57%),^7,9,16-22 USA,²³ Australia,²⁴ Iran,²⁵ Ghana,⁸ Colombia,²⁶ and India²⁷ with one study each per country.

Concerning the methodology used in the studies, the qualitative paradigm prevailed with^{7,8,15-17,21,24-26,29} 62%, followed by the quantitative, three corresponding to the descriptive cross-sectional method^18,21-22 and a single observational, analytical cross-sectional article.¹⁹

The average population used was 103 patients, with a minimum of 5 and a maximum of 910. The population targeted by these studies was made up of various health professionals and specifically Nurses, Patients, Caregivers and family members. The concept of comprehensive care is referred to in most articles as complete care, beyond care related to the reason for admission at the admission time.^{8,9,18,21,22,24,19)} In addition, de Castro et al.²⁴, Naidon et al.,²⁵ Pai, et al.²²⁾ and Pell et al.,¹⁸ include care for psychological needs. On the other hand,^7,16,25,26 add care for spiritual needs and others^{19,21,26,27,16,23} emphasize care for social needs and Kavosi et al.²⁵ mention that communication by professionals is a significant part of comprehensive care, since it facilitates the relationship with the patient and his or her family, the understanding of his or her illness and the processes of examination, diagnosis and care planning; it weighs and moderates the expectations of healing, and allows the patient to be proactive and participate fully in all of them. In short, adequate communication humanises care and makes the patient the owner of his/her decision-making process.^16,19 On the other hand,^8,9,27,24 agree that the care plan is the best tool to provide comprehensive care and that nursing assessment allows for a patient examination in all its aspects, but they also highlight the need to continue the methodology and implementation training to increase our capacity and promptness when using them.

Assessment of Methodological Quality. The selected articles were evaluated using the peer review technique independently. Each study was evaluated for minimum quality. The methodological quality assessment was found to be between moderate and optimal, with the exception of 4 papers with low quality.²⁸.³¹

Discussion

This research study aimed to identify how the concept of "comprehensive care" in nursing care has been described from a professional point of view. After a systematic search, 14 documents were identified using an appropriate methodology; these documents were both qualitative and quantitative. The concept "Comprehensive Care" is used to refer to or describe various health services. Regarding the nursing profession, it is mainly used to refer to comprehensive nursing care techniques, protocols, programmes and plans, which cover care in all areas of the individual as a complement to or independently of the clinical needs arising from care.

In the results of the systematic search, the Nursing Care Process is highlighted as an implementing tool for care planning as reflected by Noia et al.¹⁵⁾ and Overcash et al.³² This includes a vehicle that allows the provision of comprehensive care applied to the needs that diseases trigger in all areas of the individual. Nevertheless, the care plan can be considered as a hardly operative tool that needs some time of evaluation for the patient, in order to provide an effective care, as mentioned by Andre et al.,⁸ Alvarenga et al.,²⁹ Lima Rocha et al.,¹⁶ Peel et al.,¹⁸ and Overcash et al.,³² for whom patients were the object of study.

Concerning the theoretical training, this should be focused on the health-disease process, diagnosis, treatment and approach to the patient in different circumstances, as sound scientific training improves and complements the nursing service, as ponted out by Overcash et al.³² The technical specificity of the nursing practical skills is undeniable, as it is the importance of the theoretical biological support in the care for users. But the symbiosis between the other human conformations is also recognised, which at some point will coincide with the treatment, either to enhance it or to hinder it. Therefore, this outlook is presented from the beginning of training in academic life, highlighting for future professionals the integrating components of the paradigm and of the genuine human transcendence. Where the latter, even during physical illness, demonstrates elements that participate in the health continuum and spread beyond the homeostatic alteration.

On the other hand, it can be seen that nurses provide partial coverage of the care plan, since care in the psychosocial sphere is neglected due to the scarce inclusion of the family in the patient’s comprehensive care.⁸ However, providing psychosocial and spiritual care is paramount, since this care impacts directly on the patient’s quality of life.²⁹ In addition, de Castro et al.²⁴ point out that good management of resources and services is necessary to achieve comprehensive care. It should be noted that, although at first glance they do not seem to be essential, nor do they seem to influence the patient’s clinical situation, well-being and quality of life are impaired without the necessary care in the long term, or there may be cases of somatisation and major clinical complications that delay the patient's healing and complete recovery.

Providing comprehensive care for the individual in all aspects is a moral and ethical obligation for nursing, because it is based on the existence of meeting the needs that the disease triggers in people through the care plan, as an orderly nursing tool that allows diagnosis in all aspects and address the patient’s needs. Nencetti et al.⁷ and Agyeman-Yeboah, et al.²⁰⁾ agree on this. In addition, according to Agyeman-Yeboah et al.,⁸ having a care plan allows the patient to recover faster, avoids complications or health problems, increases patient satisfaction and autonomy and, in economic terms, reduces health costs.

It should be noted that, as a whole, the different tools constitute a system that contemplates the whole being, providing care with changing and versatile components in their implementation that provide different guidelines for the nursing method of each patient. With regard to comprehensive care in the family and primary caregiver^{19) (25) (28)} emphasise that comprehensive care must include spiritual care and seek to focus on the patient's circumstances through prevention, promotion and health education in the individual, family and community, extending to all ages.

This review supports reflective exercise where it is required to consider the patient and the primary caregiver within the interdisciplinary team, as they live and cope with the disease. This experience is useful and valuable during the different stages of the nursing method, giving a resolving nature demonstrated by modification of indicators.

Conclusion

Comprehensive care must be personalised and prioritise what the person needs most, even if it is not related to the clinical reason for admission. This care must be extended to the family and society. In addition, it should focus on spiritual care, social relations and personal projection, which are just as important as technical care, since their attention improves quality of life and patient satisfaction with the care received. Comprehensive care should be the lever that favours a balance between the patient's health, personal autonomy and satisfaction with his or her life in general terms.