Description and Analysis of Research on Death and Dying during the COVID-19 Pandemic, Published in Nursing Journals Indexed in SCOPUS

Citation: Cuellar-Pompa, L.; Rodríguez-Gómez, J.Á.; Novo-Muñoz, M.M.; Rodríguez-Novo, N.; Rodríguez-Novo, Y.M.; MartínezAlberto, C.-E. Description and Analysis of Research on Death and Dying during the COVID-19 Pandemic, Published in Nursing Journals Indexed in SCOPUS. Nurs. Rep. 2024,14, 655–674. https:// doi.org/10.3390/nursrep14020050 Academic Editor: Richard Gray Received: 15 December 2023 Revised: 25 February 2024 Accepted: 11 March 2024 Published: 22 March 2024 Copyright: © 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Article Description and Analysis of Research on Death and Dying during the COVID-19 Pandemic, Published in Nursing Journals Indexed in SCOPUS Leticia Cuellar-Pompa 1,*, José Ángel Rodríguez-Gómez 2, María Mercedes Novo-Muñoz 2, Natalia Rodríguez-Novo 2, Yurena M. Rodríguez-Novo 3and Carlos-Enrique Martínez-Alberto 4 1 Instituto de Investigación en Cuidados del Ilustre Colegio de Enfermeros de Santa Cruz de Tenerife, Calle San Martín, 63, 38001 Santa Cruz de Tenerife, Spain 2Departamento de Enfermería, Facultad de Ciencias de la Salud, Sección de Enfermería y Fisioterapia, Universidad de La Laguna, Sta. María Soledad, s/n, Apartado 456, C. P., 38200 San Cristóbal de La Laguna, Spain; [email protected] (J.Á.R.-G.); [email protected] (M.M.N.-M.); nr[email protected] (N.R.-N.) 3Hospital Universitario Nuestra Señora de la Candelaria, Carretera General del Rosario, 145, 38010 Santa Cruz de Tenerife, Spain; [email protected] 4Escuela de Enfermería Nuestra Señora de Candelaria, Carretera General del Rosario, 145, 38010 Santa Cruz de Tenerife, Spain; [email protected] *Correspondence: [email protected] Abstract: Aim: To offer an overall picture of the research published regarding the different aspects of death and dying during the COVID-19 pandemic in journals covering the field of nursing in the Scopus database. Design: bibliometric analysis. Methods: The metadata obtained were exported from Scopus for subsequent analysis through Bibliometrix. Using the VOSviewer co-word analysis function, the conceptual and thematic structure of the publications was identified. Results: A total of 119 papers were retrieved, with the participation of 527 authors. The publications were found in 71 journals covering the nursing area. The main lines of research revolved around the keywords “palliative care” and “end-of-life care” in regard to the ethical, psychological, and organizational challenges faced by the health professionals who cared for these patients. Conclusion: The results obtained offer a range of data and images that characterize the scientific production published on this topic, coming to the conclusion that, due to the multifaceted and multidisciplinary approach to the experience of death, care, and accompaniment in the dying process, bibliometric maps improve the comprehensive understanding of the semantic and conceptual structure of this field of research. This study was retrospectively registered with the OSF Registries on the 14 March 2024. Keywords: nurses; palliative care; attitude to death; death; bibliometrics; knowledge discovery 1. Introduction Bibliometrics, as a discipline, allows for the description and evaluation of scientific publications in any field of knowledge [ 1 ]. This makes it possible to define the state of research, as well as analyze the different characteristics of scientific activity and predict trends through the analysis of different indicators that are established from the numerical data extracted from academic and scientific publications [ 2 ], such as the frequency of publication, authorship, collaboration, citation or co-citation by countries, institutions, etc. Thus, it is also possible to analyze the thematic development or the conceptual structure of a field through the analysis of keywords. Based on these considerations, this study focused on the analysis of publications on death and dying during the COVID-19 pandemic that were published in nursing journals indexed in Scopus. The health crisis caused by the pandemic represented a great challenge for health systems globally due to the drastic consequences caused by the sudden hospital overload. This scenario increased the pressure on healthcare professionals, with the workload resulting in Nurs. Rep. 2024,14, 655–674. https://doi.org/10.3390/nursrep14020050 https://www.mdpi.com/journal/nursrep Nurs. Rep. 2024,14 656 increased stress, physical and emotional exhaustion, fear, loneliness, the risk of contagion and death [ 3 – 5 ], which led to, according to data from 44 countries, the International Council of Nursing announcing at the end of 2020 that as many nurses had died from COVID-19 as during the First World War [6]. The health professionals had to dedicate themselves full time to their care activities. In this context, other common activities, including research, were relegated to the background [7]. This was made clear in a study in which the authors found a marked increase in nursing publications related to COVID-19 in the first months of 2021 compared to what was published during 2020 when the worst stage of the pandemic occurred [7]. Different bibliometric studies, where the keywords of the publications on nursing production throughout the pandemic were analyzed, agree that, in the first stage, the research was related to topics on coronavirus infection, infection control and health and nursing policy, after which the focus changed to the effects of the pandemic on mental health and quality of life, as well as issues related to nursing education, types of online training, nursing students, and new experiences of remote assistance [8–10]. Although death is part of the life cycle [ 11 ], the data on the impact experienced by health professionals and the large number of deaths associated with COVID-19 were frequently discussed in the media [ 12 , 13 ]; however, the different aspects of the process of death and dying during this period do not seem to have been developed in the scientific literature. Furthermore, there do not seem to be any bibliometric studies addressing this issue, although there are several bibliometric publications on COVID-19 in relation to nursing [10,14]. Nurses must provide care to both patients and family members, and they have to deal with death and the fear of facing this [ 15 ]. On the other hand, due to the relevance of bibliometric research in identifying, understanding and promoting problem solving [ 16 ], this study aims to provide a more precise picture of the quantity and characteristics of international scientific production published in the journals covering the field of nursing in the Scopus database, examining all issues related to the processes of death and dying. 2. Materials and Methods There are two methodological categories for the development of bibliometric studies [ 17 ], which are scientific performance and scientific mapping. Performance analysis is, by its very nature, descriptive. It has been established as the distinguishing feature of bibliometrics analyses because it concentrates on the contributions made by the contributors (author, journal, institution, country, etc.) of a particular field of knowledge within a given discipline [ 18 ]. The maps of science, focus on the analysis of the connections between these contributions in terms of the analysis of annual production, citations, co-citations, co-words, or co-authorship. The combination of these analyses with network analysis makes bibliometrics an indispensable tool for presenting the bibliographic and intellectual structure of a research area [19,20]. 2.1. Aims • To develop a statistical-descriptive analysis of the publications retrieved with the search. •To analyze the main indicators using Bibliometrix 4.1.4. • To visualize the main concepts and focuses of interest in the research based on the analysis of co-words in VOSviewer 1.6.16. 2.2. Study Desing This is an exploratory, descriptive, longitudinal, and retrospective study about the different aspects of the process of death and dying during the COVID-19 pandemic. It was conducted through two bibliometric tools to analyze the publications of the journals of nursing indexed in the Scopus database. Ethical approval was not required for this Nurs. Rep. 2024,14 657 study as it did not involve the use of data from human participants, relying solely on bibliographic data. 2.3. Information Sources The Scopus database was selected, as it is a fundamental source of information for the evaluation of the research and also contains all the bibliographic data available. The records were downloaded in May 2023. Firstly, a search strategy was designed to obtain the corpus of information using the following fields: title, abstract and keywords. The search was limited to the years 2020–2023 and the subject area “Nursing”. The search strategy and the results are shown in Table 1. Table 1. Search strategy performed in Scopus on 9th May 2023. No. Query Results #5 (LIMIT-TO ((PUBYEAR, 2023) OR LIMIT-TO (PUBYEAR, 2022) OR LIMIT-TO (PUBYEAR, 2021) OR LIMIT-TO (PUBYEAR, 2020)) AND LIMIT-TO (SUBJAREA, “NURS”)) 119 4 #1 AND #2 AND #3 665 3 TITLE-ABS-KEY (grief OR bereavement OR mourning OR “End of life care” OR end-of-life OR “end of life” OR “End of life decision-making” OR suicide OR “Traumatic Death” OR death-related OR “Death and Dying” OR “Attitude to death” OR “Death education”) 253,309 2 TITLE-ABS-KEY (thanatology OR religion OR religious OR spiritual OR spirituality OR philosophy OR anthropology OR sociology OR socialization OR cultural OR ethical OR legal OR institutional OR “Life Span” OR “Legal Aspects” OR “Historical Perspectives” OR “Contemporary Perspectives” OR “Professional Issues”) 2,695,503 1 TITLE-ABS-KEY (pandemic OR covid-19 OR sars-cov-2 OR “Severe Acute Respiratory Syndrome Coronavirus 2” OR “NCOV” OR “2019 NCOV” OR 2019-ncov OR “Novel Coronavirus” OR “Coronavirus disease 2019”) 570,295 2.4. Bibliometric Data Analysis The analysis parameters included the data corresponding to production by countries, authors, journals, and institutions. In addition, the main concepts and focuses of interest were identified through the co-occurrence analysis of the indexed keywords (IKs), which are terms chosen by Scopus and standardized based on the vocabulary of the Elsevier thesaurus [21]. The metadata obtained were exported from Scopus, in txt format, for subsequent analysis through Bibliometrix, an open-source program, developed in R, which provides a set of tools for the scientometric analysis of the literature. This program allows for the analysis of various bibliometric indicators within a corpus of bibliographic information [22,23]. In the same way, using the VOSviewer co-word analysis function [ 24 , 25 ], the conceptual and thematic structure of the publications was identified by means of the graphic representation of the different lines of research [ 26 , 27 ]. Labeled and density maps were chosen from the types of representations available. The former uses labels with the names of each term, and the sizes of these labels are proportional to their weight (frequency). Density maps are characterized by the representation of nodes in colors ranging from blue to green and yellow to red. These colors reflect the density of the relationships between the terms (co-occurrence). When the density or co-occurrence is higher, the hue on the map will be closer to red; in contrast, with greater dispersion and, therefore, less co-occurrence, the hue on the map will turn bluer [25]. Nurs. Rep. 2024,14 658 VOSviewer combines visualization and clustering techniques to favor the analysis; thus, for the positioning of the IKs on the map, the VOS (visualization of similarities) technique was used [ 28 ], which builds a similarity matrix from the matrix of co-occurrence, using the Association Strength measure as a similarity index to normalize the bibliometric network [ 29 ]. The Association Strength is based on the normalization of co-occurrence values and is applied so that these values adequately represent the analyzed corpus and facilitate clustering. As a phase prior to the analysis in VOSviewer, the file with the keywords was subjected to a normalization process with the aim of cleaning the information collected to improve its quality. In this process, the duplicate elements and those that represented the same concept (but were written differently) were unified, while those that contained errors in writing were corrected. A thesaurus was then created with this data, which was then uploaded to VOSviewer to promote clarity in the representation of the maps. Likewise, some terms used in the search strategy (COVID-19, coronavirus, pandemic, etc.) were dispensed with, as well as those terms referring to types of publication (article or clinical article, etc.) and the study design (review, qualitative research, surveys, questionnaires, etc.). Similarly, high-frequency IKs with zero input into the representation, such as the keywords human or humans, were removed from the analysis. Finally, in this case, due to low frequency, the names of countries (USA, Canada) were also eliminated. Several trials were carried out where different frequency thresholds were tested until it was verified that the map with the best visualization criteria was obtained by limiting the frequency parameter to ≥ 4 appearances. Thus, it was possible to distinguish the thematic structure of the analyzed research more clearly based on the eighty-two most frequent terms. A clustering algorithm was executed [ 30 ], using the VOS technique, that positions and classifies the keywords to be mapped. This algorithm allows for different resolution parameters depending on the value provided for their configuration; thus, a low resolution parameter simultaneously implies a decrease in the number of generated clusters and vice versa. After several tests applying different resolution values, and once the different test results were analyzed, it was decided that the resolution parameter should be kept with a value of 1, which is configured by default in VOSviewer. The minimum size of the clusters was configured to a value ≥ 3 IK, guaranteeing a minimum of consistency in the thematic groups. 3. Results 3.1. Descriptive Analysis A total of 119 [ 31 – 149 ] works were retrieved by the search strategy in Scopus. The complete metadata, exported from Scopus, is available in the supplementary material attached to this publication (File S1) [ 31 – 149 ]. The data obtained showed that these documents were published in 71 journals in the nursing area, featuring the participation of 527 authors. An amount of 549 signatures were counted, which comes to an average of 4.43 authors per document. There were 89 registered articles and 14 reviews in addition to less-frequent documentary typology. The United States and the United Kingdom were, respectively, the countries with the highest number of publications. Table 2shows an overview of the main results of the analysis. The most productive year was 2021, with 45 publications. In 2020, 19 works were published, and 16 references have been registered to date (9 May) in Scopus in 2023 related to the subject of study. Nurs. Rep. 2024,14 659 Table 2. Main Information about the collection, from Biblioshiny for Bibliometrix. Description Results Main Information about Data Timespan 2020:2023 Sources (Journals, Books, etc.) 71 Documents 119 Average years from publication 1.6 Average citations per documents 7.4 Average citations per year per doc 2.3 References 4191 Document Types article 89 book 2 book chapter 3 editorial 6 letter 2 note 3 review 14 Document Contents Keywords Plus (ID) 750 Author’s Keywords (DE) 350 Authors Authors 527 Author Appearances 549 Authors of single-authored documents 12 Authors of multi-authored documents 515 Authors Collaboration Single-authored documents 12 Documents per Author 0.23 Authors per Document 4.43 Co-Authors per Documents 4.61 International co-authorships (%) 22.7 Collaboration Index 4.81 3.2. Journals Analysis Bradford’s law is a useful tool for analyzing the distribution of information, as well as to better understand its structure and how the different aspects of a topic are related to one another. Taking this into account, the present analysis established that, of the 71 journals reported, the Journal of Pain and Symptom Management (Q1) with 11 publications [57,62,65,70,77,81,87,99,103,109,124], the Journal of Palliative Medicine (Q2) with 10 [ 59 , 71 , 89 , 91 , 93 , 96 , 98 , 131 , 148 ], the Journal of Religion and Health (not JCR) with 7 [ 58 , 63 , 67 , 78 , 107 , 112 , 118 ], Nursing Ethics (Q1) with 6 [ 39 , 56 , 69 , 73 , 75 , 104 ], Journal of Medical Ethics (Q1) with 4 [ 53 , 100 , 102 , 106 ] and BMJ Supportive and Palliative Care (not JCR) with 3 publications [ 68 , 85 , 97 ] were the central sources, with accounting for only 8.5% of the total. See Figure 1. All the above-mentioned journals are on the thematic area of nursing, which includes general nursing; problems, ethics and legal aspects; medical and surgical nursing; and oncology nursing, gathered from the Scopus database. Nurs. Rep. 2024,14 660 Nurs. Rep. 2024, 14, FOR PEER REVIEW 6 Figure 1. Bradford’s Law, applied to articles on death and dying published in the Scopus nursing journals between 2020 and 2023. All the above-mentioned journals are on the thematic area of nursing, which includes general nursing; problems, ethics and legal aspects; medical and surgical nursing; and oncology nursing, gathered from the Scopus database. The theme addressed in the papers published by these six central journals revolved around end-of-life care, palliative care, patient dignity, and the ethical challenges in critical care and end-of-life care during the pandemic. In addition, support for grief, death anxiety, mental health in relation to stress, as well as the moral conflicts experienced by nurses in the midst of the situation generated by the health crisis, were also addressed. Several studies have been developed on the perspective of nursing students and medical residents in regard to death and dying and the ethical challenges related to end-of-life care. Other issues developed had to do with spirituality and religion as coping strategies in the midst of the health emergency situation. 3.3. Authorship and Productivity Analysis The most productive authors were Betty R. Ferrell and William E. Rosa, each with three co-authored publications [51,114,124]. Two papers were published by 3.4% of the authors, while 96.2% of the authors had only one publication. These results correspond to the premise of Lotka’s Law regarding the unequal distribution of productivity. This law states that a few authors publish most of the papers on a research topic, while the majority publish a minimum number of studies. See Table 3. Table 3. Author Productivity Using Lotka’s Law. Documents Written No. of Authors Proportion of Authors 1 507 0.962 2 18 0.034 3 2 0.004 3.4. Scientific Production by Countries Only 10.5% (United States, Canada, Spain, and United Kingdom) out of a total of 38 countries published approximately 49% of the works. See Figure 2. Figure 1. Bradford’s Law, applied to articles on death and dying published in the Scopus nursing journals between 2020 and 2023. The theme addressed in the papers published by these six central journals revolved around end-of-life care, palliative care, patient dignity, and the ethical challenges in critical care and end-of-life care during the pandemic. In addition, support for grief, death anxiety, mental health in relation to stress, as well as the moral conflicts experienced by nurses in the midst of the situation generated by the health crisis, were also addressed. Several studies have been developed on the perspective of nursing students and medical residents in regard to death and dying and the ethical challenges related to end-of-life care. Other issues developed had to do with spirituality and religion as coping strategies in the midst of the health emergency situation. 3.3. Authorship and Productivity Analysis The most productive authors were Betty R. Ferrell and William E. Rosa, each with three co-authored publications [ 51 , 114 , 124 ]. Two papers were published by 3.4% of the authors, while 96.2% of the authors had only one publication. These results correspond to the premise of Lotka’s Law regarding the unequal distribution of productivity. This law states that a few authors publish most of the papers on a research topic, while the majority publish a minimum number of studies. See Table 3. Table 3. Author Productivity Using Lotka’s Law. Documents Written No. of Authors Proportion of Authors 1 507 0.962 2 18 0.034 3 2 0.004 3.4. Scientific Production by Countries Only 10.5% (United States, Canada, Spain, and United Kingdom) out of a total of 38 countries published approximately 49% of the works. See Figure 2. Nurs. Rep. 2024,14 661 Nurs. Rep. 2024, 14, FOR PEER REVIEW 7 Figure 2. Distribution of publications according to the country of the corresponding author. 3.5. Institutional Scientific Production Bibliometrix performs a disambiguation task with the goal of cleaning the data to account for single institutions. The ambiguity in this case refers to the different ways of representing the institutional names in the bibliographic metadata, which can involve misspellings or the writing of acronyms or abbreviations of the name, which makes them seem different when they refer to the same institution. Of the 234 institutions, the 10 most relevant were selected (see Table 4). Seven were universities, while the rest were medical centers or hospitals. Table 4. Frequency of publication of the 10 most productive institutions in the analyzed period. Affiliation Freq. University of California, San Diego 12 Massachusetts General Hospital 10 University of Toronto 10 King’s College, London 9 Maastricht University Medical Center 9 Mayo Clinic 9 Maastricht University 8 Icahn School of Medicine at Mount Sinai 7 The Ohio State University 7 University of Michigan Medical School 7 3.6. Main Topics Of the 119 documents recovered, 14.3% [17] did not have IKs, so they were not included in the analysis. After applying the clustering algorithm, with a resolution parameter of one, five clusters were generated that reflected the degree of similarity between the IKs. The clusters were visualized by a labeled bibliometric map and a bibliometric density map. The size of the clusters in the labeled bibliometric map was determined by different factors, such as the number of IKs within each group, as well as the frequency and the weight or similarity index. The color of each cluster was randomly assigned by the program (see Figure 3). The five clusters represented on the map defined the main topics published in Scopus nursing journals in the defined period and on the subjects related to death and dying in times of pandemic. 0 5 10 15 20 25 30 35 40 USA Canada Spain UK France Japan Australia Austria China Denmark Ireland Italy Netherlands Switzerland Argelia Chile Ethiopia Georgia Germany India Corresponding author’s country Single Countries Publication Multiple Countries Publication Figure 2. Distribution of publications according to the country of the corresponding author. 3.5. Institutional Scientific Production Bibliometrix performs a disambiguation task with the goal of cleaning the data to account for single institutions. The ambiguity in this case refers to the different ways of representing the institutional names in the bibliographic metadata, which can involve misspellings or the writing of acronyms or abbreviations of the name, which makes them seem different when they refer to the same institution. Of the 234 institutions, the 10 most relevant were selected (see Table 4). Seven were universities, while the rest were medical centers or hospitals. Table 4. Frequency of publication of the 10 most productive institutions in the analyzed period. Affiliation Freq. University of California, San Diego 12 Massachusetts General Hospital 10 University of Toronto 10 King’s College, London 9 Maastricht University Medical Center 9 Mayo Clinic 9 Maastricht University 8 Icahn School of Medicine at Mount Sinai 7 The Ohio State University 7 University of Michigan Medical School 7 3.6. Main Topics Of the 119 documents recovered, 14.3% [ 17 ] did not have IKs, so they were not included in the analysis. After applying the clustering algorithm, with a resolution parameter of one, five clusters were generated that reflected the degree of similarity between the IKs. The clusters were visualized by a labeled bibliometric map and a bibliometric density map. The size of the clusters in the labeled bibliometric map was determined by different factors, such as the number of IKs within each group, as well as the frequency and the weight or similarity index. The color of each cluster was randomly assigned by the program (see Figure 3). The five clusters represented on the map defined the main topics published in Scopus nursing journals in the defined period and on the subjects related to death and dying in times of pandemic. Nurs. Rep. 2024,14 662 Nurs. Rep. 2024, 14, FOR PEER REVIEW 8 Figure 3. Labeled bibliometric map where the 82 analyzed IKs are represented. The labels and the size of the circles reflect the weight of the IK, while the color of the circles shows the thematic group which each IK belongs to. VOSviewer assigns the color of the clusters automatically by applying the VOS algorithm, as explained in the methods section. The following section provides a detailed description of the contents of each cluster. Table 5 displays the most significant IKs within each cluster, along with their frequency of appearance and corresponding thematic group color. Table 5. IKs with the greatest weight within each cluster (the color corresponds to the different identified thematic groups). Cluster Color Indexed Keywords Occurrences 1 Psychology 15 1 Grief 12 1 Bereavement 11 1 Pneumonia, viral 11 2 Adult 28 2 Aged 19 2 Religion 14 2 Epidemiology 11 3 End-of-life care 28 3 Health care personnel 15 3 Intensive care units 12 3 Interpersonal communication 10 4 Spiritual care 13 4 Personal experience 6 4 Mortality 5 4 Dying 5 5 Palliative therapy 35 5 Palliative care 26 5 Child 5 5 Palliative nursing 4 Cluster 1 (red): in general, publications were found on family, social, and healthcare support in the face of loss and mourning, as well as ethical, cultural, and psychological factors related to attitudes towards death and advanced care planning. Figure 3. Labeled bibliometric map where the 82 analyzed IKs are represented. The labels and the size of the circles reflect the weight of the IK, while the color of the circles shows the thematic group which each IK belongs to. VOSviewer assigns the color of the clusters automatically by applying the VOS algorithm, as explained in the methods section. The following section provides a detailed description of the contents of each cluster. Table 5displays the most significant IKs within each cluster, along with their frequency of appearance and corresponding thematic group color. Table 5. IKs with the greatest weight within each cluster (the color corresponds to the different identified thematic groups). Cluster Color Indexed Keywords Occurrences 1 Psychology 15 1 Grief 12 1 Bereavement 11 1 Pneumonia, viral 11 2 Adult 28 2 Aged 19 2 Religion 14 2 Epidemiology 11 3 End-of-life care 28 3 Health care personnel 15 3 Intensive care units 12 3 Interpersonal communication 10 4 Spiritual care 13 4 Personal experience 6 4 Mortality 5 4 Dying 5 5 Palliative therapy 35 5 Palliative care 26 5 Child 5 5 Palliative nursing 4 Nurs. Rep. 2024,14 663 Cluster 1 (red): in general, publications were found on family, social, and healthcare support in the face of loss and mourning, as well as ethical, cultural, and psychological factors related to attitudes towards death and advanced care planning. Cluster 2 (green): publications on spirituality and the religious perspective in the face of anxiety, anguish, depression, and stress, as well as the role of empathy, human relations, and coping behaviors in the mental health of adults and the elderly, in addition to the development of care by health personnel and the problematic issue of suicide in nurses. Cluster 3 (blue): this covers the organizational and administrative point of view regarding care for the critically ill and those at end of life in intensive care units from the perspective of health personnel, particularly nurses, in relation to policies, procedures, health care systems and services, as well as access to therapeutic measures to alleviate suffering in critical patients when faced with the challenge of communication with the patient and the family in the midst of confinement and strict isolation measures during the pandemic. Cluster 4 (yellow): Publications on death and dying from a clinical, spiritual and psychosocial perspective. The problematic issue of the well-being of patients in regard to the control of symptoms and complications derived from COVID-19, as well as the situation of loneliness and isolation during the dying process in the period of the pandemic; the personal experiences of both patients and their families regarding the medical care received; spiritual care in this environment, the importance of training nursing staff in spiritual care, and the resources and barriers to providing spiritual care or experiences with spirituality in clinical practice were some of the issues addressed, in addition to the psychosocial perspective of care in the midst of mobility and accompaniment of dying patients’ restrictions. Cluster 5 (purple): IKs related to different aspects of palliative care were included in this cluster. Different nuclei related to the most developed themes were identified in the bibliometric density map (see Figure 4). The fields with the greatest IK impact were identified in the center of the map (in red), and several foci of interest were found. These central groups are connected to one another by different bridge nodes, as well as with the rest of the groups on the periphery of the map, which present less interaction (in yellow, green, and blue). Nurs. Rep. 2024, 14, FOR PEER REVIEW 9 Cluster 2 (green): publications on spirituality and the religious perspective in the face of anxiety, anguish, depression, and stress, as well as the role of empathy, human relations, and coping behaviors in the mental health of adults and the elderly, in addition to the development of care by health personnel and the problematic issue of suicide in nurses. Cluster 3 (blue): this covers the organizational and administrative point of view regarding care for the critically ill and those at end of life in intensive care units from the perspective of health personnel, particularly nurses, in relation to policies, procedures, health care systems and services, as well as access to therapeutic measures to alleviate suffering in critical patients when faced with the challenge of communication with the patient and the family in the midst of confinement and strict isolation measures during the pandemic. Cluster 4 (yellow): Publications on death and dying from a clinical, spiritual and psychosocial perspective. The problematic issue of the well-being of patients in regard to the control of symptoms and complications derived from COVID-19, as well as the situation of loneliness and isolation during the dying process in the period of the pandemic; the personal experiences of both patients and their families regarding the medical care received; spiritual care in this environment, the importance of training nursing staff in spiritual care, and the resources and barriers to providing spiritual care or experiences with spirituality in clinical practice were some of the issues addressed, in addition to the psychosocial perspective of care in the midst of mobility and accompaniment of dying patients’ restrictions. Cluster 5 (purple): IKs related to different aspects of palliative care were included in this cluster. Different nuclei related to the most developed themes were identified in the bibliometric density map (see Figure 4). The fields with the greatest IK impact were identified in the center of the map (in red), and several foci of interest were found. These central groups are connected to one another by different bridge nodes, as well as with the rest of the groups on the periphery of the map, which present less interaction (in yellow, green, and blue). Figure 4. Bibliometric density map showing the 82 analyzed IKs. The colors close to red show the areas with the highest density of IKs co-occurrences; the colors close to yellow and green show the areas with the lowest density IKs co-ocurrences. Figure 4. Bibliometric density map showing the 82 analyzed IKs. The colors close to red show the areas with the highest density of IKs co-occurrences; the colors close to yellow and green show the areas with the lowest density IKs co-ocurrences. Nurs. Rep. 2024,14 670 51. De Campos, A.P.; Levoy, K.; Pandey, S.; Wisniewski, R.; Dimauro, P.; Ferrell, B.R.; Rosa, W.E. Integrating Palliative Care into Nursing Care. 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