Focus and trends in nurse advocacy in the Pan American Health Region: a bibliometric analysis*

Objective: this study examined scholarly output relating to nursing advocacy contributions toward influencing policy by authors in countries of the Pan American Health Organization. Method: the study utilizes a bibliographic analysis of papers indexed in Scopus authored by PAHO member state scholars. VOSviewer conducted coauthor and cooccurrence analysis to generate visualizations of the relationships between authors, countries of origin and keywords. Results: 7,773 papers with 21,523 authors met the inclusion criteria. An increase of publications on policy starting in 1962 was found. Co-authorship identified a fragile relationships structure with few authors bridging networks of collaboration. By country of origin, 22 of 35 member states contributed to policy literature; 17 in a connected network and 5 contributing but neither connected to peers nor other member states. Keyword analysis identified 20 specific data clusters. Conclusion: our findings are aligned with the Nursing Now Campaign. This bibliographic analysis provides an important benchmark into current policy advocacy activity in PAHO against which future progress in the region can be assessed. There is scope for greater collaboration amongst authors and this could be targeted toward engagement of nurses in member states not-yet or only partially active in this space.

Introduction 2020, sees the celebration of 200 years since the birth of Florence Nightingale (1) . Over the two centuries since her birth, the profession of nursing has evolved considerably not least as a result of the innovative actions of Nightingale herself (2) . Hence, we will argue that this is a time to reflect and acknowledge on both our successes and failures but importantly look to the future to describe what the profession can achieve in the years ahead.
It has been reported that Lord Nigel Crisp has suggested that the actions of the World Health Organization (WHO) naming 2020 as the International Year of the Nurse and Midwife provides a once in a generation opportunity for governments to really show nurses and midwives how much they are valued (3) . To do this, the profession needs to play its part. In today's era of evidence-based policy there is a need to curate our existing contributions, acknowledge their impact and promote a vision of what is yet to come. The Nursing Now Campaign has initiated a social movement encouraging the profession to bring its expertise and voice to the policy table (4) . To be an effective voice, nurses must come prepared to offer evidence, suggest  (5)(6) . PAHO has also been active in producing a wide range of policy documents targeted at priority health challenges such as non-communicable disease as well as more widely addressing the role and contribution of professions like nursing (7)(8) .
To address the challenges and objectives (7) set in the PAHO strategies on human resources for universal access to health there is a need for the profession to answer the call of the Nursing Now Campaign.
Historically, nurses have advocated for those we care for as well as for the advancement of profession through practice, research and policy change. Ever since Florence Nightingale, advocacy has been foundational to the success of the profession. Indeed, for nursing to continue to advance we must build on past successes to shape and improve health care as we speed towards the attainment of the sustainable development goals (9) . To do this we must understand the contribution of nurses in the Pan American Health

Method
This mixed method bibliographic study examines the published and indexed output of scholarship relating to the profession of nursing written by authors based in the countries of the Pan American Health Organization.
The intent is to provide a high-level analysis of the origins and thematic content of the work so as to identify current strengths as well as future opportunities for further scholarship.
While bibliometric analysis has been used extensively in the information sciences it is only recently that nurse scholars have used the method on a regular basis (10) . One of the early protagonists for the technique of bibliometrics (11) described the approach as one that applies statistical methods and mathematics to the collation of the content of books, articles and other communication. Accordingly, it provides a means of synthesizing the content of published work to determine general themes, the evolution of thinking and metrics based on the most prolific authors, frequency of citation and published sources (12) . Additionally it has been argued, that visualization of data that incorporates the use of proximity (closely related values are located near to each other), color (signifying related items being grouped into a single cluster), size of nodes (offering an indication of frequency), and thickness of links (providing a marker of strength of relationships), can present images that engage the viewer and make information more comprehensible (13) . To extract data from Scopus a document search of the entire database using standard keyword, wildcard and delimiters was used. The search took place on January 28, 2020 and used the search string TITLE-ABS-KEY (("Advocac*" OR "Influenc*") AND ("policy" OR "Politic*" OR "Legislat*" OR "Guidance" OR "Guide*" OR "Model*" OR "Framework")) AND LIMIT-TO (SUBJARE, "NURS")). Subsequent to this search the resulting list of articles was further limited by selection of those papers that were identified as being authored by a person or persons from a PAHO member state.
The identified papers were then downloaded as a comma separated value (CSV) file ready for import to the analytical software. In this case, VOSviewer, a freeware package developed by the University of Leiden, generates a visualization of relationships between the variables of interest. Multivariate scaling techniques were used to calculate relationships between authors, their countries of origin and the keyword themes used by the authors to describe their work (14) . A frequency threshold of three occurrences of the name/theme was set as this has been suggested as the minimum frequency to identify meaningful clusters (15) . In addition, Excel 365 was used as a means of graphing and calculating the general trend associated with the frequency of publications indexed and retrieved from Scopus.

Results
A total of 7,773 papers met the inclusion criteria.
The first paper, identified by the search strategy, focused on policy advocacy, and published by an author from a PAHO member state dates to 1962. The 7,773 papers were authored by a total of 21,523 individuals. Figure   1 illustrates the frequency of production of papers by authors from a PAHO country or territory. By inspection there has been a significant increase over the years and Rev. Latino-Am. Enfermagem 2020;28:e3312.  analysis allocated to 20 specific clusters (14) . Figure 5 provides a brief title and synopsis of each of the clusters.  Primary and community health advocacy

Benton DC, Brenton AS
Focuses on various dimension of advocacy for primary and community health care provision. Twenty [20] Life and death dilemmas Identifies a range of situations where there is increased risk associated with life, death or significant adverse outcomes. Rev. Latino-Am. Enfermagem 2020;28:e3312.

Discussion
It can be seen from Figure 1  region, language needs to be considered as a potential barrier to accomplishing collaborative work. Indeed, in a study of the social networks of nurse leaders (16) it was identified that factors associated with the establishment of peer to peer connections was related to geographic proximity, language and participation in professional associations. In a subsequent study, the same authors (17) identified that technology can be used to maintain links between participants of such networks. Furthermore, although not ideal, the advancement of technology based translating services may help alleviate or even eliminate some of the historical barriers that authors who speak different languages have faced. Certainly, we can build on existing strengths such as multi-lingual journals like the Revista Latino-Americana de Enfermagem (RLAE).
By publishing in such journals, a nexus for collaboration is produced as well as offering a platform that facilitates the identification of authors from English, Spanish and Portuguese speaking countries.
Turning to Figure 4, and more specifically, Figure   5, there is already a wealth of scholarship that focuses on priority topics that will support PAHO in pursuing a wide range of strategic goals. It is therefore essential that when addressing these challenges, the leaders of policy development groups actively seek out and engage nursing expertise. wellbeing and the economy of individuals and nations (18) .
Nursing in its advocacy efforts in the region have clearly  profession has already demonstrated from these results that it has a policy advocacy voice. It is up to this and the next generation of nurses to ensure that we not only focus on clinical issues but also diversify and intensify our contribution to these wider determinants of health (22) .
There are limitations to this study. Using a single bibliographic database, Scopus, does mean that the journals that are not curated by the database have been