Evidence for the central line-associated bloodstream infection (CLABSI) bundle effectiveness remains mixed, possibly reflecting implementation challenges and persistent ambiguities in how CLABSIs are counted and bundle adherence measured. In the context of a tertiary pediatric hospital that had reduced CLABSI by 30% as part of an international safety program, we aimed to examine unit-based socio-cultural factors influencing bundle practices and measurement, and how they come to be recognized and attended to by safety leaders over time in an organization-wide bundle implementation effort.We used an interpretivist qualitative research approach, based on 74 interviews, approximately 50 h of observations, and documents. Data collection focused on hospital executives and safety leadership, and three clinical units: a medical specialty unit, an intensive care unit, and a surgical unit. We used thematic analysis and constant comparison methods for data analysis.Participants had variable beliefs about the central-line bundle as a quality improvement priority based on their professional roles and experiences and unit setting, which influenced their responses. Nursing leaders were particularly concerned about CLABSI being one of an overwhelming number of QI targets for which they were responsible. Bundle implementation strategies were initially reliant on unit-based nurse education. Over time there was recognition of the need for centralized education and reinforcement tactics. However, these interventions achieved limited impact given the influence of competing unit workflow demands and professional roles, interactions, and routines, which were variably targeted in the safety program. The auditing process, initially a responsibility of units, was performed in different ways based on individuals’ approaches to the process. Given concerns about auditing reliability, a centralized approach was implemented, which continued to have its own variability.Our findings report on a contextualized, dynamic implementation approach that required movement between centralized and unit-based approaches and from a focus on standardization to some recognition of a role for customization. However, some factors related to bundle compliance and measurement remain unaddressed, including harder to change socio-cultural factors likely important to sustainability of the CLABSI reductions and fostering further improvements across a broader safety agenda. Contributions to the literatureMany have highlighted the importance of socio-cultural factors in central-line-associated bloodstream infection bundle implementation. Yet limited evidence provides specific guidance on how to consider or act on such factors.We provide insight into the ongoing adjustments in implementation approaches that occurred in response to variability in factors including beliefs, workflows, interprofessional interactions, and measurement practices related to the bundle across three units.Movements between central versus unit, and standardized versus customized, implementation approaches can explain successful measured outcomes.Not all behaviors related to bundle compliance and measurement, though, were addressed, which may have implications for broader safety agendas.The concept of the care bundle as a quality improvement (QI) tool emerged in 2001 from a joint initiative between the Institute for Healthcare Improvement (IHI) and the Voluntary Hospital Association. This initiative included a bundle to reduce central-line-associated bloodstream infections (CLABSI) –12.Reflecting on the Michigan project, Bosk et al.  emphasizThis lack of clarity about the ways specific socio-cultural factors exert their effects may explain the observed variability in bundle adherence and outcomes achieved across efforts to implement the CLABSI bundle , 21. TheThe findings reported in this paper are part of a larger qualitative study of the implementation of a hospital-wide safety program. The safety program, part of the international Children’s Hospitals’ Solutions for Patient Safety (SPS) Network –29, aimeThe study was conducted at a 300-bed tertiary academic pediatric hospital in Canada. SPS provided a CLABSI bundle developed using evidence from the medical literature as well as testing and analysis to identify practices highly likely to result in decreased harm . The bunThe hospital used standardized methods for CLABSI surveillance already in place in select areas but spread hospital-wide over the course of the project. Infection prevention and control practitioners utilized blood culture data as a trigger to identify potential CLABSI, and then performed chart review to assess whether the case met the NHSN surveillance definition. Determination of the denominator  initially involved a combination of electronic and manual methods, eventually becoming a unified process via the comprehensive electronic health record. Each of the units under study had different baseline CLABSI rates, and each achieved improvement over the 2017–2019 period, contributing to an overall hospital-wide reduction of 30% . Interview guides covered perceptions of the bundle and its implementation, perceived challenges and facilitators to implementation, and changes with implementation over time. Interviews were audio recorded, transcribed verbatim, and anonymized.As part of the larger study, we conducted observations of safety meetings and activities in the units and among hospital safety leadership to attain an in-depth understanding of safety practices. These observations consisted of events where CLABSI appeared as a topic of conversation  as well as events where CLABSI was the specific focus . The observations were ethnographically informed whereby we were attentive to details such as space, people, objectives, interactions, activities, time, goals, and feelings . Prior tWe also collected documents such as hospital strategy documents, safety coach reports, and hospital communication about safety stories and outcomes.We used a reflexive thematic analysis  approachWe conducted 74 interviews  with 71 participants with different professional backgrounds and roles. At the organizational level, participants included hospital executives and safety leadership. At the unit level, participants included those with varied professional backgrounds  and who worked in clinical, managerial, education, and QI roles. Interviews were one-on-one except for two with two or three people. Six hospital executive and safety leaders were interviewed a second time nearer the end of data collection as their interviews occurred in the initial stage of the hospital safety program and we thought it could be useful to also interview them at later stages of implementation. We undertook approximately 50 h of observations. The findings are organized in three sections, based on the themes developed through data analysis, that demonstrate different ways that socio-cultural factors influenced CLABSI bundle implementation: variable belief in CLABSI as an improvement target, variation in unit-specific bundle practices and priorities, and complexities of assessing and monitoring adherence.Our focus on reducing hospital acquired conditions is relentless. We’re particularly focused on reducing the number of CLABSIs and SSIs  patients experience … as these … represent a high proportion of our preventable conditions. (p. 10)The hospital identified CLABSI prevention as an organizational priority with the expectation that all units would similarly prioritize it as a QI target. Hospital leadership conveyed this priority in hospital communications. For example, the 2017–2018 safety progress report stated:So, I’m not a big believer … I think we have overshot the bundle stuff because once those lines are healed in, really it’s not that common that they got infected. But everyone feels very good about it so I don’t argue… Study participants did not appear to fully share this prioritization, as they expressed different preferences based on their professional roles and experiences. Some participants expressed reservations about investing resources in CLABSI prevention because the CLABSI rate on their unit was low or there was little data supporting a problem. This perception was expressed by a physician in the medical specialty unit:We’re always thinking when can we take out that central line? I haven’t seen any big data on the ward about our CLABSI rates … I know there is a bundle … and the nurses are supposed to follow it. That I’m aware of but if you ask me what are our CLABSI rates I couldn’t tell you. The surgeons interviewed noted that if there was a problem with CLABSI, they were already doing what they needed to do, and, in most cases, other healthcare professionals were more directly responsible for its prevention. In particular, surgeons explained that they already avoid central lines if possible. Furthermore, if lines are put in, insertion is done by interventional radiology, nurses handle the lines, and other physicians monitor patients with them:There are some oncology providers who believe that CLABSI is something that we should expect in oncology. They all have central lines and many of them don’t have any neutrophils, so they will get a CLABSI. So, that has been a big education point … People are coming around. Convincing people that zero is achievable is very difficult, but there’s buy-in now that we can do better. That’s a good start … Others, particularly in the medical specialty unit, did agree that their CLABSI rate was high. However, some viewed that rate as a natural function of their patient population that would make it unresponsive to a QI intervention, and were also concerned about the reliability of CLABSI report data:how to achieve CLABSI reduction goals, some viewing the new bundle as being “less rigorous than we had been” . ICU staff reported that their patient population is at higher risk and therefore required a stricter protocol for central line care.We had concerns about changing practice so that the practice was the same across the hospital. Totally understand about why we need to have the same practices … The problem is, is that neonates are different and especially preterm babies and I know there are neonates in the rest of the hospital. But I felt that maybe our voice was not being completely heard in terms of our concerns and so, we did our best to identify that as well as listen to their recommendations and we made changes. In contrast, ICU participants welcomed the hospital’s focus on CLABSI prevention as it supported their prioritization of this goal several years earlier. ICU staff, though, had divergent perspectives from hospital leadership about I don’t know that there always is a true understanding of what it’s actually like at the front line. Just in terms of the things that they’re asking nurses to do, it feels like we’re always adding extra things, and we’re not taking anything away. And so, they think, oh well, it’s just one more thing. It’s just this small little thing … it’s only five checks and it only takes five seconds. But, when we’ve added 100 things that are five seconds, it takes a lot of time. Nursing leaders in the units studied were not as focused on whether or not CLABSI should be an improvement target, but were more concerned about CLABSI being one of an overwhelming number of QI targets for which they were responsible. They struggled with not having sufficient resources to respond to numerous top-down QI initiatives.Given the variable support among staff for CLABSI as an improvement target, hospital safety leaders had to work over time with each unit according to their responses to the organizational CLABSI prioritization. However, as the leaders noted, there was also tremendous variability within each unit:Some teams dive right in. When you talk about the focus needing to be bundle adherence, the why is clear, they understand what their part is and that’s … what we need to understand more … is what makes a unit culture thrive and dive right into CLABSI … .versus other units where a lot of my work is proving that it’s important work that we need to do or proving or answering questions related to the why, mostly. Each [hospital-acquired] condition has its own set of practices and the belief is that if applied the same way for every patient, then we will be able to get to zero. The messaging around CLABSI prevention focused on the implementation of standard practices across the hospital, as expressed below by a safety leader during a meeting:However, findings revealed challenges to achieving bundle practice standardization.Education was the primary strategy to support bundle implementation, with each unit responsible for doing this education initially. This put significant pressure on units as they had to figure out how to deliver education for nurses given competing requirements . They adapted by using their limited education days or one-on-one teaching by unit nursing leadership. Hospital safety leadership recognized that there were inconsistencies in what was being taught and how terms such as “aseptic non-touch technique” were being interpreted. They therefore developed centralized education such as a website with learning material and resources, and organized reinforcement tactics such as a common cart with materials for standardized dressing changes and had clocks installed to support timing requirements. Safety leaders reported progress over time to standardize practices such as nurses’ increased use of print or online bundle resources, and having discussions to anticipate the procedure and manage the physical environment ahead of time.If you have six babies in one room and there’s three nurses, and all of them have central lines. And all of your TPN  and lipids come up at 5:00 and your handover’s at 7:00, but all of your babies need to be done up and fed at 6:00. And you’ve got meds, and parents are usually visiting, then it’s a really busy time and there isn’t another person to help you … when you start adding additional components, sometimes it’s tough to follow through with exactly what you need to do… The findings demonstrated, though, that behavioral changes were contingent on factors beyond knowledge and equipment availability. ICU nurses, for example, described challenges enacting the recommended two-person approach to line care procedures, given patient care needs and family visiting patterns:If the family gets it, and they are terrified of their kid getting an infection, then they’ll do what we ask. If they prioritise it differently in the sense that they’re more focused on the fact that their child doesn’t feel very well today, and they don’t like baths anyway, so I’m not going to do the bath because that’s just going to make them feel even worse, it’s difficult … Our staff are pretty good at offering … Trying to make it as easy as possible. But sometimes for some families, the most that they can accomplish is just physically being here and not falling apart because they’re just so stressed. Nurses also had to make decisions about competing patient care priorities. For example, medical specialty nurses described the tensions between CLABSI bundle requirements and patient and family preferences:But then how do we talk about a line in a way that’s meaningful for staff? How often are we doing blood work? Can we switch anything to oral? Is [the line] working well?… so those [types of] conversations. We have to shift a little bit of that, not necessarily away from the bundle, but shift it in a way that it made meaning for staff … That is still where we struggle the most, is that discussion, and having it happen on a consistent basis. We’re really good about talking about lines when they’re not working well, not so much when they’re working well … The nurses received education about the CLABSI bundle requirement for a standard daily discussion among nurses and other interprofessional team members around three questions: (1) line necessity, (2) functionality, and (3) utilization. However, nursing abilities’ to initiate and discuss these questions required more than changes in an individual nurse’s knowledge and practice, as it was contingent on each unit’s existing rounding routines and interprofessional interaction patterns. In the ICU, physician safety leadership, an established practice of questioning around the line, and creation of a rounding sheet to structure interactions, facilitated nursing input into standard daily discussions. The medical specialty unit also had interprofessional rounds; however, participants explained that the three required questions concerning line necessity, functionality, and utilization did not fit their patient care practices. The unit therefore adapted the line discussion to focus more on how often the line is accessed as opposed to whether it continues to be required. This change, though, continued to require ongoing attention:… it’s tough, because of your clinical judgement, you know if this patient has a stricture they’re going to the OR in a week, they’re staying NPO for a week before they go to the OR. Of course it’s a necessity. We don’t need to be asking that question every day when we know there’s a plan. Nurses in surgery also expressed some resistance to the bundle questions. For example, they viewed the line discussion to be redundant:However, there was not the same investment of attention as in the medical specialty unit to strategizing how the surgical unit could adapt the line discussion. This was compounded by the surgical unit not having routine interprofessional rounding routines, but rather variable rounding practices of individual surgeons. Nurses and physicians both described the variability in opportunities for interprofessional interactions in this context.… in the early days of spreading the HAC bundle, there was a desire to spread the bundle as it is, but then an acceptance of unit and local contextual interpretation … there has been a lot of conversation about this balance between having a standard approach, which means everybody does the same thing at all times, regardless of where the location is, versus those adaptive changes to fit an environment. Over time, as the variability of units’ bundle practices became apparent, hospital leadership worked to address the emerging issues by meeting with the range of relevant stakeholders “to have different groups understand what their role is” . However, they also noted the resources and time required. This led some hospital safety leaders to recognize limitations to a top-down approach that expects all units to perform the bundle in a uniform way:Audits assessed bundle adherence and by extension were expected to correspond to CLABSI rates. Auditing was not a straightforward assessment process because each unit conducted their own audits and these were subject to personnel and resources available in the unit. In addition, responsiveness to being audited and audit results differed based on who was doing the auditing such as a nurse champion, manager, or QI leader.… I’m not fixated on we need to do 20 (audits) and check off boxes. I’m fixated on it being a meaningful and deep conversation around what could have done better so that I’m hardwiring practice. I think audits are a good idea in theory, but, full disclosure, if I’m auditing my roommate, we’re friends, we’re colleagues, am I watching literally every minutia she’s doing? Probably not. I’m giving her the checks. Right? So, does that necessarily negate the efficacy of the audits? Probably. A little bit … everything’s supposed to be a two-person procedure for CLABSI. Do we always have time for that? No. So, we do our best, but it’s also kind of that marrying of reality and expectations. Unit QI leaders tended to describe the audit as an opportunity to provide teaching and guidance. In the ICU, for example, clinical navigators support new staff, and therefore being audited by them was viewed as beneficial by providing a second person to help with the cap or line change and correct technique and therefore “you almost wanted to be audited” . In contrast, peer to peer auditing in the ICU was described by a participant as a routine, check box activity. These different approaches are apparent in the quotes below:The auditing tool was also used differently depending on the individual, as auditors distinguished between “green” versus “red” when an action was not initially performed but then consequently completed, resulting in variability in the assessments. Relatedly, audit results were not seen by hospital safety leadership as correlated with CLABSI rates, and therefore not helping to identify where the gaps were. In response to reliability concerns, unit-based auditing was supplemented by three central hospital auditors, who received the same training to develop a consistent approach to completing the audit form and providing feedback to nurses. However, even these auditors encountered dilemmas given the ambiguity and complexity of bundle practices and their documentation. In some instances, nurses documented earlier in a day in anticipation of a bath being done or a team discussion happening, but one could not be certain whether they actually occurred. There was also the possibility that nurses did not document a required action but had done it .And I think honestly the main difference is the cultures on those units are just so different … So, how they receive audit, how they are open or not to our team coming in and doing practice observations has looked very, very different … The centralized auditing approach demonstrated lower levels of bundle adherence and was therefore perceived to improve measurement reliability; however, other factors affected central auditors’ abilities to audit, specifically their varying interactions with each of the units. While the auditors had organizational support, units exerted control over access. Some units collaborated with the central auditors to supplement their own efforts, while others were more resistant to them coming into their units.The nurses had varied perspectives about being audited, which influenced their responsiveness to, and engagement with, the auditing process, and also morale. For some, auditing was perceived as useful feedback to help them with their practice. Others viewed the auditing as problematically targeting nurses when bundle practice is dependent on a wider group of healthcare providers.This study provides insight into the trajectory of a hospital-wide implementation of a central-line bundle among three units within a hospital which ultimately achieved its measurement outcome goals. The themes of variability in beliefs about CLABSI as an improvement target, in unit-specific bundle practices and priorities, and in assessment and monitoring of bundle adherence, contribute to our understanding of how clinically contextual factors influence CLABSI prevention practices. These findings highlight the opportunities and challenges of balancing central versus unit-based approaches, and standardization versus adaptation, of bundle practices in organization-wide improvement –43.Our findings extend understandings of socio-cultural factors influencing central-line bundle implementation, addressing gaps in understanding how clinical contexts influence the nature and effectiveness of improvement interventions , 45. TheAt our study site, safety leaders made efforts to respond to socio-cultural factors influencing bundle implementation, which involved shifting between centralized and unit-based approaches. Our findings confirmed the importance of hospital prioritization of CLABSI prevention, a noted implementation facilitator . This orA related, but different, issue in our findings was the tension on standardization versus customization of bundle practices. The emphasis on “standardization” in QI is challenged when standardized practices are being placed into spaces with pre-existing norms, practices, and procedures . In our Our study has limitations. The data reflect three units in one Canadian hospital which may limit the transferability of findings, as clinical and hospital contexts differ. However, the nature of our findings are consistent with results from other implementation studies, and, additionally, the findings are important from a conceptual generalizability perspective, in terms of how they can inform other healthcare settings . Our metOur qualitative findings, in addition to hospital CLABSI measurement outcomes, demonstrate the efforts required to implement a central-bundle. They also reinforce the importance of moving from a narrow focus on intervention fidelity to viewing bundle implementation as an emergent, dynamic, and long-term process that attends to the reciprocal interaction between an intervention and its unit and hospital socio-cultural contexts , 55, 56.


The analysis reveals that the words or expressions in which inclusive language resources are employed (-e and x) work as traces of harassed identities and manifest comments by the speaker on their own enunciation. This way, this research shows that gender inclusive language holds conflict linguistic marks which point to historically denied dissidence forms, linked to gender identity and the assertion of collective rights. Finally, this article aims at, on the one hand, contributing to the description of Argentinean Spanish, and on the other, promoting reflection in favor of linguistic education. Undoubtedly, opening instances of debate on the subject can have an impact on the deepening of linguistic reflection and the training of speakers who contribute to forging a more egalitarian society, one which is inclusive and respectful of differences.In Argentina, the so-called “inclusive language” aims at avoiding the bias for a particular sex or gender and objects to a grammatical binary system (feminine – masculine). Although in most Spanish-speaking countries, inclusive language has been limited to the realms of activism, gender studies and a certain type of public administration, in Argentina, its use has been extended to different social spheres, mostly urban. Considering such context, this work aims to investigate the inclusive language in Spanish and characterize its most relevant resources in a series of public texts that circulated in Argentina between 2018 and 2020. On the one hand, its origin is explained, differentiating it from non-sexist language and the different theoretical positions around inclusive language are exposed. On the other hand, from the Dialogical Approach to Argumentation and Polyphony, this paper proposes to address inclusive language resources as subjectivity and polyphony marks which evidence certain aspects of the discourse of patriarchy, with respect to which there is dissent; therefore, inclusive language resources show viewpoints that were once silenced and rejected. For this, a corpus of various speeches is addressed, made up of outdoor urban inscriptions, flyers (advertisements), audiovisual informative speeches and digital press, written in inclusive language, between 2018 and 2020. Throughout the paper it is warns that the inclusive language marks, such as – Among the sexist forms attributed to the Spanish language, morphological aspects are usually mentioned, such as the generic or universal masculine gender, and also lexical forms are noted, together with the asymmetrical employment of address forms and the use of the masculine variant for professions and titles.For several decades, studies with a gender perspective have questioned the androcentrism and the patriarchal character of language. If we refer to the Spanish language, it has been deemed el*, and la –e.Then, from the postulate that the use of the masculine to refer to the two sexes does not manage to show the woman, and that this comes from the lack of symbolic representation of women in the language  (2015) and those that supported the Interrupción Voluntaria del Embarazo (Voluntary Interruption of Pregnancy) Bill (2018), inclusive language broke into the voices of the protesters and made long overlooked identities visible.It is worth mentioning that, despite the fact that, in most Spanish-speaking countries, inclusive language has been limited to realms of activism, studies with a gender perspective and certain public administration sectors, its use in Argentina has extended to various social areas, especially urban ones. Starting with the activist movements of Based on previous works Tosi, , and empThe design of the research carried out for this analysis was based on qualitative methodology, since qualitative approaches are better suited to investigate “delimited and focused groups and segments of social histories from the perspective of the actors, of relationships, and for the analysis of discourses and documents”  Bill. Its circulation was commented on in the mass media covering the event, and on many occasions, there were heated debates about the novel linguistic phenomenon. Finally, in order to obtain a representative sample, we extended the corpus collection period until September 2020.A exhaustiveness, that is, “not to leave in the shadows any discursive fact that belongs to the corpus, even if it ‘disturbs the researcher”'  , captured in the statement. Thus, by understanding the statement as a link in the discursive chain , which are recorded in the textbooks of the different periods under analysis, breaks the neutrality, evidences the inherent polyphony and produces different meaning effects.According to the author, there are two great enunciative heterogeneities: the constitutive one and the shown one. The former demonstrates that discourse, despite the subject's pretension that they are an autonomous source of meaning, is constituted by other discourses; the latter alters the apparent unicity of discourse by incorporating other voices with explicit or non-explicit signals. Within this latter group, we can distinguish between unmarked forms, where the presence of In this regard, Authier-Revuz  argues tTo give an example, in Tosi , we show(1) The Huns, dark men with bony faces, small eyes and depressed noses -so strange to European types- lived on horses or in carts, dominating villages in the exercise of what some have called “Asian barbarism.” However, seen as a rebellion against the imperial corruption of the Romans, their struggle could be felt as an executioner of a primitive but destructive justice.Thus, S refutes the meaning, or the scope, of “Asian barbarism.” In fact, the speaker disagrees with the veracity of the semantic content of this nomenclature and proposes a counterargument by means of the inclusion of the adversative connector “however.” In this way, the speaker refutes the premise that the “Huns were barbarians” and puts forward their own point of view by proposing the following premise: “the Huns executed a primitive justice.”Also in Tosi , we obseeconomic and demographic growth and the expansion of transport, trade, and industry led to an important urbanization process, regarding which Buenos Aires was its leading exponent.(2) Although the driving force behind the economy was rural production, x or the morpheme -e indicate that the speaker distances themself and makes a comment on such marks, and they produce different meaning effects, as the analysis will show.Taking into account what has been presented so far, the most characteristic resources of inclusive language are addressed below as marks of marked shown heterogeneity  in Spain in 1983 and the publication of the first guides to non-sexist language, which were employed in public administration. From then on, there began to emerge multiple groups that objected to sexism in language and proposed alternative resources. Among them, we can mention the NOMBRA group, No Omitas a las Mujeres, Busca Representaciones Adecuadas , created in 1994 and linked to the Advisory Commission on Language of the Women's Institute (Spain), which is responsible for much of Spain's academic production on the subject. Among its members are Carmen Alario, Mercedes Bengoechea, Elira Llendó, and Ana Vargas, who support the thesis of women's lack of symbolic presentation in language. In this regard, they state that the use of the generic masculine to refer to the two sexes does not manage to represent them, since it hides or excludes women, to the extent that it is based on an androcentric way of thinking that configures men as reference subjects and women as subsidiary subjects (1995).With respect to Spanish, since the 1980s, there have been feminist movements that have promoted actions to eradicate sexist uses. Some of these movements worked for the creation of the o, médica” ; “voluntario, voluntaria” (volunteer)]. In addition, when reference is made to nouns pointing to animate beings, the masculine designates the class that corresponds to all individuals, without distinguishing between the sexes. For example, in the sentence “A nivel mundial, unos 18 000 voluntarios fueron inoculados con vacunas experimentales dentro del programa de pruebas para luchar contra el Covid-19” , the phrase “los voluntarios” includes both men and women because the masculine is the unmarked gender, which refers to the member of a binary opposition and can encompass both members. According to Spanish grammar, this makes it unnecessary to mention the marked term, i.e., the feminine one.At this point, it should be made clear that, according to Spanish grammar, when things are designated, there is no relationship between grammatical gender (feminine and masculine) and sex; for example, “la cuchara” (the spoon) and “la espumadera” (the skimmer) are feminine; “el cuchillo” (the knife) and “el tenedor” (the fork) are masculine; however, as we know, this categorization has nothing to do with extra-grammatical aspects. Now, as for the words that refer to women or men, there is a match between grammatical gender and the sex of the person  Alive), “Si nuestras vidas no valen, produzcan sin nosotras” , among many other phrases  actions, a feminist collective formed in 2015, which opposes violence against women in all its forms. In their discourse, one of the most frequent mechanisms to make women visible and to refer to the feminist struggle is the use of the feminine variant of nouns, pronouns and adjectives. This mechanism affects the evident configuration of a specific gender collective: “Ni Thanks to the struggle of the LGBTTTIQ+at sign, the asterisk and x, there is the e morpheme, which began to circulate widely in 2018, with the marches and discourses that supported the Interrupción Voluntaria del Embarazo (Voluntary Interruption of Pregnancy) Bill (2018), as we have already mentioned.Inclusive language proposes resources for the non-visibility of gender - which we mentioned in the previous section, but rejects the use of the feminine variants, since it objects to binary forms. In addition to the graphic resources already addressed -the -e phoneme acquires the status of a morpheme, since it becomes filled with meaning. Thus, the choice of this morpheme is the matrix of a possible reconstruction of the gender paradigm which, as stated by Martínez FEMININE: -A (S)OTHERS: -E (S)Therefore, “the semantic substance that categorizes the plural paradigm would be: ‘different from one + gender' and the gender type categorized as masculine, feminine, and others”  Les vecines de Adrogué aplaudimos al personal de salud que atiende a les enfermes contagiades de COVID-19.Adrogué, located in the province of Buenos Aires, August 23, 2020).The neighbors of Adrogué applaud the health personnel who take care of COVID-19 infected people  ¡Feliz día a los maestros, las maestras y les maestres!Happy Teachers' Day! -e morpheme is detected as a neutral gender replacing the established binary genders. The morphological changes are applied throughout the phrase, on articles, nouns and adjectives: “Les vecines” and “les enfermes contagiades.”Accordin to Martínez, in example (1) the use of the -e is neither feminine nor masculine, because it is others, or it makes no difference, according to Martínez. But, in reality, “vecines” and “enfermes” could be saying that they are people with different gender identities, or even that the speaker does not know their gender identities. We really don't know if the “vecines” or “enfermes” are only men and women, or if they are, for example, transgender people and men. With respect to (2), an alternative can be observed in the use of the -e morpheme. Although, as we saw in the previous example, -e replaces the generic masculine variant, here a splitting into three genders is produced: masculine, feminine, and one that encompasses the gender dissent not included in those two options. That is, the two binary genders are distinguished (“los maestros y las maestras”) and a third one of a dissident type is included, which objects to such binarism (“les maestres”). This last case corresponds to the interpretation of -e as a different option from masculine and feminine.Here e morpheme, in its beginnings, its use was limited to informal contexts, both in oral and written discourse. However, it is worth pointing out that, in the last year, inclusive language has begun to be legitimized in more formal discursive practices and institutions, such as schools, teacher training courses and universities. Gradually, in Argentina, books are also being published employing inclusive language, corresponding to different discourse genres: literature, cookbooks, journalistic reports, etc.As for the --e form, we have found uses of x, but we did not find any of @ and *, so we propose that the latter be resources falling into disuse.In this work, as we have already mentioned, we analyze texts written in external inscriptions of the urban environment and in certain discourses that circulate in virtual space. In them, besides the Real Academia Española (RAE), object to non-sexist uses of language, due to their ungrammaticality in the case of @, x, and -e, or because they deem them artificial and unnecessary, regarding the employment of gender-form splitting, paraphrasing or abstract nouns. With respect to RAE's position, Ramírez Gelbes , whose use was fought against for decades by the Argentine State without any success. Let us bear in mind that the Argentine State tried, for decades, to eradicate the use of voseo through different regulations in school, radio, and written language in general, etc., but without achieving any success. Thus, we see that, when it comes to a language phenomenon, already systematized, impositions do not work and end up failing. Let us remember that, according to Arnoux  or predominantly verbal (text). The latter, which are our object of study, usually have, according to Chiodi , the preBelow, we analyze a series of inscriptions in public spaces that employ inclusive language resources. As it can be seen, they are all short statements that can be easily read by a passer-by. The six inscriptions, presented as examples, are constituted as affirmative clauses, but with nuances that give rise to different meaning effects. Many of them are anonymous; the empirical author of the texts is not made explicit.In Facultad de Filosofía y Letras (School of Philosophy and Literature) of the University of Buenos Aires, in Caballito neighborhood, in the city of Buenos Aires, where it reads: “Les estudiantes ya elegimos.” It is a graffit that was made in reference to gender intersectionality in the political realm of the school. In 2019 (November) by the representatives of the Commission for Women and Sexual and Gender Diversity of the Student Center of the Faculty of Philosophy and Letters (CEFYL).In turn, A is obligatory,” where A replaces a statement that describes an action that is obligatory (taking care of the square). In addition, X), but on the construction of a collective S “nosotres les estudiantes” , ratified by means of the exclusive plural verb (“elegimos”/we choose). Let us remember that inclusive “we” implies the use of the first person plural which includes the listener , as is the case that we have just analyzed.Although both inscriptions are made up of declarative sentences, Moreover, in x.Here, unlike the previous cases, what is displayed is an expression of denunciation of child death due to poverty. In this case, the personal pronoun “ellxs,” which is the object of the enunciation and what is predicated about (“mueren”) is acted upon with The three examples show how the “inclusive” act is placed in different elements of the phrase and thus causes different meaning effects. If, in the first case, the relevance was placed on the configuration of the addressees to whom it referred in order to provoke an action involving care and responsibility over the square, in the second, the emphasis is placed on the identity construction of the speaker of the inscription, while, in the third one, the focus is on the object of the enunciation, that is, on what is being predicated. The comments that operate on the introduced inclusive resource can be the following ones:e/x is what is convenient/must be done-e/x with a broad, non-binary value,-e/x in opposition to the sexism of Spanish,-e/x instead of -o.-Undoubtedly, these comments, raised here in a broad or general way, with the aim of laying the foundations for the analysis, may have a different hierarchy, or they may be different, in each future example according to their meaningful effects.In contrast, the murals of In -e morphemes are acted upon with some gray spots. In this way, we observe a form of intrusion on a public message, which is contrary to what we saw in But if we look in detail at the last mural, i.e., symbolic signifying space, which allows the subject to situate themself in the world because they are located in “the world of significations,” that is, they recognize themself and circulate among the diverse subject positions. Following Zoppi Fontana , S is constructed as part of “trabajadorxs freelance y monotributistas organizdxs” (freelance workers and organized autonomous workers). In turn, “artesanxs, emprendedorxs, productorxs músicxs y maestrxs”  are the addressees of the other flyers (cf. 8–10), while the configuration of the addressee through the inclusive resources contributes, in addition, to the construction of the image of S  as more inclusive, open and egalitarian.As it is known, several communicative contexts, which emerged with the advent of new technologies, have given rise to new formats or discursive genres, such as flyers on social networks and informative audiovisual forms, etc. Similarly to what happened in the urban outdoor inscriptions recently analyzed, the texts circulating on social networks appeal to the inclusive trait to configure the different discursive subjects. Some employ (7) Reunión de trabajadorxs freelance. Vamos a discutir sobre los problemas de trabajadorxs freelance e independientes para sumar nuestras demandas a la lucha de Monotributistas Organizadxs. 31/1/2020.(8) Día Nacional del Músicx. ¡Feliz día a todxs los músicxs! 23/1/2020.(9) Feria del Faro. Feria colectiva de artesanxs, emprendedorxs y productorxs locales. 15/2/2020.(10) ¡Feliz día, queridxs maestrxs! Editorial Riderchail. 11/9/2020.x, some very aggressively. Cases like this set up the discussion about what strategies to take if one wants to convey a message to a wide audience. In relation to the journalistic realm, Ingrid Beck, journalist and director of Barcelona , asks herself: “When we want to reach other people: what do we do?, do we use inclusive language, which distances us from many?, or do we try to use, for example, neutral words like “las personas,” “la gente” (people)?” (2019). For now, Beck chooses to use some other resources, such as paraphrases or non-gendered pronouns, to resolve such a dilemma, but at the same time trying to reach those audiences who, if they see or hear e or x, will not read or listen. This is the current trend in mass media: not to use inclusive language, except to provoke some meaning effect, as we see in the following headlines of Página/12.As we have already mentioned, inclusive language generates strong reactions. For example, some of the comments regarding these flyers questioned the use of (11) La organización de los nietos de los desaparecidosLes Nietes llegaron para tomar la postaPágina/12, August 29 of 2020).Más de 70 jóvenes de todo el país empezaron a reunirse para “mantener viva la memoria” y también para reconstruir sus propias historias. Enlazan la militancia por los derechos humanos con la lucha por la violencia institucional y por los feminismos y las disidencias sexuales ((12) La inteligencia ilegal alcanzó parroquias, comedores y festejos por el día de las infancias.El espionaje macrista no respetó ni a les niñesPágina/12, September 27 of 2020).El Proyecto AMBA de la AFI que conducía Arribas se enfocó, como anticipó Página 12, en control a los partidos políticos y en investigar la actividad de los movimientos sociales en sus locales  reader, open and sensitive to social and gender matters.The headlines in both pieces show inclusive language marks , but in the rest of the news text, the generic masculine form is used, as it is possible to observe in the header of (11) (“los nietos de los desaparecidos”/the grandchildren of the disappeared). Why is the To conclude our analysis, in (13) we have transcribed an explanatory video about COVID-19, made by Paula Bombara and Luciano Nieves. It is an informative-educational text for children that has circulated on the networks during 2020.“¿‘Qué es el coronavirus?”Hola, soy Paula Bombara, soy escritora y bioquímica. Y él es Luciano Nieves, bioquímico y docente de la Universidad de Buenos Aires. Queremos explicarte qué son los virus.Los virus son parte de la naturaleza pero, pero, los virus no respiran, no están vivos. Por eso no son ni animales, ni plantas, ni bacterias ni hongos. Tampoco están muertos porque tienen la capacidad de reproducirse, claramente, no son como las piedras. No son animales, no son vegetales, no son minerales, son virus. Interesante, ¿‘no?Básicamente, lo que hacen es reproducirse cuando encuentran materiales para lograrlo. No son ni malos ni buenos. No nos enferman a propósito, tampoco son seres imaginarios, no son monstruos. Los virus no pueden verse a simple vista, se necesita un microscopio especial porque son muy, muy pequeños. Están formados por una molécula de material genético, en la que está la información que necesitan para reproducirse, y proteínas que protegen esa información.Es gracias a esas sustancias, las proteínas, que pueden entrar a nuestras células. Y es en nuestras células donde encuentran todos los materiales para reproducirse. Para ellos, encontrar una célula, es genial. Pero para nosotres, eso no es una buena noticia. Si sucede en nuestro sistema respiratorio, en nuestros pulmones, como pasa con el coronavirus, lo más común es que entre por la nariz, por la boca o por los ojos. Al principio no vamos a darnos cuenta. Pero luego de unos días comenzaremos a toser, a producir mocos, a estornudar, tener fiebre, temblar. Todas estas son reacciones positivas del cuerpo para sacarnos al virus de encima.Si nuestro estado de salud antes de la llegada del virus no es bueno, puede que nos provoque alguna complicación mayor. Pero, en la gran, gran mayoría de los casos, después de un tiempo, lograremos superar la infección. Quedate en casa, para cuidarte a vos y cuidarnos entre todes.#Quedate en casaGracias por las ilustraciones a Viviana Bilotti, a Rosario Oliva a y a Eugenia Nobati.“What is the coronavirus?”Hi, I'm Paula Bombara, I'm a writer and biochemist. And this is Luciano Nieves, biochemist and professor at the University of Buenos Aires. We want to explain to you what viruses are.Viruses are part of nature but, but, viruses do not breathe, they are not alive. That's why they are neither animals, nor plants, nor bacteria, nor fungi. Nor are they dead because they have the capacity to reproduce, clearly, they are not like stones. They are not animals, they are not plants, they are not minerals, they are viruses. Interesting, isn't it?nosotres”), that's not good news. If it happens in our respiratory system, in our lungs, as it happens with the coronavirus, the most common thing is that it enters through the nose, through the mouth or through the eyes. We won't notice it at first. But after a few days we will start coughing, producing mucus, sneezing, having a fever, shaking. These are all positive reactions of the body to get rid of the virus. If our state of health before the arrival of the virus is not good, it may cause us some major complication. But, in the great, great majority of the cases, after some time, we will manage to overcome the infection.Basically, what they do is reproduce when they find materials to do so. They are neither bad nor good. They don't make us sick on purpose, nor are they imaginary beings, they're not monsters. Viruses cannot be seen with the naked eye, you need a special microscope because they are very, very small. They are formed by a molecule of genetic material, in which there is the information that they need to reproduce, and proteins that protect that information. It is thanks to these substances, the proteins, that they can enter our cells. And it is in our cells where they find all the materials to reproduce. For them, finding a cell is great. But for us (“entre todes”).Stay at home, to take care of yourself and each other  Transcript of the video: “What is the coronavirus?” by Paula Bombara and Luciano Nievez. Available at: -e morpheme. Thus, “Nosotres” and “todes” refer to an entity that includes the addressee, and is reinforced with other pronominal and verbal marks corresponding to the inclusive we (“nuestros pulmones” (our lungs), “no vamos a darnos cuenta” (we won't notice), “comenzaremos a toser” (we'll start coughing) “cuidarnos” (we'll take care of ourselves etc.). The use of the –e in those cases “agrees and corresponds,” as it refers to a broad and non-binary audience, which can be brown, female or the LGBTTTIQ + collective, an audience that is not always considered in the school environment.As we can see, the first-person plural pronoun and the indefinite adverb are enunciated with the As in the previous cases, inclusive language provokes strong reactions and, on many occasions, there is a great resistance to reading or listening to it. In fact, several school principals decided that the video should not be show in their institutions due to, exclusively, the use of inclusive language.-e/x is what is convenient/must be done, -e/x with a broad, non-binary value, -e/x in opposition to the sexism of Spanish, -e/x instead of -o. The same discourse reveals, thus, a sexist, patriarchal image of the Spanish language, which it comments on and refutes, while at the same time proposing new subject representations.In these virtual spaces, also, the use of inclusive marks points to a configuration of a certain dialogical positioning, which presents an image of patriarchal discourse that gives way to it and from which it dissents: As we have already pointed out in the previous sections, for various researchers, inclusive language is a proposal that seeks to impose a value around a social claim Moure, , or a MaIn contrast to this position, other researchers argue that language accounts for social reality and therefore transformations take place and are necessary. In this respect, Cartín  maintainIn contrast to these positions, and according to the analysis performed, in this work we consider, as do other specialists  X/-e in the absence of other options/resources are not present; (3) -o and -a are not valid, thus, X/-e; (4) X/-e instead of -o; (5) X/-e, as gender studies dictate, or as inclusive language guides recommend, among others.Considering this framework, we propose that In each one of the texts analyzed in the Analysis section, it was possible to notice the positions of S in the face of other discourses, as a way of accepting political movements of gender or social demands of gender and inclusive language guides, or as a form of criticism or rejection of generic use of the masculine in Spanish grammar and legitimized by society.x mark is added, in which the commentary on the enunciation is made explicit. The use of x is explained in the following terms:By way of illustration, a note from a thesis written entirely with the The way we conceive of sex and gender is not independent of the way we name them, and therefore, represent them. Given that in this thesis I take up an explicit position against gender binarism , in order to reflect that position in my writing I have opted, among other possible forms, for the selective use of the x-ending, understood as the indicator of a diversity that goes beyond or transcends the masculine/feminine binarism. In some cases, the use of a masculine grammatical gender was intentionally maintained, to refer to historically patriarchal actors and institutions Undoubtedly, the characteristics of a doctoral dissertation demand the inclusion of a note that explains the editorial decisions made and the reasons behind departing from the conventions and the legitimized language norms.ethos, that is, in Amossy's (dir.)   terms, t Amossy, . In othex and -e can be seen in those cases as discursive interventions that show a certain dialogical positioning of S before a discourse framework alluded to in that enunciation. In effect, they evidence a dispute against the use of the generic masculine form and, therefore, they raise an objection to the discourses considered sexist and patriarchal that circulate and are legitimized in different social realms. Such resources show positioning spaces and the configuration of collectives and of subjects of saying.The Taking into account, then, that the dialogical-polyphonic dimension cuts through the different inclusive language mechanisms, it can be argued that its resources are linguistic marks of dissent, insofar as they function as spaces for the staging of generic otherness and emerge as traces of historically denied diversity. Undoubtedly, all these inclusive language forms generate meaning effects that challenge us as speakers and therefore also make us uncomfortable and destabilize us.x, -e) carry a commentary by the speaker on their own enunciation. The forms of inclusive language point to the image of previous discourses that they present as sexist and patriarchal and with which they disagree. They are forms that object to grammatical binarism, propose new rupture variants and evoke other discourses that have been forbidden up until now. And therein lies the strength and novelty of the so-called “inclusive language”: its marks make room for a questioning, offer new meanings and evoke traditionally silenced voices. Where an e or an x appears, instead of a masculine mark, there is a commentary that emerges and questions. In line with Zoppi Fontana (As we have argued throughout this work, inclusive forms are subjectivity marks, which shape discourses that are positioned and differentiated from others. Thus, the words or expressions acted upon with some of the elements of inclusive language ( Fontana , we undeTo conclude, it is worth mentioning that the driving force behind this article has been the desire to contribute to the description of Spanish today and to offer a discursive analysis that puts the focus on the subjective and dialogical dimensions of a linguistic phenomenon enjoying a wide circulation and exerting a great impact in Argentina. We believe that approaching inclusive language can open spaces for debate and discussion. In addition, it can have an influence on the deepening of linguistic reflection and the promotion of respect for diversity from a gender perspective that advocates for a more egalitarian and inclusive society, one which is respectful of differences.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This article challenges the “tyranny of P-value” and promote more valuable and applicable interpretations of the results of research on health care delivery. We provide here solid arguments to retire statistical significance as the unique way to interpret results, after presenting the current state of the debate inside the scientific community. Instead, we promote reporting the much more informative confidence intervals and eventually adding exact P-values. We also provide some clues to integrate statistical and clinical significance by referring to minimal important differences and integrating the effect size of an intervention and the certainty of evidence ideally using the GRADE approach. We have argued against interpreting or reporting results as statistically significant or statistically non-significant. We recommend showing important clinical benefits with their confidence intervals in cases of point estimates compatible with results benefits and even important harms. It seems fair to report the point estimate and the more likely values along with a very clear statement of the implications of extremes of the intervals. We recommend drawing conclusions, considering the multiple factors besides P-values such as certainty of the evidence for each outcome, net benefit, economic considerations and values and preferences. We use several examples and figures to illustrate different scenarios and further suggest a wording to standardize the reporting. Several statistical measures have a role in the scientific communication of studies, but it is time to understand that there is life beyond the statistical significance. There is a great opportunity for improvement towards a more complete interpretation and to a more standardized reporting. For decades, the “P-value”-based binary interpretation and reporting of results, based on a cutoff point for the P-value dominated the publications. However, many concerns arose about such rules dictating clinical implications of research results. Nowadays, the scientific community seems to agree that this binary approach is not advisable. The problem is that treating results as either ‘statistically significant’ or ‘statistically non-significant’ implies categorizing a continuous variable, which is at least misleading , 2.In a very influential publication in “Nature”, Valentin Amrhein and more than 800 scientists including statisticians, clinical and medical researchers, biologists and psychologists worldwide rose up against statistical significance and its misleading interpretation . They clP-values and significance judgements in individual studies.This debate is not new , 6, howeHowever, given that “statistical significance” is so frequently misreported and misinterpreted, there seems to be a consensus that terms such as ‘significant’, ‘statistically significant’, ‘borderline significant’, and their negative expressions, should not be reported anymore. The expression ‘trend towards’ is also frequently misused as “near statistically significant” and prone to bias if used selectively. It is invalid to only report the trends aligned with the researcher’s hypothesis, but the approach is acceptable if all trends, regardless of their direction, are reported. Furthermore, a P < 0.05 should not be considered at all when deciding which results to present or highlight. It is correct to highlight significant results, but the decision on what result to present or highlight should be based on the research hypothesis not on which result is significant. Similarly, Ioannidis recommends not to use P-values unless there is a clear justification that it is the best choice, and to be always highly skeptical about “statistically significant” results at the 0.05 level .Reporting and interpreting point and interval estimates together should be the rule but it has not been the case for a long time. The number of studies using the term “statistically significant” but not mentioning confidence intervals (CIs) for reporting comparisons in abstracts range from 18 to 41% in Cochrane Library and in the top-five general medical journals between 2004 and 2014 . These fP-values must still be used, but they should be reported as continuous exact numbers , clearly describing its scientific or practical implications to better interpret it. Moreover, rather than adopting rigid rules for presenting and interpreting continuous P-values, we need a case by case thoughtful interpretation considering other factors such as certainty of the evidence, plausibility of mechanism, study design, data quality, and costs-benefits that determine what effects are clinically or scientifically important. It is also important to remember that clinical implications of results cannot be extrapolated to patient groups other than the patients included in a study .There are many frequentist and Bayesian tools to provide a significance level , but theDeciding whether the size of an effect is relevant or not depends on how critical an outcome is. For example, it is difficult to define a lower threshold for clinical significance/relevance of mortality estimates as of any benefit of a new treatment, whatever small, is relevant , 18. ConA judgment and rationale are required to decide what constitutes appreciable benefits and harms. Regardless of the type of outcome, an intervention with a small beneficial clinically relevant effect will not be recommended if adverse effects are relevant , 18. SerFor a drug with no serious adverse effects, minimal inconvenience, and modest cost, even a small effect would warrant a strong recommendation. For instance, we may strongly recommend an intervention with a MID of at least 0.5% of absolute risk reduction of abortion (NNTB of 200). However, if the treatment is associated with serious toxicity, we could prefer a more demanding MID like 1% (NNTB of 100).We consider that reporting a point estimate and CI is much more informative and should be the rule. Additionally, the P-value informs the probability that this effect has been observed by chance.However, a binary use of confidence or credible intervals  could lead to the same problem caused by the use of the statistical significance. In fact, some authors propose the alternative term “compatibility” intervals to guard against overconfidence . AuthorsOne of the most polemic scenarios is the situation of point estimate showing important clinical benefits with 95% CIs compatible with both, even better benefits or important harms and a P-value > 0.05 (i.e. P = 0.08). We have argued against interpreting and/or reporting results as statistically non-significant. A better statement could be “the intervention did not demonstrate superiority vs the comparator”. Although this is true, it is still possible that this result could be interpreted as indicating “no effect”  and thisTherefore, it seems fairer to report the point estimate as to the more likely value jointly with a very clear statement of the implications of extremes of the confidence interval. In fact, this is the approach recommended in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines .To better explain these concepts, Fig. For example, the Study 1 (S1) is completely inside of the clinical inferiority area for the New treatment since its upper 95% CI limit is below -MID and the related P-value of 0.0001 indicates that the probability that the cause of the observed difference could be attributed by chance is only 1/10,000. A mirror scenario in the opposite direction occurs with S2 completely inside of the clinical superiority area for the New treatment.Another lesson is that “statistically non-significant results may or may not be inconclusive” even with the same point estimate. For example, S3 presents a very narrow 95% CI and a P-value of 0.70 and is conclusively considered as “Equivalent”. S8 presents a very wide 95% CI and a P-value of 0.90 and its results are inconclusive since it is compatible with both important benefits and harms.S4 could only be considered clinically as “non-inferior” and statistically non-significant . S2 and S4 present similar point estimates but S2 presents a narrower 95% CI inside de clinical superiority area and P = 0.01).To express narratively the aforementioned concepts in order to effectively, and consistently, communicate the conclusions of a review is even more challenging . CochranGRADE defines evidence certainty  differently for systematic reviews and guidelines. For systematic reviews, certainty mainly refers to the confidence in the estimates of effect for a specific outcome. For guidelines, certainty refers to the extent to which our confidence in the effect estimate is adequate to support a particular decision.As the certainty of the evidence incorporates a judgement about the precision of effect estimates, it is not necessary to say anything more about the confidence interval or P-value in these statements about effects. However, situations where the point estimate indicates an important benefit (S4 and S7) or harm (S5 and S6), but the CIs are wide involving no benefit or harm, regardless of the non-statistical significance (like S4 and S5 cases) should be explained using statement mentioning both possibilities:[Intervention] may lead to [better outcome /worse outcome ], however, the 95% CI indicates that [intervention] might make little or no difference/might worsen/increase [outcome].[Intervention] may lead to [little to no difference in outcome (S8)], however, the 95% CI is compatible with both important beneficial and harmful effects.For example, “Using lay health workers as an add-on to usual care may increase care-seeking behavior for children under five. However, the 95% confidence interval indicates that it might make little or no difference” .GRADE guidelines suggest a default threshold for appreciable relative benefit and harm of 25% ± 5%  if thereHaving determined a threshold for an important effect, it is highly desirable to make it explicit in the protocol of any study assessing interventions.Preparing summary of findings (SoF) tables for systematic reviews according to the GRADE guidelines  , funding agencies and regulators should reduce the impact of statistical significance on publication, funding and promotion. Some groups have eliminated the binary statistical significance approach from their editorial practice.Furthermore, the certainty of the evidence should be presented together with effect estimates for each outcome using similar words and expressions, such as those suggested in Table Changing editorial policies will not be easy to implement, but if journals provide clear guidelines to authors, besides improving the quality of reporting, the editorial work burden will be reduced at the end of the day. The CONSORT  2010 guidelines for reporting parallel group randomized trials encourage the use of continuous exact P-values alongside with CIs, but it does not include a strong position against the binary way of reporting results . Surely A detailed statistical analysis plan preventing the misuse of the statistical significance should also be a request to approve a protocol that must be accessible to other researchers. It should be based on strong theory and a context of relevant prior empirical evidence. Therefore, the study team should have statistical knowledge, skills and experience to interpret and communicate findings.Regulatory agencies like the U.S. Food and Drug Administration (FDA), have long-established significance thresholds for P-values for Phase III drug trials. This kind of institutions might require more time for making changes. The objection against retiring statistical significance is that it is needed to make yes-or-no decisions, however this misconception ignores that decisions are made based on multiple factors besides P-values including net benefit, economic considerations and values and preferences.The life beyond the statistical significance will emphasize estimates and the uncertainty around them which will be accompanied by a discussion about the practical implications of the lower and upper limits of their intervals in the context of MIDs. Hopefully, the methods sections will be more detailed and anchored in real life. They will provide more background information that allows other researchers to execute meaningful alternative analyses. Thus, the interpretation of results not based on statistical thresholds will promote thinking about the potential consequences of the estimations and preventing confusions between statistics and reality.The “P-value”-based binary interpretation and reporting of results is insufficient to capture the complexity of the problem and limits the true understanding of the evidence. There is a great opportunity for improvement towards a more complete interpretation and hopefully to a more standardized reporting.The statistical community has not yet reached a consensus about the interpretation of statistical inference for treatment effects or a wording for reporting results. But solid bases for the use of statistics and communication skills do exist, and applying them could help to greatly improve science and decision-making.All of those who embarked in health research have imposed a rigorous methodology on research planning, analyses and reports because of the relevance of research results for the health, quality of life and survival of the population. It is a duty to be proactive in continuously improving health research methodology. The discussion in this article is a compelling call to reconsider the “tyranny of P-value” and move towards interpretations that are more valuable with better applicability of the results of research on health care delivery. Those responsible for producing and communicating the scientific literature—authors, editors, reviewers—need to apply the considerations and recommendations set out in this commentary in the generation, evaluation and publication of articles.


China is the world’s largest producer of food fish, and Chinese consumers have a preference to buy live fish. Live transport of fish is, therefore, a common procedure in aquaculture and is a potential animal welfare hazard. Little has been published on current fish transportation practices in China or the knowledge and attitudes of stakeholders in this industry. Our qualitative study aimed to obtain original information about live transport processes from a cross-section of aquaculture stakeholders in China by conducting individual interviews. Stakeholders were interviewed about their knowledge of live transport and their attitudes towards the welfare of fish. Self-described knowledge of live transport varied between participants with different job types. Most participants had heard of and understood the concept of “animal welfare”, but many understood it to only refer to terrestrial livestock, not fish. This suggests that knowledge of fish welfare in the industry may be less than for other farm animals. The findings of this pilot study contribute to a better understanding of live fish transport from a stakeholder point of view. The findings will also assist in informing, educating, and sensitizing stakeholders to the importance of fish welfare during live transport.China is the largest food fish producer in the world. Chinese consumers normally purchase fish that are still alive to ensure freshness. Therefore, the live transport of fish is important in China’s aquaculture, although it carries potential risks for animal welfare. This study investigated the attitudes and knowledge of stakeholders within Chinese aquaculture towards the live transport and welfare of fish. Semi-structured interviews were conducted with 12 participants who were involved with the aquaculture industry in China. Most participants self-rated their transport-related knowledge as moderate and had some understanding of animal welfare, although this term was generally considered only relevant to terrestrial animals. Participants’ responses indicated that the live transport of fish occurs frequently in China, generally using sealed tanks, plastic bags, and foam boxes, in purpose-built vehicles. Seasonal changes, such as changes in ambient and water temperature, are considered to be important contributors to successful live transport, as well as sufficient oxygen supplies and stocking density. The use of anesthetics was not commonly reported, particularly in food fish, and fish capture is predominantly by conventional dipnets. The health status of transported fish is determined mostly by morphology , as well as vigor and swimming ability. Our results indicate that live transport poses a number of welfare risks to fish but that participants in the process associated welfare concerns more with terrestrial animals, not fish. Fish is an important dietary protein for many people in the world, and global fish consumption has continuously increased over recent years . With thRoad transport of live fish by vehicle  is a common practice in aquaculture, but it can lead to detrimental effects on fish well-being. Fish are often transported between farms or to markets for on-growing or sale . There aCtenopharyngodon Idella and silver carp Hypophthalmichthys molitrix) are predominant in most of the production in China  another [sales target] is the private buyer” and H “[…] there are some casual buyers, such as households from a residential community, we also deliver live fish to them.” Except for direct human consumption, fish are also transported alive for research purposes to laboratories. Participants D and G respectively noted, “We transport [wild-caught] fish from mountain areas to a laboratory” and “Fish are transported to our [university] laboratory for experiments.”Participants were asked what sort of destinations they usually transported live fish to and where these places were located. They reported wholesale markets, supermarkets, wet markets, laboratories, restaurants, residential communities, and private residences as popular destinations. Wholesale markets were the most common destination mentioned (n = 8), with some in suburban areas (n = 2). Most destinations were reported to be provincial cities  or larger cities . Participant E said that large wholesale markets are gradually moving into suburban areas: “Nowadays, this sort of fresh market is to the extent possible near to the edge of the [Changsha] city, clustered between the city and suburb, where those transport trucks can get in and out.” The two animal advocates were not directly involved with live transport, but they stated that they purchase live fish in supermarkets and fresh markets, which are near to their (urban) residence . Live transport also occurs frequently within a province or between adjacent provinces, for instance, “[from a farm in Hangzhou to the transport destinations], within this area of Jiangsu, Zhejiang and Shanghai [up to 500 km approximately]” (Participant A) and “[live transport] usually occurs within the province, for example, from Jilin to Changchun [approximately 120 km], similar to that, maybe 2–3 h of trip” (Participant G).According to participants’ answers, the connecting and final destinations were mainly in urban areas (n = 9) said that freshwater fish are mostly transported alive, for example, (Participant A) “From our experience, the fish transported are all alive, throughout the process of catching to putting into the transport tank” and (Participant G) “Fish all need to be alive for the transport.” While many marine fish species or other aquatic animals, such as crustaceans, can also be cold preserved  or directly frozen (dead) before transport, Participant J reported that “Our seafood here, it is live transported. There is also some seafood that is dead [due to capture], how is that transported? Under normal circumstances after being caught from the sea, they are directly frozen and iced [for transport].”Participants were asked how many fish are generally transported alive as a percentage of the fish transported in total. Their responses indicated that the live transport of fish in China is close to 100%, particularly for freshwater fish species. Most participants (n = 10) believed that seasonal changes have a great impact on the success of live transport. Water and ambient temperature were considered particularly important factors, for example, Participant A reported that “[…] when the ambient temperature is high, the water temperature will also be high, and the fish may experience hypoxia. So basically, the proportion of live fish transported in summer is very small.” Participants also suggested that fish mortality is higher in summer compared with other seasons. According to Participant G, “[…] under hot weather conditions, the [fish] survival rates are little lower. Then after they arrive at the destination, the fish condition apparently does not look good, and they need more time to recover, [during the recovery], even have a few deaths.” Similarly, Participant F stated, “[…] fish require constant water temperature during the whole transport [to survive]. In summer, you need to add ice [into the water]. In the winter you probably need to increase water temperature.”Interviewees were asked whether seasonal changes have an impact on the success of live transport. According to their responses, live transport occurs more in cool-weather conditions and less in summer, and the majority  “This [live transport] will not change [due to seasons], it is mainly to do with workdays, or related to holidays, but for seasons, there is not that much relationship. […] for long-distance transport during holidays, the highway will be packed with traffic, and this is not good for live transport.” Live transport is also associated with fish production cycles throughout the year. Fish of different sizes and life stages are transported in different ways, as suggested by Participant C: “[…] in springtime, actually most transported fish are fry, then the rest in other seasons. Live transport of market size fish occurs more frequently.”During the interviews, we asked about what sort of vehicles are commonly used for live transport. Interviewees reported that the size and volume of the vehicle used in fish transport vary, dependent on transport purpose and distance. Commonly, purpose-built vehicles were used, as well as vehicles modified for live transport, such as trucks/lorries, vans, and private cars. According to Participant A, “Transport vehicles (活水车) must be professionally modified and equipped with oxygen supply, as well as water storage systems.” Modified trucks were typically used for transferring larger volumes of fish, as indicated by Participant F:” They are modified vehicles that have a tank with a circulation system, refrigeration and heating equipment.” In contrast, research fish can be transported using private cars because of their small volumes and smaller fish size. Participant G mentioned that “For fish transport vehicles, basically it is just us transporting them in the private cars that we drive, […] If we do not transport lots of fish, we just transport them back in our own private car[s]. Sometimes we find a van [for live transport] if there are more fish.”Participants were asked about the most commonly used methods of transporting live fish. Based on their responses, transport tanks, plastic bags, and foam boxes were commonly used. Transport tanks made with polyvinyl chloride (PVC) plastic were commonly reported to be used for large volumes of fish or over long distances, with modified vehicles. For example, Participant A stated that “For large-scale transport, it has to be transport trucks with [PVC] tanks. For small-scale transports like we do, well, within a certain limit, we use plastic bags or foam boxes.” Participant E also mentioned: “Transport vehicles all use compartmented tanks made from that sort of PVC material, with oxygen added.” Small volumes of fish or short-distance deliveries were often carried out using aerated bags: (Participant G) “For transport within the province, about 2–3 h, fish are all in bags, fish transport bags.” Participant E also described that “If we are talking about after arriving at wholesale markets and transporting separately to grocery stores, or restaurants, then after arriving at wholesale markets they use foam boxes and aerated bags. At wholesale markets, they use that sort of foam box with aerated bags inside. This can also be used to transport live fish.” One participant (L) transported live fish regularly using a carrying pole (扁担). Fish were placed in homemade baskets with sealed plastic bags for transporting from his house to the local market on foot.n = 7) said that no fish anesthetics are used during live transport of food fish based on their experience, but other methods such as the addition of ice, a high concentration of sea salts, or vitamin C were applied to control water quality and reduce transport stress in the fish. Participant H: “We never use chemical anesthetics [for food fish], but sometimes we add a little vitamin C or sea salt.” The use of fish anesthetics seems to be species-specific in our study, evidenced by “There are some fish for which we will use anesthetics, such as yellow catfish because their body has a lot of spines and sharp bones” and “I know anesthetics have been used for marine fish. In terms of farmed fish, either freshwater or seawater, as long as they are relatively valuable fish types, they will usually use anesthetics”, from participants A and C, respectively. Two participants (D & G) answered that fish for research purposes were occasionally transported with anesthetics, as those are nationally protected species that are easily stressed by handling and transport processes.The use of chemical anesthetics in the live transport of food fish was not reported by participants in this study to be common. Most (n = 9), fish were caught by manual methods using dipnets or trawls. It is suggested by Participant A that “Fish are loaded and unloaded traditionally […] using a so-called ‘fishing net’ (拖网), or a fully sealed bucket with water, and [fishermen] will use that for loading and unloading.” Two participants mentioned that fish can be transferred by pumping and cage trapping. For example, participants C and J, respectively, stated that “One way is just directly to use a net to scoop up some fish […]. Another way, for relatively smaller fish, will be a sort of water pump that directly sucks the fish out” and “[…] in summer, you cannot pull fish out with a net. Generally, they use cages to trap fish, then to pull them up.”Question 25 obtained information on loading and unloading processes and their time points. According to most participants (n = 8) indicated that loading may occur several hours before transport starts, and fish were unloaded shortly after arriving at their destination. However, Participant F suggested that unloading may also occur at different times of the day, depending on traffic conditions and the opening hours of a market: “Fish do not have to be immediately unloaded [after arrival]. Basically, fish are unloaded in the afternoon or evening. Sometimes when the market has not yet opened, if a transport vehicle arrives [at the market] a little early, they will wait a bit. It is normal.”Most stakeholders ((i.)Very low level of knowledge/very poor understanding(ii.)Low level of knowledge/not much understanding(iii.)Moderate level of knowledge/general understanding(iv.)High level of knowledge/rich understanding(v.)Very high level of knowledge/very rich understandingWe asked all participants to self-rate their knowledge level and understanding in terms of live transport of fish on a five-point scale:Five participants indicated they had a moderate level of knowledge/general understanding. Four participants said their knowledge level was low. Two reported a high level of knowledge/rich understanding, and only one participant self-rated a very high level of knowledge/very rich understanding.n = 11). Sufficient oxygen was aerated into plastic bags, e.g. by aerating from a liquid oxygen tank, when fish were transported in a closed transport system; therefore, no oxygen was supplied during live transport (n = 2).Participants were asked how oxygen was typically provided during live transport. Oxygen was considered necessary in both open and closed transport systems, according to participants’ answers. For an open transport system, liquid oxygen cylinders and air generators were used to provide dissolved oxygen (n = 7) was the maintenance of dissolved oxygen levels in transport containers. Transport density was also identified by three stakeholders, while transport time, fish species, travel time, and vehicle vibration were each mentioned twice or less in the study.Participants were asked to identify potential challenges that arise when transporting live fish. The control of water temperature, oxygen levels, transport density, water quality, vehicle vibration, the selection of transport distance, transport time, fish species, capture method, and driver experience were all mentioned by different participants as potential challenges during live transport. All participants identified more than one challenge during live transport, and water temperature was mentioned by 8 of the 12 respondents. The second most reported challenge , a change of body color (red/white spots), eye color, and the secretion of skin mucus. For example, Participant A stated that “You must rely on experience to assess whether or not fish are healthy. You can observe whether or not fish bodies are descaling, whether they are bleeding, whether there are any red spots.” Similarly, Participant E reported: “Firstly, when fish arrive at their destination, one point is observing whether their eyes are clear (眼睛是否清澈), then the fish body, even checking whether their color is normal.” In addition to appearance, fish equilibrium, vigor, and swimming ability were also used to assess fish health after live transport. Participant D, for example, stated that they looked for whether fish showed a “floating head” .Assessment measures were reported to be more complicated for research fish, as evidenced by Participant G, “[…] we first observe the body color of the fish. Any fish that show abnormal body color will be excluded from our formal experiments. Furthermore, uneven fish sizes—too large or too small ones—we will not use them as well. For some high-value and expensive fish, we may do a microscopic examination to see whether they have any parasites, viruses or bacteria. […]. For the appearance check of fish, we only do simple checks, for instance, to see whether there is any body damage or mechanical injury to the fish.”Nine participants had previously heard of the phrase “animal welfare” and also were able to explain their understanding of the term. The remaining three did not know this term or were not sure of its meaning.Some participants mentioned that pre-slaughter and slaughter conditions were influential for animal welfare, and animals should be treated well before or during slaughter. For example, “[…] animals should be treated as calmly as possible during slaughter” was suggested by Participant B. Some participants also believed that animal welfare affects product quality, in particular meat quality, as evidenced by Participant E: “[…] during the slaughter process, if animals experience that sort of excessive fear or shock, their bodies will produce acidic substances. It probably will result in worse meat quality, or fish quality. [animal] Welfare is probably just like this.” Some participants suggested that the husbandry and slaughter of farmed or aquatic animals should be standardized within China to improve animal welfare. They also indicated that animals should be kept in a good environment and that their mental state should be considered. Participant D suggested that “no matter the farming or processing practices, we should follow a principle that reduces pain and fear to animals.” Similarly, Participant G stated: “We should treat farmed animals as, how to say it, as humans. We should pay attention to their mental states and relevant issues. If we do not treat animals well during husbandry, they do not keep in a good mood or a good state. Their own condition can also affect their product quality.”Three participants said that they were familiar with this term being applied to terrestrial livestock, but it was novel to describe fish or other aquatic animals in this way. For example, Participant A stated: “[…] it is quite fanciful for me that the term of animal welfare can be used in aquaculture.” Another participant (K) thought that aquatic animals did not have welfare, as she suggested that aquatic animals were not sentient like livestock and humans. This perspective differed between interviewees, as another participant (G) stated that fish should be treated the same as other farmed animals and that all food animals should have good welfare, regardless of the species.The attitudes of stakeholders towards different animals could affect their welfare. Participant C gave an example that “[…] animal welfare is relative to our kinship distance (亲缘关系) and determined by the degree to which our lives are similar. As for non-food animals, for example, those ornamental fish, their welfare is probably a little better compared to food animals who are usually seen as food to prepare, so they probably do not have good welfare.” Animal welfare specifically in relation to transport was also mentioned by two participants. For example, Participant H mentioned that a low fish mortality rate meant better fish welfare during transport from a producer’s perspective. Participant E suggested that a good environment should be provided during transport.The results of this study are not fully representative of the entire Chinese aquaculture industry, but the findings provide insight into the industry in China and reveal fundamental information on fish welfare during live transport. We discuss live transport processes, fish health and care, and the animal/fish welfare implications of our findings.Our results confirm that live transport remains a key component of the Chinese aquaculture industry, in line with previous literature ,46, partParticipants indicated that fish are transported to various locations, but wholesale markets, often located in suburban areas, appear to be the most common commercial destination for food fish. Sales channels for aquaculture in China generally include producers, processors, traders , retailers, consumers, and restaurants . Fish atCoreius guichenoti) were transported in cool water [Seasonal effects on the occurrence and success of live fish transport are substantial. Heat stress may be an influential factor on fish welfare during live transport, as most participants indicated that live transport occurs less frequently on hot weather days. Acute increases in water temperature are known to adversely affect fish physiology, with negative implications for fish welfare . If fishol water .Apart from water temperature, the maintenance of appropriate oxygen levels during live transport was also reported as one of the key controlling factors in our study. Sufficient oxygen supply is an essential component of the transport process ,47. Low From participant responses, it is clear that a variety of transport methods/containers are used to transport live fish, including transport tanks, plastic bags, and foam boxes. Plastic bags were noted to be more commonly used for the short-distance transport of a small volume of fish. This aligns with the literature from outside of China, which notes that market-sized fish are often transported in truck-mounted, high volume tanks over long distances ,55, whilFrom our interviews, chemical anesthetics were rarely used in live transport of most food fish but might occasionally be used for valuable fish , research fish, and some food fish that are challenging to handle, although specific drugs were not mentioned in this study. Tricaine methane sulphonate (MS-222) is a common sedative that is approved as a food fish anesthetic by the US Food and Drug Administration (FDA), but it requires a 21-day withdrawal period before sale . No anesCapture, loading, and unloading methods noted in these interviews were still traditionally manual methods of moving fish, such as using dipnets. Chinese freshwater farming systems are typically carried out as a polyculture in pond systems, which enhances the utilization of all the available food resources in the pond ecosystem . In thisXiphophorus variatus), an ornamental fish, show increased occurrence of biting and freezing behaviors post-transport, which may increase the risk of injury [Participants mentioned that the appearance, swimming ability, vitality, and mortality of fish were often checked after transport to estimate their health status and sale value. Physical damage to a fish looks unsightly and may lower the value of the fish . Consumef injury .This research provides insight into how stakeholders in Chinese aquaculture view animal welfare. Previous studies indicated that animal welfare is still in an early stage of development in China, reporting that about half of respondents had never heard of this term ,65. ThesThe concept of “animal welfare” has attracted growing attention within Chinese social media and researchers in recent years, although it was only introduced to mainland China in the 1990s . There hSome participants felt that the concept of animal welfare refers more to the welfare of terrestrial animals, rather than fish. Currently, the main welfare focus for Chinese researchers, producers, and government authorities is to improve conditions for livestock, specifically for pigs ,72 and cHowever, farmed fish welfare has not received the same attention as terrestrial livestock from the general public and industry stakeholders in China. Legislation and welfare standards for farmed fish are already available in some European countries, while China as a major fish producer has paid little attention to fish welfare . The recFish are ectotherm (cool-blooded) animals that live in aquatic environments completely different to those of humans, and this difference may create barriers to understanding their feelings and welfare needs . One parParticipants in this study were a small cross-section of people specifically approached because they represented different stakeholders within the Chinese aquaculture industry. While we collected detailed answers from them in response to a range of free-text questions, the participants cannot be considered representative of the industry. The findings from this research will contribute to the development of a larger questionnaire that aims to be more representative in investigating fish welfare during live transport in China. Additionally, in this study, we not only aimed to investigate stakeholders’ attitudes towards animal welfare but also their knowledge on specific transport processes, to gain insight on this topic in China, as little is currently published. The two participants who were interviewed because of their role in animal welfare advocacy were not directly involved in fish transport and so were less likely to provide detailed contextual information compared with others who were directly involved with the process . However, they provided valuable insight into attitudes and perceptions around animal welfare. Therefore, a future study could be potentially developed to further examine similar insights from a range of non-industry stakeholders, such as the public and consumers, animal rights advocates, and aquaculture students. Although most participants indicated their willingness to participate in all the questions, one interview occurred in a market, and the participant was not able to answer all questions due to time limitations. The interview was interrupted by the participant’s business; therefore, the length of this interview was shorter than the rest.Participants in this study confirmed that the live transport of fish (mainly farmed freshwater species) is common in the current Chinese aquaculture industry. Fish are transported using various methods and different vehicle types. The effect of seasonal changes on live transport is considered important, and transport is less commonly carried out in hot weather. Fish anesthetics are used to sedate some fish species but seldom used for food fish. Trawling and netting are still commonly used to catch fish from water due to the dominance of polyculture systems and many small-scale farms in Chinese aquaculture. Oxygen is always provided during live transport, and other challenges of keeping fish healthy are similar to those reported in the scientific literature. Physical appearance and fish vigor are used to measure fish well-being and marketability, according to participants’ answers. The self-estimated knowledge level of live transport was at a moderate level because most participants were not directly involved with live transport as a fish transporter. This study also provides information on the understanding of animal welfare and attitudes towards fish during live transport in China, as identified by a small sample of stakeholders in the industry. Although most stakeholders had heard of animal welfare and could provide their understanding, this term is considered more relevant to livestock or poultry, rather than fish. Future research should identify key welfare issues during live transport with a broader range of stakeholders and should investigate their attitudes towards fish welfare.