Access Issues Research Articles

“If we could look at kids as a whole”: Teachers negotiating science of reading approaches with multilingual learners

ABSTRACT “Science of Reading” approaches are prevalent in U.S. schools, but have not adequately addressed cultural and contextual factors for teaching in bilingual programs. Using cases from three bilingual teachers, we explore how teachers negotiated their biliteracy instruction after their district implemented a Science of Reading approach based on the simple view of reading. Data included coursework and interviews and were analyzed iteratively. Findings from this study show how Science of Reading approaches developed teacher knowledge of English foundational skills. However, participants interrogated the direct application of a simple view of reading to Spanish literacy and questioned instructional practices designed from a monolingual view for application with multilinguals. Teachers leveraged supports in their contexts and their professional and personal expertise to adapt and enhance their instruction. Issues of equity and access were raised since not all teachers shared this prior knowledge or contextual supports. Study findings point to the need for fostering pedagogical clarity within cultural contexts, preparing educators for critical decision-making in literacy reform. We call for approaches that recognize the unique cultural and linguistic resources of multilingual learners and their teachers.

Exploring the voice of patients: Mapping their experience following care in an integrated health area

Measuring patient-reported experience measures (PREMs) is essential for the continuous improvement of quality. This study aims to assess the quality perceived by patients in the key care processes of an integrated health area measuring PREM elements, with the goal of identifying opportunities for improvement. The research was conducted in the first half of 2023 within a Spanish integrated health area, analysing five key healthcare processes: Primary Care, Emergency Services, Hospitalisation, Consultations, and Surgery. To assess perceived quality, PREM elements such as accessibility, information, and professionalism were measured using the Net Promoter Score (NPS). The Lot Quality Assurance Sampling (LQAS) method was employed to identify specific areas for improvement by detecting rejected lots and optimising sample sizes. Although the perceived quality was generally high, with good or excellent NPS scores, significant variability was observed between processes. A total of 104 rejected lots (21%) were identified across the processes evaluated. The highest number of rejections occurred in and Emergency Services (67%), with notable issues in accessibility and information. The study underscores the need for targeted interventions in accessibility and information to enhance the patient experience, particularly in Primary Care and Emergency Services. The measurement of PREM elements using NPS, in conjunction with the LQAS method, proves to be an effective tool for identifying and prioritising areas for improvement, especially when applied on a regular basis.

A case of surgical treatment combined with interventional therapy for refractory hemodialysis access with catheter-related right atrial thrombosis.

This case report describes a surgical treatment combined with interventional therapy for a patient with refractory hemodialysis access combined with catheter-related right atrial thrombosis (CRAT). During surgery, an artificial graft was established from the left brachiocephalic vein to the right atrium and the right atrial thrombus was removed. After the operation, the tunneled cuffed catheter (TCC) was replaced with digital subtraction angiography (DSA). The hemodialysis access issue was addressed for this patient, and the access remained functional for normal hemodialysis during the subsequent 10-month follow-up.

Reimagining psychosis prevention: responding to the accessibility issues of At-Risk Mental State (ARMS) services through a selective public health approach.

At-Risk Mental State (ARMS) services aim to prevent the onset of first-episode psychosis (FEP) in those with specific clinical or genetic risk markers. In England, ARMS services are currently expanding, but the accessibility of this preventative approach remains questionable, especially for a subgroup of FEP patients and those from specific ethnic minority communities. This commentary outlines the key debates about why a complimentary approach to psychosis prevention is necessary, and gives details for an innovative public health strategy, drawing on existing research and health prevention theory.

Effectiveness and user experience of nose and throat swabbing techniques for SARS-CoV-2 detection: results from the UK COVID-19 National Testing Programme

BackgroundThe UK’s National Health Service Test and Trace (NHSTT) program aimed to provide the most effective and accessible SARS-CoV-2 testing approach possible. Early user feedback indicated that there were accessibility issues associated with throat swabbing. We report the results of service evaluations performed by NHSTT to assess the effectiveness and user acceptance of swabbing approaches, as well as qualitative findings of user experiences from research reports, surveys, and incident reports. Our intent is to present and summarize our findings about the application of alternative swabbing approaches during the COVID-19 pandemic in the UK.MethodsFrom May 2020 to December 2021, NHSTT conducted a series of service evaluations assessing self-swabbing and assisted swabbing of the nose and throat, and nose only (anterior nares/mid-turbinate) using polymerase chain reaction (PCR) and lateral flow devices (LFDs), for diagnostic suitability within the COVID-19 National Testing Programme. Outcomes included observational user feedback on swabbing approaches and quantitative testing performance (concordance, sensitivity, and specificity). A post-hoc indirect comparison of swabbing approaches was also performed. Additionally, an analysis of existing cross-service research was conducted in April 2021 to determine user feedback regarding swabbing approaches.ResultsObservational data from cross-service research indicated a user preference for nose swabbing over throat swabbing. Significantly more users reported that nose swabbing was easier to perform than throat swabbing (50% vs. 12%) and there were significantly fewer reported incidents. In the service evaluations, while there was reduced sensitivity for nose-only swabbing for PCR (88%) compared with nose and throat swabbing, similar sensitivities were observed for nose-only and nose and throat swabbing for LFDs. The sensitivity of nose-only swabbing for LFDs was higher for individuals with higher viral concentrations.ConclusionsUser experience analyses supported a preference for nose-only swabbing. Nose-only swabbing for LFDs provided sufficient diagnostic accuracy, supporting its use as a viable option in the COVID-19 National Testing Programme. Less invasive swabbing approaches are important to maximize testing accessibility and alongside other behavioral interventions, increase user uptake.

What About the Kids? Identifying Children in the Housing Support System in Aotearoa, New Zealand

ABSTRACTIn Aotearoa New Zealand (henceforth referred to as Aotearoa) a range of housing supports are aimed at improving homeownership rates and making both private rental and public housing more available. Despite these “supports”, a large number of children, adolescents and young people are experiencing housing insecurity or severe housing deprivation. Housing intersects with health, education, state care and welfare to influence a range of outcomes for children, therefore this paper addresses the critical issue of access to housing supports for children and adolescents. Through Official Information Act requests and a review of existing housing sector data, we found 323,257 children within the housing support system in Aotearoa New Zealand, with Māori (Indigenous People of Aotearoa) children disproportionately represented. We describe how children are largely unaccounted for in housing support system data, and this invisibility therefore challenges the understanding of the extent, inequities, and impact of the housing sector on children. We argue the urgent need for transformative policies centred on children, embedded in Te Tiriti o Waitangi (the Treaty of Waitangi), to ensure all children have access to stable, healthy, and secure housing for a brighter future.

Crop Diversification for Ensuring Sustainable Agriculture, Risk Management and Food Security

AbstractAgriculture faces growing challenges from climate change, pest pressures, and market instability. Crop diversification offers a sustainable strategy to enhance resilience and reduce the risks of monoculture. This review examines crop diversification as a response to these challenges, with a focus on its applications in sustainable agriculture, risk management, and food security. Strategies such as spatial, temporal, genetic, and intercropping diversification enhance soil health, improve pest management, and boost resilience to climate variability. The review highlights key principles, including ecological resilience, risk distribution, and resource optimization. By adopting diverse crops, farmers can mitigate soil degradation, reduce pest outbreaks, and stabilize incomes. Successful case studies from various regions, such as integrated rice‐fish farming and agroforestry, demonstrate how diversification can improve productivity and sustainability. However, challenges remain, such as knowledge gaps, market access issues, and policy limitations. The review concludes with recommendations for future research and policy interventions, stressing the need for tailored diversification strategies, better support systems, and further exploration of innovative practices. This overview underscores the potential of crop diversification to build resilient, sustainable agricultural systems while addressing global food security concerns.

Editorial Volume 50 Issue 2

The Editorial team completed and released this issue as the calendar changed to 2025. CJLT’s scope covers all things relevant to education and technology use. The current state of Canadian and global education includes demands for change in response to social and economic challenges. According to a well-known GenAI program, the two biggest issues facing education in Canada are accessibility and quality. More distressing is that the Education in Canada Current Issues Report of May 1994 identifies those same two issues as education’s most critical. Despite significant contextual changes, and those in technology and education design, these two things continue to plague us. CJLT provides research addressing this changing education context, the same issues of accessibility and quality, and emerging education theories and practices.

Conservation-led palaeolimnology: a review of applied palaeolimnology and lessons to improve accessibility and value to conservation practice

AbstractThe integration of palaeolimnology into conservation practice is crucial for effective ecosystem management and restoration. Palaeoecological data provide a unique long-term perspective on key ecological challenges and enable decision makers to better understand pre-disturbance conditions, natural system dynamism and responses to change. Despite this there exist well-recognised accessibility issues and a clear research-implementation gap, in particular, poor communication and lack of understanding of conservation practitioners’ constraints. This study evaluates the accessibility and value of palaeolimnological research to conservation practice by interrogating 60 key applied research papers identified via a rigorous pre-screening process to ensure relevance. The papers were assessed on the use of best practice accessibility criteria, from knowledge-exchange literature, and conservation-practitioner feedback was gathered on the value of conservation recommendations made within the papers. Despite widespread recognition of the importance of accessible research, our review reveals that essential accessibility criteria are inconsistently applied. Although there has been an increase in accessibility practices over time, co-production practices (including co-authorship, co-design of research, and linkage to relevant environmental legislation), showed no significant increase, despite being advocated for by the research community. Practitioner review highlighted the need for research to provide clear, actionable recommendations, and papers that detailed specific management or restoration guidance were particularly well-received, as were those that considered financial implications and summarised their findings more clearly. Equally, many papers were criticised for overly technical language and poor expression, generic suggestions, and a lack of practical consideration in their recommendations. The study highlights the importance of improving accessibility and co-production of knowledge to ensure that research outputs are accessible, relevant, and feasible to guide conservation efforts. To enhance the relevance and impact of applied palaeolimnology, we propose five key recommendations: (1) situate recommendations within existing practice and knowledge; (2) consider the practicalities for practitioners, including material and socio-economic aspects; (3) use clear and simple language; (4) employ easy-to-interpret diagrams and bullet points for recommendations; and (5) improve accessibility of older work. These recommendations are key in helping palaeolimnology progress towards a ‘gold standard’ of applied research, where it can be employed to greater effect to support conservation practice.

Cationic Magnetically Active Nitrogen-Doped Polycyclic Aromatic Hydrocarbon with Record Low Band Gap.

Polycyclic aromatic hydrocarbons (PAHs) have attracted significant interest in material chemistry, particularly if they own extremely low band gaps and magnetic properties. However, challenges remain regarding the synthetic accessibility and energy saturation issues. In this study, we introduceNR-11, which consists of eleven aromatic rings in its main conjugation and is separately doped with two electron-rich nitrogen atoms. This unique structure imparts intriguing oxidation characteristics toNR-11. The cationic radicalNR-11+•exhibits enhanced stability and demonstrates strong absorption in the range of 1250 nm to 3000 nm, peaking at 2570 nm. As a result, the optical energy gap ofNR-11+•is one of the lowest reported to date. Additionally, X-ray crystal structure analysis reveals thatNR-11+•displays unusual symmetry-broken charge separation. For the dication, variable-temperature NMR and variable-temperature EPR studies indicate thatNR-112+exhibits a high diradical character with a ∆ES-Tof approximately-1 kcal/mol. Additionally, its spins are polarized at two ends of the PAH. Meanwhile, its strong absorption in the near-infrared II region suggests promise in photoacoustic (PA) conversion applications. This work underscores the significance of cationic species of extended long PAHs, highlighting their exceptional properties and potential applications.

Observational cohort study of a group-based VR program to improve mental health and wellbeing in people with life-threatening illnesses

IntroductionBeing diagnosed with a life-threatening illness (LTI) is often accompanied by feelings of fear, uncertainty, and loneliness that can severely impact mental health. Relatively few interventions are available to address the existential concerns of individuals facing LTI, while treatment of the underlying physical ailment typically remains the priority of the healthcare system. Research has shown that psychedelic-assisted psychotherapy (PAT) holds promise for supporting mental health in people with LTIs. However, PAT’s potential in this population remains curtailed by several limitations, including regulatory and accessibility issues. Novel approaches that could provide some of the benefits of psychedelic experiences, while avoiding associated challenges, would therefore be highly desirable for supporting the mental wellbeing of people with LTIs. Among such interventions, virtual reality (VR)-based experiences have been suggested as a promising candidate. We here evaluate a program that includes weakly representational, multi-user VR experiences based on a design aesthetic previously described as “numadelic,” which has been demonstrated to elicit self-transcendent experiences comparable to psychedelics.MethodsA prospective cohort study design was used to assess the effects of “Clear Light” (CL), a group-based, 6-session multimedia program that included VR experiences, video calls, and text chats spanning 3 weeks. Participants were individuals suffering from LTIs that self-selected to participate in the CL program. A total of N = 15 participants were evaluated based on assessments 1 week before and after the program, using self-report measures of anxiety, depression, wellbeing, and secondary psychological outcomes.ResultsThe intervention was well-tolerated among participants. Significant improvements with moderate effect sizes were observed on self-reported measures of anxiety, depression, and wellbeing. Secondary measures assessing demoralization, connectedness, and spiritual wellbeing also showed significant improvements.DiscussionThis observational study demonstrated the feasibility and potential benefits of a group-based VR program that can be delivered at-home to people suffering from LTIs. While conclusions are presently limited by the lack of randomization or a comparison group, our findings strongly suggest further research is warranted, including randomized controlled trials.

Exploring oral health challenges and integration strategies in opioid treatment programs: perspectives from clinicians and clients.

Background Despite the paramount importance of oral health, individuals undergoing treatment for opioid use disorder face unique challenges beyond traditional addiction care. This qualitative study explores the challenges Opioid Treatment Program (OTP) clients in Australia encounter when accessing oral health care, aiming to understand the underlying factors and identify effective strategies for integrating oral health into an OTP. Methods Semi-structured interviews were conducted with OTP clients, OTP clinicians and oral health clinicians using tested interview guides. Thematic analysis identified patterns and themes across participants' responses. Results Client behaviour and traits such as inadequate health prioritisation, crisis-driven care and lack of motivation, shaped by a complex social environment, contribute significantly to inconsistent care and neglected oral health. Addiction exacerbates oral health issues as clients prioritise drug use over oral care and financial constraints, resulting in poor oral hygiene and a higher prevalence of dental problems. Psychological barriers such as dental anxiety deter clients from seeking care, while access issues including administrative burdens and system barriers, lost phones and unstable living conditions hinder consistent management of oral health. Stakeholders recommend actionable steps to address OTP clients' challenges, including integrating holistic care, establishing collaborative support systems, improving awareness and education and enhancing accessibility and flexible scheduling. Conclusion This study established a framework for improving OTP clients' oral health through integrated, holistic strategies. By addressing gaps in existing research, it supports the development of public health policies integrating oral health care into OTPs, aiming to foster collaboration, improve access and advance client education for better health outcomes.

Telehealth equity and access communication skills pilot simulation for practicing clinicians

Objectives This pilot study evaluated a telehealth training simulation program for practicing clinicians, specifically focused on addressing patient issues of equity and access to healthcare via improving telehealth communication. Methods Participants participated in a one-hour simulation experience with two cases. Performance was assessed pre- and post-intervention using a checklist measuring communication domains related to equity and access in telehealth. Participant satisfaction was secondarily measured via survey. Results Results showed measurable gains in clinicians’ abilities to effectively incorporate equity and access communication skills. Participants found the session useful and recommended the training experience. Conclusions The findings of this pilot study highlight the potential of simulation-based telehealth training for practicing clinicians, emphasizing clinicians’ attention to patients’ equitable access to healthcare. Future studies should aim to explore the durability of learning and investigate the generalizability of this training approach to other telehealth competencies and settings.

From Cold War to Cold Brew: Crop Replacement Strategies, Bean Logistics, and Ethnicized Coffee Commerce in Northern Thailand

ABSTRACT In the past three decades specialty coffees have gained greater visibility in the high-end consumer marketplace. These coffees include Arabica varieties grown in northern Thailand, the borderlands area of the Golden Triangle. In the 1970s Thai Royal Project initiatives sought to eradicate upland minority groups’ swidden rotational farming and opium cultivation. Despite minorities’ issues of land access, geopolitics of the Cold War, and citizenship challenges, Royal Project crop replacement schemes offered a technical, management-based solution. These projects imposed alternative crops, including avocado, macadamia, and coffee. Through interviews with Akha and Lisu coffee growers, roasters, and marketers in three villages in Chiang Rai Province, supplemented with discussions among neighboring Chinese and Lahu villagers, this paper explores varied coffee livelihoods in the changing context of the uplands. Ethnicized coffee marketing has latched onto royalist and touristic narratives about hill tribes, presenting individuals as culturally quaint loyal subjects who are doing better for the nation by growing coffee. However, these stories occlude Cold War histories, social stratification, and ecological damages resulting from coffee production.

Uncovering women's healthcare access challenges in low- and middle-income countries using mixed effects modelling approach: Insights for achieving the Sustainable Development Goals.

Access to healthcare services for women in low- and middle-income countries (LMICs) is crucial for maternal and child health and achieving the Sustainable Development Goals (SDGs). However, women in LMICs face barriers to accessing healthcare, leading to poor health outcomes. This study used Demographic and Health Survey (DHS) data from 61 LMICs between 2010-2023 to identify women's healthcare access challenges. This study used data from the DHS conducted in 61 LMICs to identify women's healthcare access challenges from 2010 to 2023. A weighted sample of 1,722,473 women was included in the study using R-4.4.0 version software. A mixed-effects modeling approach was used to analyze access to healthcare, considering individual-level factors and contextual factors. The mixed-effects model takes into account clustering within countries and allows for the examination of fixed and random effects that influence women's healthcare access across LMICs. For the multivariable analysis, variables with a p-value ≤0.2 in the bivariate analysis were considered. The Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) and a P value < 0.05 was reported to indicate statistical significance and the degree of association in the final model. The pooled prevalence of the healthcare access problem was found to be 66.06 (95% CI: 61.86, 70.00) with highly heterogeneity across countries and regions. Women aged 25-34 years, and 35-49 years, had primary education, and secondary or higher education, married women, poorer, middle, richer, and richest wealth indices, had mass media exposure, first birth at age ≥20 years, birth interval of 24-36, 37-59 and >59 months as compared to < 24 months birth interval, had health insurance, delivered at a health facility, had at least one ANC visit, being from lower-middle-income countries, upper-middle-income countries, regions like West Africa, South Asia, and East Asia/Pacific compared to women living in East Africa, low literacy rates, medium literacy rates, and high literacy rates as compared to very low literacy rate were associated with lower odds of having problems accessing healthcare respectively. On the other hand, divorced/widowed women, having 1-2, and more than two under five, living in households with 6-10 family members and >10 members, female household heads, living in rural areas, women living in South/Central Africa, Middle East/North Africa, Europe/Central Asia, and living in Latin America/Caribbean were associated with higher odds of having problems accessing healthcare respectively. Approximately two-thirds of women face healthcare access problems. Sociodemographic factors such as age, education, marital status, wealth, media exposure, and health insurance are associated with lower odds of experiencing healthcare access issues. On the other hand, factors such as divorce/widowhood, the number of young children, household size, female household heads, rural residence, and region have been linked to higher odds of facing healthcare access challenges. To address these disparities, policies, and interventions should focus on vulnerable populations by improving access to health insurance, increasing educational attainment, and providing support for single mothers and large households. Additionally, tailored regional approaches may be necessary to overcome barriers to healthcare access.

Evaluation on Accessibility in Historical Environments in Turkey: Ankara Ulus Environment Example

Historical environments bear traces of the past and have cultural and historical importance. These places are essential to respect the past, understand history, and preserve cultural heritage. However, many historic neighborhoods face accessibility issues. Accessibility is a fundamental concept that refers to the ability of people to be present and participate effectively in any space. This principle has an importance that cannot be ignored in every academic discipline in its own field of specialization and there is a need to take this principle into account in all kinds of production processes. The most problematic spatial area for this participation to be ensured through universal access is the historical environmen which form a unique part of cultural identity with their characteristic structures and distinctive features. Therefore, accessibility is crucial to ensure the preservation of cultural heritage and the active participation of society in. Problems in these areas restrict access to these spaces for people with disabilities, pregnant women, people with strollers and the elderly, and have a negative impact on the visitor experience. In this study, the Turkish Grand National Assembly / War of Independence Museum located in Historical Ulus, the Turkish Grand National Assembly Museum, Is Bank Museum, Ankara Social Sciences University Campus, and Hacı Bayram Veli Mosque and its surroundings were evaluated. The evaluations were supported with visuals, according to the criteria specified in the Accessibility Guide prepared by the Ministry of Family, Labor and Social Services. The study found attempts to improve accessibility for individuals with disabilities, but correct practices were largely absent. Issues such as dimensional errors, improper material selection and structural inadequacies were common. These problems are summarized in the evaluation section. This study aims to demonstrate that historical buildings can be made accessible by addressing access issues with solutions like tactile surfaces, markings, and ramps.

Decidual Control of Trophoblast Invasion: Mechanisms and Implications for Preeclampsia

Trophoblast invasion is essential for establishing a functional placenta and maternal-fetal exchange, regulated by the maternal decidua, which secretes both pro- and anti-invasive factors to balance trophoblast penetration into maternal tissues. Disruptions in this regulation are linked to pregnancy complications, particularly preeclampsia—a disorder marked by high blood pressure and impaired placentation due to insufficient trophoblast invasion. This study investigates the mechanisms of decidual control over trophoblast invasion and their implications for preeclampsia, utilizing clinical data from 50 patients at a tertiary care hospital in Karachi and an extensive literature review. We collected and analyzed blood and placental samples, quantifying cytokines, chemokines, and matrix metalloproteinases (MMPs) related to trophoblast function, and conducted patient interviews to assess psychosocial factors. Findings reveal elevated pro-inflammatory cytokines (e.g., IL-1β, IL-6) and chemokines, coupled with reduced MMP activity and increased tissue inhibitors, contributing to restricted trophoblast invasion. Interviews highlighted that stress, limited awareness, and healthcare access issues may compound biological risks in preeclampsia. These insights underscore the need for a multifaceted approach to managing preeclampsia, combining molecular and psychosocial interventions. Future research should aim to develop therapies targeting the molecular pathways that regulate trophoblast invasion while addressing social determinants to support maternal health and improve pregnancy outcomes.

Analysis of the Spatial Structure of Rural Areas in the Context of the Need for Land Consolidation and Exchange Works: A Case Study of the Zagnańsk Municipality

This study examines the spatial structure of rural areas to evaluate the demand for land consolidation and exchange, using the Zagnańsk commune in Świętokrzyskie Voivodeship, Poland, as a case study. The commune's land use is dominated by forested areas (60.16%), followed by arable land (20.15%), highlighting both its natural resources and agricultural significance. The analysis identifies substantial land fragmentation, with 40.12% of private parcels under 0.10 ha, and a lack of road access to 39% of parcels, especially in districts like Kaniów and Gruszka. Land tenure is primarily divided between state-owned (59%) and privately owned (36.41%) lands, with significant variations across cadastral districts. Soil quality assessments reveal productivity indices ranging from 21.47 to 45.90 for arable land and 26.25 to 43.13 for grasslands, underscoring regional disparities. The study develops a ranking of consolidation needs, identifying Kaniów, Gruszka, and Kajetanów as priorities due to high fragmentation and accessibility issues, while Długojów is deemed least urgent. Findings emphasize the necessity of targeted land management strategies to optimize agricultural efficiency and spatial organization. Prioritizing consolidation efforts can address key challenges, including parcel geometry and accessibility, to enhance rural development.

Post-Merger Challenges and Their Impact on Customer Satisfaction

Background: The global banking sector, including Nepal, has witnessed significant mergers and acquisitions (M&amp;As) to enhance competitiveness and operational efficiency. These strategic moves, while beneficial for financial stability, often disrupt customer satisfaction, particularly in aspects like service quality, trust, and accessibility. The merger of GBIME Bank and NABIL Bank offers a unique opportunity to explore these dynamics. Methods: A quantitative research design was employed, utilizing a structured survey of 300 customers stratified by banking channels. Key variables examined included service quality, trust, accessibility, and customer satisfaction. Regression and correlation analyses tested the relationships between these variables. Results: Findings reveal that service quality (β = 0.42) and trust (β = 0.48) positively influence customer satisfaction, while accessibility challenges (β = -0.20) negatively impact it. High service quality and trust were maintained post-merger, fostering customer loyalty. However, accessibility issues, particularly in rural areas and digital banking platforms, emerged as significant concerns. Conclusion: The study underscores the importance of maintaining service quality and trust while addressing accessibility challenges during banking mergers. The findings provide actionable insights for enhancing customer satisfaction and managing post-merger transitions effectively. Novelty: This research uniquely emphasizes accessibility’s dual role—physical and digital—in customer satisfaction, offering targeted strategies for mitigating disruptions during mergers. It extends existing literature by addressing the specific dynamics of Nepal's banking sector.

Education 4.0 In healthcare: How can artificial intelligence help clinical reasoning?

Introduction: Artificial Intelligence (AI) can develop software and systems capable of performing functions that normally require human skills. Its integration with the health field brings numerous optimizations to medical practice. However, it is crucial to ensure that AI does not replace the clinical judgment of the professional because, despite promising advances, challenges and ethical issues arise that need to be widely discussed. Objective: To investigate the use of AI to improve clinical reasoning, highlighting advantages, challenges and ethical implications. Methodology: This integrative literature review searched the following databases: PubMed, LILACS, SciELO, Cochrane Library and Google Scholar, using the descriptors “Artificial Intelligence” AND “Clinical Reasoning”. Publications from 2019 to 2024 in Portuguese and English were included, and 19 articles were selected for the study. Results and discussion: Clinicians have a positive perception of AI in medical practice even though significant challenges remain, such as the integration of clinical reasoning, data protection, unequal access and ethical issues. Despite this, AI has transformative potential, highlighting the urgent need to develop specific discussions, protocols and legislation to ensure its safe and effective use in healthcare. Conclusion: AI should be used as a complementary tool in medical practice, broadening the clinical and objective view, but without replacing the subjectivity of the doctor-patient relationship. Its innovative capacity is crucial for the advancement of health, as long as it respects and preserves the human function in the clinical process.