Evidence-based Practice Model Research Articles

A Quality Improvement Approach to Elevate Clinicians’ Use of Evidenced-Based Practice

ABSTRACT Mental and behavioral health needs amongst youth are on the rise, increasing the demand for community clinicians to treat increasingly complex cases. Extensive, complex caseloads contribute to burnout particularly when clinicians do not have the training to deliver effective treatment. Case conceptualization is a crucial component of effective treatment, as this guides intervention selection. Case conceptualization is vital within the evidence-based practice model, but this clinical skill is complex and challenging to implement effectively. A quality improvement (QI) approach was used by psychologists to develop and implement an eight-session training series with three cohorts of master’s prepared clinicians to increase their utilization of evidence-based treatments (EBTs) in clinical practice using the Project ECHO model. This QI project was accomplished via an iterative process where feedback was incorporated throughout the series. Participants’ knowledge, self-efficacy, and clinical practice were assessed pre- and post- completion of the series. Iterations in programming to improve the quality of the course are covered in detail. Participants demonstrated significant improvements in self-efficacy and reported positive changes in their clinical practice. There was no statistical change in knowledge, which was high on the pretest. Participants reported increased utilization and self-efficacy using EBTs in their clinical practice following participation in the course. Ongoing QI efforts and data collection are needed to continue to improve programming and demonstrate effectiveness of the series. Future efforts targeting specific EBT approaches for masters-prepared clinicians would be worthwhile.

Self-Defense Training to Reduce Violence Against Women and Girls: An Integrative Review.

Violence against women and girls (VAWG) is a serious threat to individual and public health with vast negative impacts, including numerous physical and mental health issues, as well as societal and economic consequences. Numerous women's self-defense interventions have been proposed to reduce the risk of victimization. The current integrative review, based on Whittemore and Knafl's framework, was completed to synthesize current evidence on women's self-defense training, the impact of such training on outcomes related to VAWG, and evaluate the strength of evidence for women's self-defense training interventions. A systematic literature search, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, was performed including a comprehensive computer-assisted database search, as well as citation searching and website searching for studies that included quantitative outcomes related to VAGW published between 2011 and 2023. Data were extracted and analyzed in accordance with Whittemore and Knafl's (2005) methodology, and the body of evidence was synthesized and best evidence recommendations developed based on the ©The Johns Hopkins Hospital/The Johns Hopkins University Evidence-Based Practice Model. Ultimately, 19 publications met inclusion criteria and were included in this review. Key findings included strong evidence for women's self-defense training to reduce attempted rape, completed rape, and nonconsensual sexual contact, as well as emerging evidence for reduction in posttraumatic stress disorder (PTSD) symptoms, among other positive outcomes. Further research is needed in more diverse populations at risk for violence and to identify key characteristics of effective interventions, including optimal content and dose.

Reducing Undue Burden on Nurses Related to Limited Care Partner Visitation: Lessons Learned for the Future.

The purpose of this article was to report best practices for reducing undue burden on nurses related to limited care partner visitation. Care partners are beneficial to hospitalized patients. Restricted care partner visitation not only impacts patients and care partners but also affects nurses. Using the Johns Hopkins Evidence-Based Practice model, best practices for reducing nurse burden during periods of restricted visitation were evaluated. Best practices include evidence-based visiting policies, technology to facilitate communication, creation of a communication liaison role or team, and communication skills training for nurses. Nursing leaders should proactively prevent the harmful impact that visitor restrictions have on nurses.

Clinical Service Incorporating Mobile Technology on Weight Loss in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease: A Translation From Research Trial.

The prevalence and healthcare cost of metabolic dysfunction-associated steatotic liver disease (MASLD) has increased alongside the epidemic surge in obesity and Type 2 diabetes. Weight loss through lifestyle modification remains the primary effective therapy for MASLD. Incorporation of mobile technology in lifestyle interventions has been previously found to be efficacious and cost-effective in facilitating weight loss. However, there is a paucity of studies that have successfully translated lifestyle research into clinical service for weight loss to alleviate disease burden. Our study aimed to describe the process of translating a mobile technology-enabled trial into a tertiary hospital outpatient dietetics service for patients with MASLD. The Iowa Model of Evidence-Based Practice to Improve Quality Care was used as a framework for this paper to guide implementation at the organizational level. Regular engagement of key operational staff and the hospital management team facilitated open discussions of the challenges faced and enabled rapid implementation of strategies that contributed to the smooth piloting of the service. A service adoption rate of 81% was achieved. Preliminary outcome evaluation found that the percentage of patients achieving ≥ 5% weight loss from baseline at 6 months was comparable at 54% and 52% for the service and trial groups, respectively. Evaluation of the implementation process found that a hybrid model of care (in-person consultation supplemented with app coaching) preserved interpersonal connections while maximizing the convenience and scalability of mobile app-enabled service. Although high digital acceptance and adoption rates propelled by COVID-19-supported telehealth, it is prudent to assess patient's access to technology and digital literacy and offer resources to help them benefit from telehealth services.

133 Research in Action: Engaging Clinicians to Advance the Academic Learning Health System

OBJECTIVES/GOALS: Research in Action is an on-demand, interactive curriculum designed to increase the ability of clinicians to advance the Academic Learning Health System (aLHS). The 7-module course provides clinicians with the knowledge and skills to lead rigorous quality improvement (QI) projects, translating research evidence into practice. METHODS/STUDY POPULATION: We engaged nurses, physicians, and advanced practice providers (APPs) working in the health system to participate in focus group and advise us in the creation of the curriculum. We conducted focus groups with these stakeholders on the proposed learning objectives, course content, and mode of delivery (in person, virtual, hybrid). Informed by the focus groups, the course was designed for hybrid format so participants could either (1) access the modules on-demand, or (2) learners could participate in a facilitator moderated course where the modules served as the curriculum to guide development of a QI project. The Iowa Model of Evidence-Based Practice was the framework for curriculum development. Upon completion of the modules, stakeholders reviewed each module and provided feedback for improvement. RESULTS/ANTICIPATED RESULTS: Research in Action is a 7-module course, with modules addressing the following topics: (1) Introduction to Quality Improvement, (2) Identify the Problem and Write a Purpose Statement, (3) Form a Team, (4) Appraise and Synthesize the Literature, (5) Design and Pilot the Project, (6) Integrate and Sustain Practice Change, (7) Disseminate the Results. The curriculum is being piloted with multiple clinician groups in the health system. In the next phase of development, a facilitator guide will be created to guide a cohort of clinicians to apply knowledge through discussion sessions and completion of a QI project in the healthcare setting. We anticipate scaling the program for spread to diverse clinician groups in the health system. Pre- and post-implementation data are being collected from current pilot sites. DISCUSSION/SIGNIFICANCE: The aLHS is an essential means for improving healthcare delivery. Research in Action, a hybrid training curriculum, engages frontline clinicians in creating and leading QI projects that implement research evidence into practice to solve problems commonly encountered in the healthcare setting; thus, supporting the advancement of the aLHS.

Structured Reporting of Computed Tomography Enterography in Crohn's Disease.

To compare the integrity, clarity, conciseness, etc., of the structured report (SR) versus free-text report (FTR) for computed tomography enterography of Crohn's disease (CD). FTRs and SRs were generated for 30 patients with CD. The integrity, clarity, conciseness etc., of SRs versus FTRs, were compared. In this study, an evidence-based medicine practice model was utilized on 92 CD patients based on SR in order to evaluate its clinical value. Then, the life quality of the patients in two groups was evaluated before and after three months of intervention using an Inflammatory Bowel Disease Questionnaire (IBDQ). SRs received higher ratings for satisfaction with integrity (median rating 4.27 vs. 3.75, P=0.008), clarity (median rating 4.20 vs. 3.43, P=0.003), conciseness (median rating 4.23 vs. 3.20, P=0.003), the possibility of contacting a radiologist to interpret (median rating 4.17 vs. 3.20, P<0.001), and overall clinical impact (median rating 4.23 vs. 3.27, P<0.001) than FTRs. Besides, research group had higher score of IBDQ intestinal symptom dimension (median score 61.13 vs. 58.02, P=0.003), IBDQ systemic symptom dimension (median score 24.48 vs. 20.67, P<0.001), IBDQ emotional capacity dimension (median score 65.65 vs. 61.74, P<0.001), IBDQ social ability dimension (median score 26.80 vs. 22.37, P<0.001), and total IBDQ score (median score 178.07 vs. 162.80, P<0.001) than control group. The SR of CTE in CD patients was conducive to improving the quality and readability of the report, and CD patients' life quality could significantly improve after the intervention of an evidence-based medicine model based on SR.

The Urgent Need for an Evidence-Based Digital Mental Health Practice Model of Care for Youth.

Abstract Australian providers of mental health services and support for young people include private and public allied health providers, government initiatives (eg, headspace), nongovernment organizations (eg, Kids Helpline), general practitioners (GPs), and the hospital system. Over 20 years of research has established that many young people prefer to seek mental health support online; however, clear client pathways within and between online and offline mental health services are currently lacking. The authors propose a Digital Mental Health Practice model of care for youth to assist with digital mental health service mapping. The proposed model offers accessible pathways for a client to engage with digital mental health services, provides clear navigation to access support for individual needs, and facilitates a seamless connection with offline mental health services using a transferable electronic health records system. This future-looking model also includes emerging technologies, such as artificial intelligence and the metaverse, which must be accounted for as potential tools to be leveraged for digital therapies and support systems. The urgent need for a user-centered Digital Mental Health Practice model of care for youth in Australia is discussed, highlighting the shortcomings of traditional and existing online triage models evident during the COVID-19 pandemic, and the complex challenges that must be overcome, such as the integration of diverse mental health care providers and establishment of a robust electronic health records system. Potential benefits of such a model include reduced pressure on emergency rooms, improved identification of immediate needs, enhanced referral practices, and the establishment of a cost-efficient national digital mental health care model with global applicability. The authors conclude by stressing the consequences of inaction, warning that delays may lead to more complex challenges as new technologies emerge and exacerbate the long-term negative consequences of poor mental health management on the economic and biopsychosocial well-being of young Australians.

Planning the future of oral health care workforce: Moving beyond demographic change.

The adoption of Universal Health Coverage for oral health care will not be sufficient to ensure that health care resources are accessible in accordance with needs for care. Government intervention in planning and allocating resources will be required to replace traditional market forces if market failure is not to be replaced by government failure. In this paper we explore the limitations of current 'fixed in time' approaches to planning the oral health care workforce and present an enhanced dynamic model for workforce planning that responds directly to changes in population, evidence-based best practice and new models of care.

“Breathe, Plan, Write, and Evaluate”: the effects of an SRSD intervention and instructional feedback on 4th graders’ writing and motivation

IntroductionOver the years, extensive literature attested to the value of the Self-Regulation Strategy Development model (SRSD) for writing. Additionally, feedback has been recognized as essential to the teaching and learning of writing, and as supporting evidence-based instructional models for writing. However, little is known of the effects of combining evidence-based practice models, such as SRSD, with instructional feedback, as well as with a component of meditation. The present study aimed to study the effects of an SRSD intervention and to study the importance of instructional feedback within an SRSD intervention.MethodA total of 69 primary students (4th graders) participated in this study. The study was divided into two phases: in Phase 1, two classes participated in a SRSD intervention program (SRSD-1 group; N = 33), whereas two others received regular writing instruction (control group; N = 36); in Phase 2, the previous control group received the SRSD intervention with or without instructional feedback (SRSD-2 with feedback, N = 19, vs. SRSD-2 without feedback, N = 17, groups), while the SRSD received regular writing instruction (SRSD-1 group).ResultsThe effectiveness of the intervention was confirmed in both phases for the writing outcomes variables, but not for motivation. Overall, our study showed that the SRSD intervention with an additional meditation component was effective in improving students’ writing planning for all intervention participants. Additionally, writing quality and writing structure improved among those with lower scores at the pretest. Concerning motivation, we only found an effect on self-efficacy for ideation.DiscussionWe expect the current research to stimulate future examinations of the value of providing students with instructional feedback in writing interventions.

Meeting the training needs of a child-protection workforce: perspectives on professional certificates in understanding, assessing, and responding to childhood trauma

ABSTRACT There is a well-established need to ensure that practitioners who work directly with children and young people impacted by abuse are well-equipped to support them. This need is coupled with a lack of evidence-based practice models and specialized responses to abuse-related trauma within the child protection/family support sectors. This study examines the outcomes of a suite of Professional Certificates that aim to support nonspecialist practitioners in developing their capacity to provide trauma-specific therapeutic interventions to children who have experienced child abuse and neglect. A mixed-methods design including both qualitative and quantitative data collection and analysis was used to evaluate the impact of the Professional Certificates on participants’ practices and development of competencies applicable to their field of work. Findings suggest that the Professional Certificates may help students develop relevant skills and knowledge applicable to a child protection workforce, and allow them to apply their learning in practice. The results of this study have important implications for the training and development of the child protection workforce. They suggest that interventions such as the Professional Certificates may be an effective way to equip graduates with the requisite skills and knowledge to foster a sense of preparedness in their practice.

Best practices for implementation of Kamishibai cards in the healthcare setting to improve nursing-sensitive indicator associated outcomes: An integrative review.

Many adverse events are identified as nursing-sensitive indicators (NSIs) and have evidence-based care bundles known to reduce risk of occurrence. Kamishibai cards are a tool from the manufacturing industry used for practice auditing and improvements. Use of Kamishibai cards is believed to be common in the healthcare setting, but true evidence-based guidelines do not yet exist to guide their implementation. The aim of this integrative review was to identify best practices around the implementation of Kamishibai cards in the healthcare setting for improvement in NSI-associated outcomes. Eleven nurses at three facilities worked through the evidence using the Johns Hopkins Evidence-Based Practice Model. Ten articles were included for this review. Broad themes included direct observation with non-punitive and timely feedback, clearly visualized results, use of evidence-based care bundles, pre-implementation education, and both leadership and frontline-staff involvement. All facilities showed improvement in NSI-associated outcomes after the implementation of K-cards. In health care, K-cards can be implemented and designed with additional focus on the bundles of care they are intended to audit and staff support, but further evidence would better define guidelines around implementation.

Detecting Early-Stage Pressure Injury in Patients With Dark Skin Tones Using an Enhanced Physical Assessment Technique and Halogen Lighting.

The purpose of this quality improvement project was to identify stage 1 pressure injuries (PIs) in patients with darker skin tones using an enhanced skin assessment (Skin Assessment for Dark Skin, SADS) and halogen lighting. This quality improvement project was conducted on 3 units at a large university teaching hospital in Southeast Michigan. The project was originally designed so that participating patients were identified by bedside nurses as having sufficient melanin to obscure blanching on the hand/forearm using regular lighting, but this goal was not met. Data analysis is based on patients who self-identified as African American or Black, Native Hawaiian or Pacific Islander, Asian, American Indian, and Native Alaskan. Bedside nurses participating in this project were also asked to complete a questionnaire describing their knowledge and experiences with this project and assessment of early-stage PI in patients with darker skin tones. The Iowa Model of Evidence-Based Practice was used to guide this quality improvement initiative. Following a trigger event, we reviewed pertinent literature and developed an enhanced technique for assessing patients with darker skin tones that involved use of halogen lighting (SADS) and documentation of findings. We selected units from our facility and taught nurses to apply the SADS approach. Data from the electronic medical record and a survey of participating nurses were used to compare findings before and after project implementation. Comparisons were based on descriptive data analysis. Following implementation of the enhanced physical assessment, the participating units experienced a 6% decrease in the total number of facility-acquired PIs during the implementation period. The enhanced physical assessment, when paired with halogen lighting, enhanced identification of stage 1 PI in persons with dark skin. The assessment method was easy to teach, learn, and can be performed at the bedside as part of a shift assessment which routinely includes inspection of skin.

Pain Assessment in the Outpatient Pediatric Burn Patient: An Integrative Review.

There is no standardized practice in pediatric pain assessment with burn injuries in the outpatient clinic setting. This review aims to identify reliable, validated tools to measure pain in the pediatric burn clinic population. The literature search for this integrative review was conducted using the databases of PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane, and Embase from 2011 to 2023. Quality and relevance were appraised using the Johns Hopkins Nursing Evidence-Based Practice Model. Reporting was done according to a Preferred Reporting Items for Systemic Reviews and Meta-Analysis checklist. Fourteen articles and two clinical practice guidelines met inclusion criteria and were included in this review. The Pain Observation Scale for Young Children and the COMFORT Behavior Scale tools have shown good reliability and construct validity and can be safely used to measure background and procedural pain in daily burn practice. Further research on reliable, validated pain assessment techniques in the pediatric burn population is needed.

A Model of Evidence-Based Practice for Law Schools to Improve System Outcomes

A Model of Evidence-Based Practice for Law Schools to Improve System Outcomes

Making evidence-based practice actionable in the social service context: experiences and implications of workplace education

PurposeResearch and experience show that evidence-based practice (EBP), i.e. using the best available knowledge in daily professional work, is difficult to achieve in social services. The purpose of this study is to understand the development of organizational EBP learning processes in daily work through workplace education for staff and managers of supported homes for people with cognitive disabilities. The authors examine how the EBP model and new knowledge are understood and made actionable in the workplace, applying theories of organizational learning.Design/methodology/approachThe authors used empirical material collected from an EBP workplace education pilot in Sweden, as well as documents on national EBP implementation in Swedish social services. Before the pilot, a focus group interview was conducted with regional senior managers. Participating managers and staff were individually interviewed two to three years after the pilot.FindingsThe study illustrates how knowledge-based action emerged from education where EBP was interpreted, understood, reflected on, and tested, supported by codified EBP tools in the work context. The participants, when supervised, and when observing and questioning their own behaviors in practice, contributed to double-loop learning (DLL) processes. Codification of EBP knowledge into useful tools and socialization processes during education and workplace meetings was crucial in developing individual and group DLL and knowledge-based actions.Originality/valueThe bottom-up approach to EBP development and the adaptive contextual learning at the workplace gave new insights into organizational learning in social service workplaces.

A REVIEW OF TEACHING STRATEGIES FOR ENGLISH AS A FOREIGN LANGUAGE IN HEALTHCARE STUDIES

Teachers of English as a foreign language are faced with difficulties in selecting the proper teaching strategy for students learning English for academic and professional purposes. Fifteen research studies were included in the current study on teaching strategies for students with English as a foreign language in healthcare studies. The objective is to determine the most useful and effective teaching strategies for healthcare students learning English as a foreign language. The review study was conducted using Noblit and Hare methasynthesis and Dearholt and Dang’s Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines for evaluation, selection and analysis. Language teaching strategies play an important role in teaching English as a foreign language especially in specific professional environments such as healthcare and medicine. The study divides language teaching strategies for English in healthcare into two perspectives; those concerned with improving students’ language learning performance and those examining specific instruction strategies and their effects on students’ knowledge. Further it gives an outline of four general English language skills and most commonly used teaching strategies. The results of the study may be used by English language teachers and content creators for developing new teaching materials and courses to help students succeed. For healthcare as a profession, a future with newly educated professional who have skills in English and other foreign languages will be beneficial in helping their target population. Key words: teaching strategies, healthcare studies, EFL, nursing, medical English

Communication Between Pregnant People of Color and Prenatal Care Providers in the United States: An Integrative Review.

Racism and discrimination negatively affect patient-provider communication. Yet, pregnant people of color consistently report being discriminated against, disrespected, and ignored. The purpose of this integrated review was to identify studies that examined communication between pregnant people of color and their prenatal care providers and evaluate the factors and outcomes arising from communication. We searched the PubMed, Embase, CINAHL, and PsychINFO databases for studies published between 2001 and 2023. Articles were eligible for inclusion if they reported on primary research conducted in the United States, were written in English, and focused on patient-provider communication with a sample that included pregnant people of color, defined as those who self-identified as Black, African American, Hispanic, Latina/x/e, Indigenous, American Indian, Asian, Asian American, Native Hawaiian, and/or Pacific Islander American. Twenty-six articles were included in the review. Relevant data were extracted and compiled into an evidence table. We then applied the rating scale of the Johns Hopkins Evidence-Based Practice model to assess the level of evidence and quality of the studies. Themes were identified using a memoing technique and organized into 3 a priori categories: factors, outcomes, and recommendations. Two overarching themes emerged from our analysis: racism/discrimination and unmet information needs. Subthemes were then identified as factors, outcomes, or recommendations. Factors included provider behaviors, language barriers, structural barriers, provider type, continuity of care, and fear. Outcome themes were disrespect, trust, decision-making power, missed appointments, and satisfaction with care. Lastly, culturally congruent care, provider training, and workforce development were categorized as recommendations. Inadequate communication between prenatal care providers and pregnant people of color continues to exist. Improving access to midwifery education for people of color can contribute to delivering perinatal care that is culturally and linguistically aligned. Further research about digital prenatal health communication is necessary to ensure equitable prenatal care.

Leadership and Negotiation in Public Health Management: A Systematic Review of the Literature

The domain of public health management has seen an increase in emerging issues that require attention to improve organizational performance. To address these challenges, this study presents a systematic review of the literature conducted between 2015 and 2023 to illuminate trends in healthcare research, including leadership and negotiation. Based on the PRISMA analysis framework developed by Liberati et al. (2009), we took an approach to assess the coverage of public health management research. Using selection criteria based on the SCOPUS database, our investigation identified 2674 articles. These publications were subjected to analysis, selecting 54 articles deemed particularly insightful and impactful. Furthermore, we developed a conceptual model using Grounded Theory that accentuates the key determinants that influence organisational performance in healthcare institutions. The main factors examined in our model include healthcare negotiation, organizational behaviour, leadership, evidence-based practices, sustainability, and corporate governance. The results of our study shed light on the intricate relationships between these determinants and their impact on overall performance in the public health sector. By elucidating these dynamics, our research provides valuable information to policymakers, administrators, and practitioners striving to achieve excellence in healthcare management. Based on our analysis, we propose an agenda for future research in public health management. This agenda seeks to address knowledge gaps, explore new approaches, and stimulate innovation in addressing healthcare organizations' complex challenges. By focusing on areas such as adaptive leadership strategies, transformative negotiation techniques, evidence-based practice, and sustainable governance models, our proposed agenda aims to catalyse advances in this field, ultimately leading to better health outcomes for individuals and communities. In conclusion, this study represents a significant contribution to public health management. Its review and the development of a conceptual model and research agenda provide stakeholders with the tools and knowledge needed to promote optimal organizational performance and drive positive change in this domain.

Implementation of Provider-Focused Education to Improve Laboratory Screening for Pediatric Patients With Elevated Body Mass Index in Primary Care: A Quality Improvement Project

Children with elevated body mass index (BMI) do not consistently receive recommended laboratory screenings. This project aimed to increase provider screening rates and knowledge of screening guidelines for this population. This project utilized the Rosswurm and Larrabee evidence-based practice model. Providers completed education with pretest and posttest design. Laboratory screening rates were measured with retrospective chart reviews, and a project satisfaction survey was conducted. Nine (82%) of 11 providers showed an increase in knowledge of screening for children with elevated BMI. Laboratory screening increased (27% to 39%) above the preintervention median (25%) for children with obesity and was above the median (22%) for one month of the project (15% to 26%) for children with overweight. Project results suggest education improved knowledge and compliance with guidelines for laboratory screening of children with an elevated BMI. Asynchronous education and sharing of compliance rates are adaptable to similar quality improvement projects.

Tailoring of exercise and dietary interventions to adverse effects and existing comorbidities in patients with ovarian cancer receiving chemotherapy: a clinical vignettes study among expert physical therapists and dietitians

Purpose This study aims to capture the complex clinical reasoning process during tailoring of exercise and dietary interventions to adverse effects and comorbidities of patients with ovarian cancer receiving chemotherapy. Methods Clinical vignettes were presented to expert physical therapists (n = 4) and dietitians (n = 3). Using the think aloud method, these experts were asked to verbalize their clinical reasoning on how they would tailor the intervention to adverse effects of ovarian cancer and its treatment and comorbidities. Clinical reasoning steps were categorized in questions raised to obtain additional information; anticipated answers; and actions to be taken. Questions and actions were labeled according to the evidence-based practice model. Results Questions to obtain additional information were frequently related to the patients’ capacities, safety or the etiology of health issues. Various hypothetical answers were proposed which led to different actions. Suggested actions by the experts included extensive monitoring of symptoms and parameters, specific adaptations to the exercise protocol and dietary-related patient education. Conclusions Our study obtained insight into the complex process of clinical reasoning, in which a variety of patient-related variables are used to tailor interventions. This insight can be useful for description and fidelity assessment of interventions and training of healthcare professionals.