Negative Professional Identity Research Articles

Health Care Clinical Preceptors' Attitudes Towards Interprofessional Education in Saudi Arabia: A Cross-Sectional Study.

IPE fosters a dynamic learning environment that may promote students' knowledge, abilities, and collaborative approach towards addressing challenging clinical circumstances. While much has been reported in the literature regarding these diverse IPE learning environments, limited information exists regarding clinical preceptors' attitude and perceptions of IPE, especially in Saudi Arabia. Given the impact clinical preceptors have on the formation of healthcare students exploring their perceptions, which may impact their actions is imperative. The study focused on understanding the attitudes and perceptions of clinical preceptors towards IPE in a healthcare setting in Saudi Arabia. The study was conducted in Saudi Arabia. Data was collected via Email letter of solicitation (LOS) which included a link to the Readiness for Interprofessional Learning Scale (RIPLS) survey. The LOS was sent to all the health care programs in Saudi Arabia. The study surveyed 182 clinical preceptors. The findings revealed consistent favorable opinions towards "Teamwork and Collaboration". The majority of preceptors concurred that learning alongside other students would increase students' efficiency on healthcare teams and deepen their comprehension of clinical issues. The "Roles and Responsibilities" category, however, obtained lower ranks in general from the preceptors. Not surprising, differences in rankings were greatest between preceptors who had and did not have IPE exposure, there were significant variations in views toward "Teamwork and Collaboration", "Negative Professional Identity", and "Roles and Responsibilities". Preceptors exposed to IPE showed lower median ratings for "Negative Professional Identity" and "Roles and Responsibilities" and better median scores for "Teamwork and Collaboration". The attitudes and perceptions of preceptors who had experienced IPE were more favorable toward IPE and thus may foster it more effectively in the students they work with. Therefore, ensuring that all preceptors are aware of and have experience with IPE is important as we seek to promote person-centered care.

Readiness for Inter-Professional Learning among Undergraduate Allied Health Science Students in Hayatabad Peshawar

Background: Inter-professional learning (IPL) is increasingly recognized as a vital component of healthcare education, fostering collaboration, enhancing teamwork skills, and preparing students for a patient-centered healthcare system. Despite its growing importance, the readiness and attitudes towards IPL among healthcare students vary across disciplines and regions, necessitating detailed exploration. Objective: This study aimed to assess the attitudes towards and readiness for IPL among undergraduate allied health science students at Khyber Medical University, Peshawar, and to explore the implications of these attitudes for healthcare education and practice. Methods: A cross-sectional survey was conducted over six months, utilizing convenience sampling to recruit 376 undergraduate students from the departments of Physical Therapy, Occupational Therapy, Speech and Language Pathology, and Nursing. The Readiness for Inter-professional Learning Scale (RIPLS) questionnaire was distributed through WhatsApp, Twitter, and email, covering aspects such as teamwork and collaboration, professional identity, and roles and responsibilities. Data were analyzed using SPSS version 25 to calculate means, standard deviations, and to conduct Independent t-tests. Results: The study found that a significant majority of students (72.1%) expressed strong agreement with the importance of IPL in their curriculum. The mean scores for the RIPLS sub-scales were: Teamwork and Collaboration (13.76 ± 2.609), Negative Professional Identity (10.57 ± 1.972), Positive Professional Identity (6.40 ± 1.359), and Role and Responsibility (7.50 ± 1.267). Independent t-tests revealed significant gender differences in attitudes towards teamwork and collaboration (Male: 13.42 ± 2.017, Female: 14.07 ± 3.034, p=0.015) and roles and responsibility (Male: 7.3187 ± 1.16940, Female: 7.6701 ± 1.33290, p=0.007), but not in professional identities. Conclusion: The study underscores a generally positive attitude towards IPL among healthcare students, with notable readiness for teamwork and understanding of roles and responsibilities. These findings highlight the necessity of integrating IPL into healthcare education curricula to enhance collaborative skills and prepare students for the complexities of modern healthcare delivery.

Autoethnography of a Japanese academic in an Australian university: the development and changes of professional identity

AbstractThis study uses autoethnography to examine the development of and changes in my professional identity through my study and work experiences since I came to Australia from Japan. I am currently an academic teaching Japanese language and research in the field of applied linguistics in an Australian university. I wrote a self-narrative about my experiences and the related emotions covering the time of my arrival in Australia from Japan in 1997. Because teaching and research are the major roles in my current position, I coded the narrative for statements concerning my teacher identity and my researcher identity. After reading the narratives and repeatedly reviewing the coding, I produced stories about my teacher and researcher identities. The development and changes of my professional identity were closely linked to sociopolitical aspects of my work in my immediate teaching and research contexts and to my linguistic and cultural backgrounds. My relationships with students and research colleagues tended to trigger positive emotions and contribute to the development of a positive professional identity, whereas relationships with higher management at the university were likely to cause negative emotions and contribute to the development of a negative professional identity.

Педагогическая практика как фактор селекции будущих педагогов

Studies of teachers’ professional development indicate that in different regions of the country, the proportion of those who do not want to work at school and have little motivation for teaching is about a third. It is not known what stages of development negative professional identity goes through and under the influence of what factors it develops. The influence of the first active experience of performing a professional role in the course of pedagogical practice was tested on the principle of ‘before-after’ on a panel from a real group of students with dual pedagogical specialization. Practice created quasi-experimental conditions. Before and after, students filled out a questionnaire determining the relationship of the desire to get a job at school with a number of socialization features, with the student’s idea of his compliance with the role of a teacher, with an assessment of the attractiveness of individual teaching functions, the material and social status of teachers in the aspect of the student’s personal claims. The measure of the impact of practice was defined as the delta of changes in numerical variables and as the presence of changes in nominal variables. About a third of the students had previously formed an internal positive motivation for the teaching profession. The share of school-oriented students is slightly less than a third (28%). It is unchanged before and after practice. Quantitative shifts are very small, which indicates either the stability of orientations, or the adaptation shock already experienced during the introductory practice and requires monitoring from the first year.

Attitude and Readiness of Nursing Students Regarding Interprofessional Collaboration in Healthcare Practice

Background: Healthcare system measures the quality of care given in a hospital. So, it is necessary to assess the quality based on the manpower and needs. Interprofessional collaboration is an important aspect in which people from different professions come together and work for the patient need. By this it satisfies the quality care and increases better outcome. Objective: To find a relation between attitude and readiness of nursing students regarding interprofessional collaboration in healthcare practice. Materials and Methods: A correlational research design was utilized to accomplish the objective of the study. A total of 134 undergraduate nursing students from Father Muller College of Nursing who met the inclusion criteria participated in the study. The data was collected by using demographic proforma along with the Attitude Towards Health Care Team Scale (ATHCTS) and Readiness for Interprofessional Learning Scale (RIPLS) to evaluate the Attitude and Readiness of nursing students regarding interprofessional collaboration in healthcare practice. Written permission was obtained from the relevant authorities and the participants before the study. The data were analyzed by using descriptive and inferential statistics with the help of SPSS Results and conclusion: The findings of the study revealed that the nursing students have a favourable attitude and readiness towards IPC (Quality of care 42.39 (SD = 8.89), time constraints 10.46 (SD= 2.56) Teamwork and collaboration 29.3(SD =11.6), Negative professional identity 9.7 (SD=3.5) Positive professional identity13.1 (SD=4.8), roles and responsibilities 9.2 (SD=3.2) and there is no significant relationship between the attitude and the readiness towards interprofessional collaboration in health care practice. Keywords: healthcare system, interprofessional collaboration, quality care, attitude, readiness

STUDENT READINESS TOWARDS INTERPROFESSIONAL EDUCATION BASED ON THE HAJJ HEALTH

Background: Interprofessional education (IPE) Faculty of Medicine and Health Science Maulana Malik Ibrahim State Islamic University (FKIK UIN MMI) were designed based on hajj health and involved prospective pilgrims (CJH) as the target. The program’s goal was to achieve collaboration among health students and support CJH to achieve the istitha’ah condition. Thus student readiness becomes one of the success parameters. This study aims to evaluate the readiness of FKIK UIN MMI students for the hajj health-based IPE program.Methods: Cross-sectional descriptive method was used with the FKIK UIN MMI students class 2018 as the population. Students who undertook the hajj health-based IPE program in 2021 were classified in the inclusion criteria. Meanwhile, the IPE participants that did not fill out the questionnaire were excluded. The questionnaire was adopted from the Readiness for Interprofessional Learning Scale and processed with Microsoft excel.Results: The readiness of 113 students was categorized as "very ready" on the aspect of collaboration and cooperation, also on the positive professional identity subject, with readiness levels of 83.36% and 81.23%, respectively. The percentage of readiness for the negative professional identity aspect was 48.20% and categorized as "quite ready". Professional roles and responsibilities had a score of 708, and were categorized as "ready".Conclusion: FKIK UIN MMI students had a good readiness level for the hajj health-based IPE program. Further studies are needed to examine the factors that emerge as barriers to joint learning between professions. The lecturer's readiness is needed to be evaluated as well.

Readiness for Interprofessional Learning Among Students of Four Undergraduate Health Professions Education Programs.

In interprofessional learning, students from different professions learn about, from, and with each other so that they can collaborate effectively, deliver high-quality healthcare, and achieve positive health outcomes. This study aimed to explore the readiness of students from four health professions education programs for interprofessional learning. A cross-sectional descriptive study was carried out on 339 students. The Readiness for Interprofessional Learning Scale (RIPLS) was used to collect data. Descriptive statistics were used. Paired-samples t-test and ANOVA test were used to compare the responses of participants. Correlations between dependent and independent variables were explored by Pearson's correlation test. The statistical significance level was set at p < 0.05. The reliability study of the collected data showed excellent internal consistency (Cronbach's ɑ = 0.819). Results revealed a statistically significant difference between the responses of students from the four programs regarding the "Roles and Responsibilities" subscale (p = 0.000). A statistically significant difference between male and female students regarding two statements within the "Teamwork and Collaboration" subscale and one statement within the "Negative Professional Identity" subscale (p < 0.05) was also detected. The correlation study showed a weak but statistically significant correlation between RIPLS mean scores and the students' study program (p < 0.015). In conclusion, the students showed readiness for IPL as evidenced by their positive perception of the interprofessional learning concepts.

Readiness for interprofessional education among healthcare students in Oman: Results of a cross-sectional survey

ABSTRACT Interprofessional education (IPE) is a promising educational strategy to strengthen the healthcare system in Oman. This study aimed to evaluate the perception and readiness of nursing and medical students for IPE in Oman. Students enrolled in medical and nursing programs at Sultan Qaboos University were invited to participate in this study by completing the Readiness for Interprofessional Learning Scale (RIPLS). A total of 390 (180 nursing and 210 medical) students completed the survey. The RIPLS scores of nursing and medical students were high. Medical students had significantly higher scores in the Negative Professional Identity subscale. Gender and GPA correlated with total scores. Medical and nursing students demonstrated positive perceptions and readiness for IPE. Efforts should be directed to facilitate its implementation in the curriculum.

Impact of an International Service Trip on Pharmacy and Medical Learners’ Attitudes Toward Interprofessional Collaboration

Objective. The purpose of this study was to evaluate the impact of an interprofessional medical service trip to rural Honduras on pharmacy and medical learners' attitudes toward interprofessional learning.Methods. In this mixed-methods research, 19 participating students and residents from medicine and pharmacy completed the Readiness for Interprofessional Learning Scale (RIPLS) before and after the service trip in fall 2017 and spring 2018. Individual semi-structured interviews were conducted with participants following each trip to better understand which aspects of the experience shaped their interprofessional learning.Results. Following the service trip, a significant improvement was found for the Teamwork & Collaboration subscale and the Negative Professional Identity subscale of the RIPLS. Several themes emerged from interviews, including that face-to-face interaction promotes collaboration; limited resources encourage team-based problem-solving; time together outside of work strengthens interprofessional connections; participating in another profession's patient care activities fosters appreciation of individual roles; interprofessional care takes time; and participants felt a greater desire to pursue interprofessional practice in the future.Conclusion. Interprofessional learning during a medical service trip improved participants' attitudes toward collaboration. This study highlights which aspects of this experience contributed most to interprofessional learning, and our results may guide future efforts to design effective interprofessional education experiences.

Does Interprofessional Scenario-Based Simulation Training Change Attitudes Towards Interprofessional Learning - A Pretest-Posttest Study.

PurposeTo investigate readiness for interprofessional learning (IPL) among Norwegian health-care students at bachelor-, postgraduate- and master’s level, before and after participating in a one-day scenario-based simulation-training course.Participants and MethodsA pretest-posttest study using readiness for interprofessional learning scale (RIPLS) was conducted with bachelor nursing students (n = 123, 4th semester), postgraduate nursing students from anesthesia, operating theatre and intensive care (n = 61, 1st semester) and medical students (n = 78, 10th semester).ResultsBachelor nursing students and postgraduate nursing students scored significantly higher in the posttest on all four subscales and on the total scale. Between professions, medical students scored significantly higher on subscale 1 (teamwork and collaboration) and subscale 3 (positive professional identity) and significantly lower on subscale 4 (roles and responsibilities) in the pretest. In the posttest bachelor nursing students scored significantly higher on subscale 2 (negative professional identity) and medical students scored significantly lower on subscale 4. The internal consistency for RIPLS was acceptable, except for subscale 4.ConclusionThe study indicates readiness for IPL in our sample of Norwegian health-care students. RIPLS had the ability to measure significant changes in attitudes both within each profession and between professions.

Interprofessional learning in a student-run dental clinic: The effect on attitudes of students in oral healthcare

ABSTRACT The purpose of this study was to gain insight into change in attitudes held by students in oral healthcare about interprofessional learning and collaboration after one year of work in a student-run dental clinic (SRDC). Third- and fourth-year bachelor of dental hygiene students (n = 221) and first- and second-year master of dentistry students (n = 203) participated in baseline and follow-up measurements and completed 570 questionnaires. The Readiness for Interprofessional Learning Scale (RIPLS) was used to measure changes in attitudes toward Interprofessional Education (IPE) during participation in the SRDC. To validate the questionnaire for the setting, professional groups, and wording of RIPLS, we performed exploratory and confirmatory factor analyses. Two modified subscales remained: “Teamwork & Collaboration” and “Negative Professional Identity.” Mixed linear models were used to assess relationships between students’ attitudes toward IPE and participation in the SRDC. Overall, the students had positive attitudes toward IPE. At baseline, the attitudes of the dental hygiene and dentistry students were almost equally positive. After one year, dental hygiene students demonstrated a significantly more positive attitude toward collaborative learning and teamwork than the dentistry students. Further research should investigate whether the positive attitudes impact behavior in professional practice.

Readiness for Interprofessional Learning Among First Year Medical and Dental Students in Nepal.

IntroductionHealth professional education curricula in Nepal do not include interprofessional education (IPE). Though a previous study conducted in Nepal identified positive attitudes among medical and nursing students, so far there are no studies assessing the health professional students’ readiness toward IPE. The aim of the study was to assess the readiness for IPE among medical and dental students.MethodsThe present cross-sectional study explored the readiness of conveniently selected first-year medical and dental students towards IPE and compared readiness among subgroups of respondents. The readiness was assessed through an online survey using the standard Readiness for Interprofessional Learning Scale (RIPLS) during June 2021. The nineteen questions in RIPLS were categorized under four domains: teamwork and collaboration (items 1–9), negative professional identity (items 10–12), positive professional identity (items 13–16), and roles and responsibilities (items 17–19). The individual statements were scored and assessed as per the study objectives. The scores were not normally distributed, so non-parametric tests (Mann–Whitney U-test and Kruskal Wallis test) were used.ResultsA total of 83 students (69 medical and 14 dental) students responded. The median total score was 75, IQR 6 with the maximum score being 95. The median (IQR) scores for the domains teamwork and collaboration were 38 (IQR 3), negative professional identity 11 (IQR 2), positive professional identity 16 (IQR 3), roles and responsibilities 10 (3). The scores were different between students aged 20 years and below = 37, and above 20 years = 38; (p =< 0.001) in the negative professional identity domain and the total score (p = 0.001). The scores were also different among those with and without previous learning exposure with other discipline students in the same class (p = 0.046). A high median score of 5 was achieved for 8 out of 19 statements in the questionnaire.ConclusionThe findings showed a high level of readiness for IPE among student respondents. Study findings can be considered as a positive factor for implementing IPE sessions.

Student readiness for interprofessional learning at a local university in South Africa

Working effectively with other disciplines has become an important competency as a graduate attribute in higher education institutions. Educational experiences should begin to foster the prerequisite competencies needed to collaborate successfully with other healthcare professionals. The purpose of this study was to determine how ready first year students are for interprofessional learning, and whether this readiness improves along the continuum of learning into their final year of undergraduate studies. First year undergraduate students from ten disciplines completed the Readiness for Interprofessional Learning Scale prior to participating in a compulsory interprofessional module, and the results were compared with that of senior students who completed the same questionnaire. Results for the study show that there were significant differences between first and senior–year level students on the subscales of negative professional identity (0.02 < 0.05); positive professional identity (0.00 < 0.05); and teamwork and collaboration (0.00 < 0.05). There was no significant difference found on the subscale roles and responsibilities (0.54 > 0.05). The results clearly show that senior students are more ready for learning interprofessionally compared to first year students. It is recommended that a scaffolded approach to learning be adopted, to ensure that students attain competence in all Interprofessional Education (IPE) core competencies when reaching their final year of study. This type of curriculum, with its specific activities and assessment methods, should be packaged in the form of an IPE model to create a clear understanding of the type of health profession graduate that will be produced.

Evolution of professional identity in Iranian occupational therapy students and new graduates: A comparative study

Introduction The development of professional attitude evolves over time and contributes to the formation of professional identity. This study tracked formation of professional identity by comparing professional attitudes of three cohorts: new graduates, final-year, and first-year students of occupational therapy. Method The online survey, including a 5-point Likert scale 17-item questionnaire and one qualitative inquiry using an incomplete statement, revealed the perception and future career prospects of 144 novice practitioners and students of occupational therapy. Written statements were compared to each other to provide insight about the participants’ perspectives during the three time periods. Findings One-way ANOVA indicated that there were significant differences in professional attitudes among the three cohorts (F (2, 141) = 14.32, p &lt; 0.0001), demonstrating a downward trend in professional identity formation. The comparison analysis of statements confirmed the quantitative results and highlighted an issue of negative professional identity through indicating great concerns over the future career prospects. Conclusion Despite increased awareness of occupational therapy over time, these participants seemed to have had trouble developing a sound sense of professional identity. Possible sources and solutions for this issue were discussed, to better facilitate a clear sense of professional identity in occupational therapy students and practitioners.

Are Filipino students ready to collaborate? Comparing the readiness of healthcare students for interprofessional education in the Philippines

ABSTRACT The inclusion of interprofessional education in healthcare curricula in the Philippines has paved the way for the researchers to examine students’ readiness to learn with, about, and from one another to foster collaboration in providing quality patient care. In view of this, we examined the differential attitude of 423 Filipino students to get involved in interprofessional learning using the Readiness for Interprofessional Learning Scale. Using multivariate analysis of variance, we found differences across gender, program, and year level among students from medical technology, pharmacy, physical therapy and occupational therapy in terms of teamwork and collaboration, negative professional identity, positive professional identity, and roles and responsibilities. These differences can inform the development of an intervention program to elicit a favorable attitude toward interprofessional collaboration. Theoretical, methodological, and practical implications of the findings are discussed.

The impact of role modeling on the professional identity of pre-service teachers

Research shows that mentoring EFL pre-service teachers during the practicum element of teacher-training courses allow them to get experience and to develop, improve, and put into practice their teaching skills. This professional practice can impact the development of a positive or negative professional identity in teachers. Current literature, however, seems to focus on the shaping of teacher identity and learner identity, but there is little empirical research regarding the development and shaping of the identity of pre-service teachers. Pre-service teachers are the main actors of this practicum stage of teacher-training programs and, therefore, by working in collaboration and being supported by a mentor as a role model, they develop their professional identity. The present qualitative case study sought to explore the shaping and re-shaping of the professional identity of fifteen EFL pre-service teachers of a northern Mexican university and the impact of working with English teacher mentors as role models. Information gathered through the constant comparative method of data from the participants taken from their reflective journals, mentor-observations, and self-observations suggests that although working with a positive role model encourages the development of a stronger teacher identity and an improvement in their teaching practice, working with a bad role model can also have the same results.

Medical students’ readiness and perceptions about Interprofessional Education: A cross sectional study

Objectives:Interprofessional Education (IPE) provides an environment where learners demonstrate the knowledge, skills and attitude required to manage the complex clinical scenarios in a collaborative and interprofessional manner. The actual sphere of influence of Interprofessional Education in many medical schools has been limited. Therefore, the present study aim was to evaluate the medical students’ readiness and perception of Interprofessional Education in a medical college in Saudi Arabia.Methods:This questionnaire based cross sectional study was executed in the Department of Physiology, College of Medicine, King Saud University during the period September 2016 to December 2017, using the 19-item Readiness for Interprofessional Learning Scale (RIPLS) with four subscales teamwork and collaboration, negative professional identity, positive professional identity and roles and responsibilities. The questionnaire was e-mailed to 1411 medical students and responses were analyzed using 5-point Likert scale.Results:A total of 158 medical students and trainees responded to the survey, 69 (43.6%) were males and 89 (56.4%) were females. The majority of participants 122-148 (77-94%) acknowledged the positive impact of IPE on teamwork and collaboration, more than two thirds 105 (64.45%) disagreed with negative attitude and 110-126 (70-80%) showed positive professional identity.Conclusions:Medical students showed a positive perception and ready to adopt the Interprofessional Educational allied activities in medical schools. The shared academic events would improve in clarifying the roles and responsibilities of medical students in health care professions.

Interprofessional education in geriatric medicine: towards best practice. A controlled before–after study of medical and nursing students

ObjectivesTo investigate nursing and medical students’ readiness for interprofessional learning before and after implementing geriatric interprofessional education (IPE), based on problem-based learning (PBL) case scenarios. To define the optimal number...

Reliability and validity of the Persian version of readiness for inter-professional learning scale.

ObjectivesTo assess the validity and reliability of the Persian version of the Readiness for Inter-Professional Learning Scale (RIPLS). MethodsA cross-sectional study was performed among final-year medical students in Iran. A total of 200 students completed the Persian versions of the RIPLS questionnaire using convenience sampling. To evaluate the construct validity of the RIPLS questionnaire, data were subjected to confirmatory factor analysis (CFA). Some goodness-of-fit indicators were used to assess the hypothesized model. The hypothesised models were tested with LISREL 7.8. ResultsCronbach’s alphas for 9 teamwork and collaboration (TAC), 3 negative professional identity (NPI), 4 positive professional identity (PPI) and 3 Roles and responsibilities (RAR) items were 0.89, 0.60, 0.86 and 0.28 respectively. The whole RIPLS was found to be highly reliable (19 items; α= 0.94). The set of fit statistics show that the hypothesised four-factor model fits the sample data. ConclusionsThe results of the study show that the Persian version of the RIPLS may be a valid and reliable scale. In addition, the results of CFA show that the hypothesised four-factor model appears to be a good fit to the data. However, the Persian version of the subscales of NPI and RAR needs to be developed. The implications and limitations of the study are discussed.

The Readiness For Interprofessional Education (IPE) In The School Setting Among The Internship Students Of Applied Medical Sciences At Taibah University.

ObjectiveThe study aims to assess the readiness of Interprofessional Education (IPE) in the school setting among the Internship Students of Applied Medical Sciences at Taibah University.MethodsThis study utilized a survey targeting internship students of Applied Medical Sciences; departments Diagnostic Radiologic Technology, Medical Laboratory Technology, and Clinical Nutrition, at Taibah University. We used a modified Readiness for Inter-professional Learning Scale (RIPLS) survey to collect the data of this study. Data were analyzed using SPSS software version 21.ResultsA 100 surveys distributed, 40 were returned. Most of the internship students (88.7%) agreed that IPE could make them more collaborated and can enhance teamwork skill to them. A total of 36.25% of the internship student agreed, and 50.01% disagree about the negative professional identity of the IPE. 86.66% of the internship student agreed, and 50.01% disagree about the positive professional identity of the IPE. They responded that sharing learning with other health care professionals will help them to communicate better with patients and other professionals and to improve practice. 65.84% of the internship student agreed, and 23.75% disagreed about the impact of IPE on their role and responsibility. The difference between the internship student at the end level of the internship and internship student at the beginning level of the internship, towards the positive thinking about other healthcare professionals was 0.015.ConclusionThe study concluded that there was a readiness of IPE in the school setting among the Internship Students Students of Applied Medical Sciences at Taibah University. The majority of the internship student agreed that IPE could make them more collaborated and can enhance teamwork skill to them. There was a significant difference between the internship student at the end level of the internship and internship student at the beginning level of the internship, towards the positive thinking about other healthcare professionals.