Recent Publications by CFE Educators

Health professionals working in an interprofessional work environment are entrusted to speak up on behalf of patients. However, that environment is comprised of dynamic intra- and interprofessional hierarchies, characterized by power differentials that affect speaking up behaviors. Drawing on the social bases of power and on power/interaction theory, we analyzed focus group and interview transcripts of 62 health professionals' accounts of speaking up. We focused on their primary sources of power, and described factors associated with health professionals' embracing power to speak up for patient safety, as well as those associated with relinquishing power and remaining silent. Nurses primarily employed direct patient information as a source of power to advocate for patients. Senior nurses and attending physicians exercised their legitimate power through titles or expertise, and when embracing that power, often influenced the healthcare team's speaking up behaviors and the team environment. Physician trainees perceived to have limited sources of power. Participants reported using hospital policies, relationships, and humor for engaging in speaking up behavior. Relinquishing power and remaining silent were associated with fear, anxiety, and lack of confidence. Given the complex, hierarchical environment in healthcare, leaders' inclusive behaviors for setting a culture for speaking up, including modeling speaking up, are critical.

BACKGROUND

Although overall survival (OS) has improved in patients with brain metastases (BMs), control of recurrent BMs remains a therapeutic challenge. Salvage surgery may achieve acceptable control rates in the setting of progression after previous stereotactic radiosurgery (SRS), yet it remains a question how additional adjuvant therapies may affect outcomes and how patient selection for salvage surgery may be optimized.

METHODS

Patients receiving salvage surgery for BM progression after previous SRS were retrospectively reviewed from a single center. Outcomes of interest included local tumor progression, leptomeningeal dissemination, and OS. Cox proportional hazard models and nominal logistic regression were applied to determine factors associated with outcomes of interest.

RESULTS

A total of 43 patients with 50 BMs were included. After salvage surgery, local progression was observed for 17 BMs (34%), leptomeningeal dissemination was observed in 17 patients (39.5%), and censored median OS was 17.9 months. On multivariate analysis, use of brachytherapy was associated with improved local control (hazard ratio [HR], 0.15; 95% confidence interval [CI], 0.04-0.6; P = 0.008). For patients treated with SRS ≥4.5 months before salvage surgery, both brachytherapy (HR, 0.07; 95% CI, 0.01-0.39; P = 0.002) and postoperative adjuvant SRS (HR, 0.14; 95% CI, 0.02-1.00; P = 0.05) were associated with improved local control compared with no adjuvant radiation therapy. Presence of extracranial malignancy (HR, 6.70; 95% CI, 2.58-17.42; P 0.0001) was associated with shorter survival. Graded prognostic assessment underestimated survival in 79.1% of patients, with a mean difference of 18.9 months between graded prognostic assessment-estimated and actual OS.

CONCLUSIONS

In properly selected patients, salvage surgery may be an appropriate therapy for BM progression after previous SRS. Adjuvant brachytherapy and repeat SRS can offer significant benefit for local control with salvage resection.