Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/locate/nedt ‘Speaking up for safety’: A graded assertiveness intervention for first year nursing students in preparation for clinical placement: Thematic analysis Julie Hanson ⁎ , Samantha Walsh, Matthew Mason, Daniel Wadsworth, Ann Framp, Karen Watson School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, QLD 4558, Australia ARTICLE INFO Keywords: Nursing students Preparedness Advocacy Safety First year experience ABSTRACT Background: The international literature highlights patient safety as a critical issue in contemporary health care. Poor interpersonal relationships and ineffective health care team communication are identified as dominant human factors contributing to clinical errors and adverse events. Of concern is that some students appear to lack the skills to speak up for themselves, their patients and others when witnessing unsafe practice on clinical placement. Study aims: To elicit student and staff perspectives on the quality, effectiveness and appropriateness of an as- sertiveness-based communication activity prior to clinical placement. Design: The study used a qualitative design. A communication module was offered in the second week of the practice laboratory and involved the use of two graded assertiveness frameworks. Setting: School of Nursing, Midwifery and Paramedicine, at a regional university in South East Queensland, Australia. Participants: Of the 535 first year undergraduate nursing students enrolled in the laboratory courses, 73 (13.6%) completed an anonymous online survey. Individual interviews were conducted with a university student well- being coordinator and student mentor to gain their perspectives of the data. Methods: An evaluation survey with seven qualitative questions and individual semi-structured interviews were employed. Data was analysed using a thematic approach. Results: Five major themes emerged from the survey data: vicarious learning, establishing boundaries, support in practice, advocacy awareness and practice utility. Three themes emerged from the interviews: empowerment and confidence; support and preparation for advocacy; and authentic learning. Conclusions: Findings indicate that teaching assertiveness skills and establishing a preparatory framework for ‘speaking up for safety’ early in a nursing students tertiary education can have important psychosocial im- plications for their confidence, empowerment and success. The activity provided an authentic learning experi- ence with perceived practical application to the workplace and, has the potential to enhance first year curricula by improving communication tools used for students preparing for practice. 1. Introduction Patient safety is a critical concern in contemporary health care settings where appropriate medical intervention and patient recovery can be compromised by poor interpersonal relationships and in- adequate communication within the health care team (Lee and Doran, 2017). The first clinical placement is a key transition experience for students requiring the assimilation of new professional knowledge, skills and behaviours (Leducq et al., 2012; Hamshire et al., 2012). It is fundamental to develop and consolidate clinical skills but this process can be problematic (Jackson et al., 2011; Levett-Jones et al., 2007). Reports of inconsistencies in hospital workplace practice compared to that which is taught in classrooms can lead to students' pre-placement concerns regarding their own health and wellbeing, patient safety and working conditions (Leducq et al., 2012; O’Donnell, 2011; Levett-Jones et al., 2015). There are many complex issues related to first year transition from a university to a hospital setting (Pryjmachuk et al., 2018). For example, entrenched hierarchical differences in the profession and disparity in clinical experience compound students' feelings of inferiority and hinder interprofessional relationships and communication (Topa et al., 2013). Nursing students are particularly vulnerable to power https://doi.org/10.1016/j.nedt.2019.104252 Received 7 June 2019; Received in revised form 11 September 2019; Accepted 16 October 2019 ⁎ Corresponding author. E-mail addresses: jhanson@usc.edu.au (J. Hanson), swalsh@usc.edu.au (S. Walsh), mmason1@usc.edu.au (M. Mason), dwadswor@usc.edu.au (D. Wadsworth), aframp@usc.edu.au (A. Framp), kwatson1@usc.edu.au (K. Watson). Nurse Education Today 84 (2020) 104252 0260-6917/ © 2019 Elsevier Ltd. All rights reserved. T