Graded Assertiveness.

Graded assertiveness is a learned skill.
It is a process of communicating, advocating and directing in stressful or crisis scenarios.

There are many factors that can block good communication during critical events including:

  • differences in seniority or experience
  • job position
  • personal power
  • personal agendas
  • fear of ‘loss of face’
  • and plain old pig-stubbornness.

One form of graded assertiveness that has been developed, can be remembered with the word PACE.

PACE consists of 4 stages or tiers of communication. Each one is a measured escalation that systematically (if the problem is not resolved) transfers power from other….to shared…and finally to self.


Here is one example to give you some idea of PACE in action.

  1. Probe:
    “did you know that this patient has a serious allergy to Latex?”
  2. Alert:
    “I think there might be Latex in the gloves you are using. Lets just check on the box”.
  3. Challenge:
    “It is against our policy for you to do this procedure wearing Latex gloves if the patient has an allergy. You should not continue”.
  4. Emergency:
    “Step away from the patient. You will not continue with this. I am contacting my team leader immediately”.

By using the 4 stages as a guideline you have a structured momentum that empowers you to move forward despite perhaps feeling uncomfortable doing so.

In such ‘moments of crisis’ you become an advocate for your patient, your colleagues or yourself.

A template for raising concerns:

Another tool that will help during graded assertiveness is to develop a structured template ahead of time that you can mentally access when you need to communicate a plan for engaging with problems or issues.
Here is such an example:

  1.  Attention:  “Excuse me John….”
  2.  State your concern:  “I notice from your fluid balance chart that the man in bed 6 has not had any output from his IDC in the last 2 hours.
  3. State the problem as you see it: “I think this man is deteriorating, and we need to have him reviewed.”
  4. State a solution: “I will phone doctor Kumar to come and review him urgently”.
  5. Obtain an agreement:  “Does that sound OK to you?”



  1. Communication in a Crisis [Internet]. Available from:
  2. Patient safety and acute care medicine: lessons for the future, insights from the past [Internet]. Available from:

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