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Nurse Education in Practice 11 (2011) 395e398

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

From SOLER to SURETY for effective non-verbal communication

Theodore Stickley*

School of Nursing, Midwifery and Physiotherapy, Faculty of Medicine and Health Sciences, University of Nottingham, Duncan MacMillan House, Porchester Road,Nottingham NG3 6AA, United Kingdom

a r t i c l e i n f o

Article history:Accepted 20 March 2011

Keywords:EducationNon-verbal communicationSOLERTherapeutic space

* Tel.: þ44 115 9691300x11214.E-mail address: theo.stickley@nottingham.ac.uk.

1471-5953/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.nepr.2011.03.021

a b s t r a c t

Background: This paper critiques the model for non-verbal communication referred to as SOLER (whichstands for: “Sit squarely”; “Open posture”; “Lean towards the other”; “Eye contact; “Relax”). It has beenapproximately thirty years since Egan (1975) introduced his acronym SOLER as an aid for teaching andlearning about non-verbal communication.Aim: There is evidence that the SOLER framework has been widely used in nurse education with littlepublished critical appraisal. A new acronym that might be appropriate for non-verbal communicationskills training and education is proposed and this is SURETY (which stands for “Sit at an angle”; “Uncrosslegs and arms”; “Relax”; “Eye contact”; “Touch”; “Your intuition”).The new model: The proposed model advances the SOLER model by including the use of touch and theimportance of individual intuition is emphasised. The model encourages student nurse educators to alsothink about therapeutic space when they teach skills of non-verbal communication.

� 2011 Elsevier Ltd. All rights reserved.

Introduction

It has been approximately thirty years since Egan (1975) intro-duced his acronym SOLER as an aid for teaching and learning aboutnon-verbal communication (Briefly, SOLER stands for “Sitsquarely”; “Open posture”; “Lean towards the other”; “Eye contact;“Relax”). There is evidence that this framework has been widelyused in nurse education with little published critical appraisal. Inthis paper, the premise of the work is examined and a new acronymthat might be appropriate for non-verbal communication skillstraining and education is proposed (SURETY).

In the UK, at the present time, there is much discussion aroundthe need for compassion and empathy amongst health care staff(DH, 2008, 2009). Furthermore, this discussion extends to howcompassion and empathy might be taught and how they might bemeasured (Danielsen and Cawley, 2007; Davison and Williams,2009; Williams and Stickley, 2010). The new model that isproposed in this article is designed to help nurse educators to teachempathic skills for non-verbal communication hopefully, in a lessmechanistic way than Egan originally proposed. An outline for themodel has already been published in a book chapter describingskills for a caring relationship in mental health nursing (Stickleyand Stacey, 2009) however the chapter does not give a critique ofSOLER that is offered in this article.

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By way of background, I have taught counselling skills to bothcounsellors and nurses for the last 15 years and have frequently usedSOLER and I have considered it a useful tool. As I continued todevelopmy teaching however, I began to think thatwhilst SOLER hasbeen useful as a teaching tool, students have tended to accept thisand practise it mechanistically, at least for classroom use, andperhaps ignore it once in practice. I wanted a model that was morerelevant to nursing practice, less rigid and more reliant upon naturalhuman ability and a model that acknowledged personal intuitionand the appropriate use of touch. To this end, I have developeda similar model that uses a mnemonic and incorporates both touch,and the use of the nurse’s intuition whilst retaining what is positiveabout SOLER. Furthermore, I have been using the new model overthe last 7 years with student nurses and it has been tested andrefined.

In this article, SOLER is described and literature is identified thatrefers to the acronym. Other literature relating to non-verbalcommunication is also introduced before an overview of SURETY ispresented.

An introduction to SOLER

For readers unfamiliar with SOLER, the model is brieflydescribed and how it was first introduced. Gerard Egan is EmeritusProfessor of Psychology and Organizational Studies at LoyolaUniversity of Chicago. His book The Skilled Helper was published in1975 and in chapter three of this book he detailed what he referredto as “microskills”. He presents SOLER as a way the listener can:

T. Stickley / Nurse Education in Practice 11 (2011) 395e398396

“.make sure you are physically present to a client” (page 75). Theacronym is explained by Egan as follows:

S (“Squarely”)

It is advocated that the listener “sits squarely” to the client. Bythis Egan meant that the preferred position is opposite the client.He acknowledges that this position may feel threatening to someclients and that an angle between the chairs may be preferred.

O (“Open posture”)

Egan recommends an open posture. One that is not crossedeither with legs or arms.

L (“Lean towards the other”)

Egan suggests this as a way of communicating interest in whatthe other person is talking about.

E (“Eye contact”)

Good eye contact is recommended and is differentiated fromstaring by having occasional breaks in the contact between the eyesof client and helper. Egan acknowledges the need for culturalsensitivity with eye contact and communication in general.

R (“Relax”)

This is largely in terms of not fidgeting or demonstratingnervousness.

Having taught SOLER for a number of years, I realised that I wasnot sticking to its literal instructions and that is why I began toadapt it, leading to my own variation of the original. I struggledwith the notion of sitting “squarely” to the client; leaning towardsthe client felt false; and furthermore, there was no room in themodel of the appropriate use of touch or for the interpretation ofthe model of the individual’s intuition. These variations ultimatelyled tomy own acronym. This realisation that I was becoming criticalof the SOLER model led me to enquire of the literature, whether ornot the model had been critically evaluated in nurse education.

SOLER in the nursing literature

Whilst there is much published work attending to communica-tion skills amongst nurses, there is little in the literature thatspecifically refers toSOLER.Where theacronymhasbeen referred to,it is usually almost inpassing. It has beenuseduncritically for testingcommunication skills in various parts of the world (Arthur, 1999 inHong Kong; Lauder et al., 2008 in Scotland), and also uncritically toemphasise the necessary non-verbal communication in educationand nursing (Studer, 1994 in the USA) and in England (Jack andSmith, 2007; Smith, 2004; Roberts, 1998). Duxbury (2000) drewfrom Egan’s helping model to outline vital skills and rules of thera-peutic communication. Active listening’ is conceptualised asa disciplined process rather thanmere hearing and proposed SOLERas themeans of portraying this to the client. Crouch (2005) exploredcommunication skills necessary for holistic health assessment andincluded SOLER. She identified and discussed optimal communica-tion skills and their barriers to effective gathering of data duringholistic health assessment and the use of SOLER in attending skillswas advocated as a way of ensuring patients feel uninhibited toexpress themselves.

MacInnes et al. (2001) examined the importance of therapeuticrelationships and critically analysed interpersonal skills. Different

therapeutic approaches and their uses are outlined. Counselling isdefined and its relevance discussed in the context of mental healthpractice. Empathy is presented as one of seven qualities of coun-selling and identifies SOLER as a non-verbal strategy of showing theclient that full attention is being paid to him/her.

Burnard (2002) proposed that the art of listening in therapeuticrelationships is the most important human action for the nurse. Healso referred to ‘noticing’ as an aspect of listening that sensitisesnurses to the needs of their clients. The importance of non-verballistening behaviourswere discussed and SOLERwas suggested as theacronym for vital activities during the listening process. For Nicolaand Sale (2001) greater emphasis needs to be put upon the two-way nature of nurseepatient interactions. Nurses need to be awarethat their approach to patients will influence the way the patientsrespond to them. Listening and non-verbal communication thereforeform an important part of the nurseepatient interaction. Far frompassive, they are skills that require effort and discipline. Dexter andWash (1997) also introduced counselling skills and suggested someimportant concepts drawn from client centred-therapy. They focusedupon non-verbal communication as one of these concepts andsuggest that certain mental health problems can cause clients tobecome easily upset or lead them to misinterpret non-verbalbehaviour. Nurses therefore ought to be aware of their own bodysignals and to use these appropriately within a helping context, inorder to create a rapport with the client. They referred to SOLER asa guideline rather than a prescription for non-verbal attending.Kacperek (1997) presented the author’s personal reflection on howher nursing practice was enhanced as a result of losing her voice.Surprisingly, being unable to speak appeared to improve the nurse/patient relationship. Patients responded positively to a quietapproach and silent communication. Indeed, the skilled use of non-verbal communication through silence, facial expression, touch andcloser physical proximity appeared to facilitate active listening, andhelped to develop empathy, intuition and presence between thenurse and patient. Quietly “being with” patients and communicatingnon-verbally was an effective form of communication. It is suggestedthat effective communication is dependent on the nurse’s ability tolisten and utilise non-verbal communication skills. Stickley andFreshwater (2009:28) argue for the preservation of therapeuticspace and suggest that practice is: “.shifting from providing a ther-apeutic space toone that ismore technical, drivenbyoutcomes,policyand external formulaic objectives that attempt to measureefficacy.”. Ultimately, what needs to be created by non-verbalcommunication, is a therapeutic space where the client experiencespsychological safety and anopportunity to openly communicatewiththe helper. Nurses can often take up too much space in their practiceand not enough consideration is given to the space between people(interpersonal space). Rather, the focus appears to bemore uponhowthis space can be filled with interventions and treatments, assess-ments and care plans. Non-verbal communication is about becomingaware of how we behave in the interpersonal space and deliberatelycreating an environment where the space becomes therapeutic andnot oppressive.

Non-verbal communication in various settings

The need for effective non-verbal communication has been rec-ognised in disciplines other than nursing; for example in teaching(Mortiboys, 2005), management (Singh, 2007), counselling (e.g.Brems, 2000) and in Dental Assistance (Phinney, 2003). The topic ismost found though in the helping professions, especially nursing. Inrelation to stoma care, Metcalf (1998) discussed how nurses caneffectivelyutilise listening skills during interactionswithpatients andallow intuition to develop in practice. Listening is considered a coreskill for all health care professionals with studies demonstrating that

T. Stickley / Nurse Education in Practice 11 (2011) 395e398 397

nurses perceive themselves to be much less skillful in the use offacilitative interpersonal skills which involve listening than practi-tioner-centered authoritative ones. Dea Moore (2005) developedpractical strategies to enhance the quality of communication in thepalliative and end-of-life medical care settings. The components ofeffective and compassionate care at the end of life require successfulcommunication with patients, families, and members of the healthcare team. They argued however that few health care professionalsare formally trained in communication skills to the detriment of thepatient and their families. Nurseswhopossess self-awareness andareskilled in effective communication practices they argued are integralto the provision of high-quality palliative care for patients and fami-lies coping with advanced malignancies.

Arthur (1999) explored the communication skills of a group ofnursing studentswhowere required to interviewasimulatedclientaspartof their studies. Inorder toassess the students and to improve theprocess of learning discrete skills, an instrument was developed andtested aspartof this process. The subjectswere 212nurses enrolled inabachelorofnursingprogramme, inNewSouthWales,Australia,whowere studying a problem-based learning package the focus of whichwas `alcohol early intervention’. The sub-groups within the sampleincluded registered nurses, a significant percentage of whom hadcompleted their basic nursing education in overseas countries. TheSimulated Client Interview Rating Scale (SCIRS) was developed toassess basic humanistic communication skills as well as beginningmotivational interviewing skills. The students were required tointerview a simulated client and demonstrate competence in inter-viewing. Thiswas assessed by the SCIRSwhichwas completed by thestudents and the simulated clients. The instrument proved to bea reliable andvalidmeansof assessing student interview techniqueaswell as a flexible educational tool, while valuable insights intostudents’ interviewing techniques were gained.

There are therefore relatively few examples in the literature ofresearch directly relating to non-verbal communication. The use ofSOLER itself has not been empirically tested as to its usefulness. Inspite of this, a new acronym has been devised to help facilitate non-verbal communication in nursing.

SURETY e a new acronym

Acronyms (mnemonics) are useful ways to help memoriserelated points and are widely used as teaching aids. In that sense,SOLER has probably become fixed in the minds of generations ofnurses and counsellors. I have therefore maintained the ideaof using an acronym (SURETY) to help facilitate the creating ofa practical therapeutic space. The content of the model is notdissimilar to SOLER but allows for cultural variations and theappropriate use of touch. In brief, the model is as follows:

S e Sit at an angle to the clientU e Uncross legs and armsR e RelaxE e Eye contactT e TouchY e Your intuitionEach point is now more fully explained.

Sit at an angle to the client

If we sit directly opposite somebody who is feeling in any wayvulnerable, this position may be interpreted as confrontational. Ifwe sit exactly next to a person (as in awaiting room), the position isimpersonal. If however, we sit at a slight angle, it creates a non-confrontational, comfortable seating arrangement, ideal for one-to-one work. Naturally, we each have our own “comfort zones” andpersonal space is determined by culture, upbringing and individual

preference. The use of intuition is imperative when we sit witha client. The tiniest clues of discomfort should be intuitivelyresponded to.

Uncross legs and arms

Research into non-verbal communication has shown thatcrossed arms and legs communicate defensiveness. Depending onthe whole body position, crossed arms and legs may also commu-nicate that we are not interested or in some way superior. If wedeliberately uncross arms and legs, we communicate that we areopen and receptive to what the person is saying. There is of coursethe danger of a slouched position or one that is too open. Somepeople feel uncomfortable maintaining an open position and it istherefore important for lengthy individual counselling sessions tohave chairs that are well designed that support good posture.

Relax

In spite of the prescriptive nature of this method of deliberatenon-verbal communication, it is most important that the listenerlearns to relax in the appropriately assumed position. It may feelawkward at first to practise this position, but it is worth it, andfurthermore, itworks! A clientmay be disclosing disturbing contentand it is important not to appear too relaxed and at the same timeappropriately concerned without looking over concerned, forexample with a heavy frown. Egan recommended leaning towardsthe clientwhich in thismodel has beendispensedwith. Leaningmaydemonstrate active listening, but it a position that is also unnaturalto maintain.

Eye contact

Retaining appropriate eye contact is a powerful way of commu-nicating respect and that you are paying attention. Eyes thatwanderto windows or the clock are sure to be read as loss of interest orattention.Appropriateeye contact is verydifferent to staring. Staringis insensitive and intrusive. Appropriate eye contact breaks onoccasions. It is always important to have eye contact at the ready ifa client is distressed and perhaps looking down. If theymomentarilylook up and your eyes are notwaiting for them, there can be a loss oftrust.

The practice of eye contact is not universal. If a practitioner isasked toworkwith a client froma different culture (especially of theopposite gender) the worker would do well to find out about thecultural rights and wrongs including the use of eye contact. Neuro-linguistic Programming (NLP) examines the mental processesassociated with the position of the eyes in conversation, but it is notnecessary to study the topic in such detail in order to appreciate thenon-verbal communication conveyed through eye contact. In theSURETY model, intuition governs the entire process of non-verbalcommunication.

Touch

Again the appropriate use of touch is not universal and culturalsensitivity is essential. Gushing hugs or kisses are not appropriate innursing practice, although sensitive use of touch is often essential,especially when working with troubled children, adolescents orolder people (Burrai et al., 2009). Respectful use of touch cancommunicate compassion, love, empathy and understanding(Krieger, 1990). Conversely, inappropriate use of touch can beabusive. The use of touch in nurse practice is both normal andfrequent and the nurse should be aware of how he/she uses touch ineveryday practice.

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Whilstworkingwith adults, there are generallyconsidered “safe”zoneson thebody that itmight beappropriate to touch. Forexample,the hand or lower arm; a hand on a shoulder may communicatewarmth, care andunderstanding. Generally speaking, all other areasof the body should be avoided. On occasion nurses may be requiredtophysically restrain somebody fromharming themselves or others.This should never be conducted in a punishing way. This form ofphysical contact should be implemented in the most respectfulmanner. A litmus test for judging the respectful use of restraint is: ata later time would the service user appreciate the manner in whichhe/she was restrained?

In a study conducted by Gleeson and Higgins (2009) touch isseen as therapeutic to clients if used judiciously, with effectiveinterpersonal skills. Brown et al. (2007) have observed how the useof therapeutic touch can become diminished when nurses them-selves feel tired and stressed. The therapeutic use of touch there-fore is not straightforward and should be guided by good intuitivenursing practice.

Your intuition

The final point with non-verbal communication is the need fornurses to trust their intuition; and this vital component is whatdifferentiates the SURETY model from SOLER. The notion of nursesdeliberately using their intuition in nursing practice was stronglyadvance by the work of Benner (1984). There are no universalguidelines for how nurses might use their intuition in every situa-tion but as the practitioner grows in confidence so they should learnthat their intuition is to be trusted. The topic of intuition has beenperiodically addressed in the nursing literature since Benner, forexample: Smith (2009); Traynor et al. (2010) andhas becomewidelyaccepted as an imperative tool for nursing practice. Interpersonalcommunication, whether verbal or non-verbal, is a human art. Eventhough what is proposed in this article is meant to be appliedconsciously by the practitioner, the need for intuition and sensitivitytobe trusted in everyunique interaction is of paramount importanceto successful nursing practice. All of the above components ofSURETY should therefore be implemented by using intuition. Everyinterpersonal encounterbetweenhumanbeings is unique accordingto environment, roles, circumstances and so on; it is intuition morethan anything that should trusted although it should be acknowl-edged that one’s intuition is dependent upon individual culture andlife experience. Furthermore, as has already been observed, whennurses themselves are in need of care, for whatever reason, theability to function effectively is compromised at times.

Conclusion

Since Egan (1975) introduced his acronym SOLER as an aid forteaching and learning about non-verbal communication it has beenwidely used although this has been with little published criticalappraisal. In this paper, the premise of the work has been examinedand a new acronym that might be appropriate for non-verbalcommunication skills training and education has been proposed.The significant amendments to the original model is the intro-duction of touch and intuition as these are regarded as essential tonon-verbal communication of the nurse practitioner. Ultimatelywhat is needed in the nurse/patient relationship through non-verbal communication is the creation of a therapeutic space. If theSURETY model does no more that help students to become moreaware of what they do or how they are in the space betweenthemselves and their patients, then it has succeeded.

Acknowledgement

I would like to thank Kerry Kyaa for help in the preparation ofthis article.

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