The Uncommon Handshake
by Donna Cardillo, RN, MA

The goal of this program is to teach nurses the significance of handshaking in their daily practice, to teach the acceptable method for shaking hands in a variety of situations, and to illustrate appropriate situations in which to shake hands. After you study the information presented here, you will be able to:

• Demonstrate proper handshaking technique.
• Discuss three intercultural differences related to handshaking.
• List three occasions when it is appropriate to shake hands.

Nurses are ever present in healthcare settings, often staying quietly in the background working tirelessly behind the scenes. While it is common for physicians and other primary caregivers to shake hands with their patients, with colleagues, and with patients’ families, nurses seem to have overlooked this important social custom. It may be because we consider ourselves as caregivers who are destined to stay in the background. Perhaps it is because we often become so task-oriented, we forget about the importance of introductions and maintaining professional relationships. Maybe it’s because we tend to think that our most important function is saving lives and easing pain and suffering and don’t see how certain "social graces" fit in with that. Whatever the reason, by not shaking hands in professional settings, nurses are missing out on a great opportunity to become more visible and credible, to make important personal connections, and to establish a high level of trust.

Although the exact origin of the handshake is difficult to pinpoint, there is a wide belief that it was originally used as a gesture between two men to show that they were not carrying a weapon. And while times have changed, the handshake remains an important symbol with different meaning today. The handshake has evolved into an important social custom in 21st century America.

While men have traditionally been socialized to shake hands with other men, women, for the most part, have not. Handshaking customs have changed over the years. Many men of an older generation were taught to use one type of handshake with a man and another, more delicate version with a woman. Likewise, in the past, men did not extend their hand to a woman unless she extended her hand first. Some women of an older generation might view a traditional firm handshake with a man or a woman as too bold or aggressive. Old standards dictated that people with the highest level of authority should extend their hands first and others should wait for this gesture. Although some consider these social norms outdated traditions in this country, nurses need to be aware of them, and respect them.

Today in western culture, everyone shakes hands with everyone else — men with men, men with women, women with women, and women with men. Shaking hands is not only proper and appropriate for everyone, cultural differences aside, but a standard credible type of handshake has emerged that is appropriate for most situations.

Why should a nurse care?

Nurses don’t have to be told how important the sense of touch is to human relations. Touch is trusted and craved; it communicates something about others and ourselves. Because people live in a climate of hypersensitivity to sexual harassment and inappropriate touching, the handshake has become the only socially acceptable form of touch in workplace and many other social situations. Obviously, the touching involved with caregiving falls into another category.

A handshake is an important opportunity to establish an interpersonal connection with another human being. Extending your hand to someone to shake conveys warmth, friendliness, and trust. It is a sign of respect and in some cases makes the statement that "we are equals." A handshake is a critical part of a job interview and a universal greeting as well. Many people "sign a deal" over a handshake or come to terms after a disagreement with the expression, "Let’s shake on that."

The handshake is an important part of a first impression. In many situations, people will evaluate you based on whether or not you shake hands and on the quality of your handshake.1 The type of handshake you use is considered to be a reflection of your personality. A limp handshake may give the impression that you are an insecure person, while a firm handshake conveys character and authority.2

Research suggests that those who use a full, firm handshake with accompanying eye contact are considered more outgoing, open to new experiences, conscientious, and agreeable. Likewise, those with a less firm or partial handgrip and weak or absent eye contact have a tendency to be viewed as shy, neurotic, and having less emotional stability. 3 If you want to be taken seriously in the workplace or in certain political or social situations, you have to shake hands. This rings especially true for women, who traditionally have not shaken hands. The research suggests that a firm handshake may be an effective form of self-promotion for women.3 A fully engaged firm handshake conveys that you are confident, have social savvy, and are open and intelligent.

A recent study conducted by researchers at Northwestern University Feinberg School of Medicine in Chicago reports that the majority of patients want to be greeted by physicians with a handshake, while being addressed by name and having physicians introduce themselves with first and last name.4 These findings have relevance for nurses. The study underscores the importance of good communication in relation to proper introductions, and when establishing a therapeutic relationship, which has long been linked to good outcomes.

Many nurses have become so busy that they have forgotten the necessity of establishing a therapeutic relationship with patients — something that every nurse learned during a Fundamentals of Nursing course while in school. Running in and out of a patient’s room to change an IV, administer a medication, or take a blood pressure does not constitute a "relationship" of any type. Every relationship starts with a proper introduction and the handshake provides the perfect opportunity for introductions, making connections, and forging a bond.

The handshake as assessment tool

As already discussed, shaking hands with patients serves a myriad of purposes. In addition to those already mentioned, the handshake also presents one more way to assess a patient’s emotional and physical condition. When offering your hand to shake, observe the degree of ease and steadiness with which the patient raises his hand. Is the hand cool or warm, dry or moist? Is the grip firm or weak? How does it compare to previous days? Are there unseen tremors in the grip? And since the offer to shake hands typically elicits eye contact, the gesture can help to detect emotional distress or discomfort through the gaze.

Because caregivers routinely wear protective gloves these days when providing any hands- on care or performing any procedures, it can make the care seem impersonal to the patient and family member. Many patients and their family members feel a sense of being "untouchable." The occasional ungloved handshake can help to minimize this. It can also help to reduce stigma and fear in patients and family members. Much was made about the fact that Princess Diana of England shook hands publicly with a patient with AIDS?years ago. That simple gesture helped to allay public fears and reduce the stigma of AIDS, not to mention what it likely did for the person with whom she shook hands. It also conveyed to those who were watching that the disease was not transmitted by casual contact. One handshake communicated all that.

How to shake hands

As in golf, tennis, and so many other things, technique is everything. Approach the person with whom you wish to shake hands. When you’re about three feet away, fully extend your hand, in a horizontal position with your thumb extended and pointing up. Engage the other person’s hand. A proper credible handshake involves a full firm grip, without crushing the other person’s metacarpal bones. Make palm-to-palm contact (don’t cup your hand), and lock thumb webs. Your fingers should wrap around the other person’s hand. Then use one or two downward pumps and release the grip.

Direct eye contact, and when appropriate, a smile must accompany the handshake; it’s a three-prong approach. A fully engaged firm handshake without eye contact is not considered credible. Some people have a tendency to use a half-hearted grip, while others grab a person’s fingertips and wiggle them. Remember, you cannot control another person’s handshake; you can only control your own.

If someone is standing and offers to shake your hand, you should stand to shake theirs, whether you are a man or a woman. This promotes a sense of equality in some cases and respect between the parties. Although a handshake would not "equalize" the relationship between an older person and a younger person or a senior person and a junior person in a corporation, it can make a statement in other situations that both parties are important in their unique roles. This could be the case with nurses shaking hands with physicians and other healthcare professionals, for example.

What not to do

Just as there is an appropriate way to shake hands, there are some things to avoid. For example, avoid a two-handed shake in which people use their second hand to cover the clasped hands or to enclose the other person’s one hand in their two hands. Although often done as a friendly gesture, people can misconstrue this handshake technique as motherly, controlling, or too intimate.

Likewise, do not put your free hand on the other people’s shoulders or grip their forearms while shaking hands. By so doing you exceed what is socially acceptable and invade other people’s personal space.

Don’t immediately pull your hand away after the shake. Take a moment to pause. Try to be the last person to release the grip. It may seem awkward at first, but you’ll get a feel for it with some experience. You can usually feel the other person’s grip relax. Often the release of the handshake grip is spontaneous after a few seconds have passed.

If you are a man and accustomed to pouring cologne into your hands to pat it on your face, be sure to wash your hands well afterwards. You don’t want everyone you shake hands with that day to smell you on their hands for the rest of the day. This applies to women, too.

Cultural diversity

Social conventions, such as handshaking and eye contact, vary from culture to culture. Although the technique described above is the American version, nurses deal with people from many different cultures in their practice settings. Nurses need to be aware of exceptions and variations. This information is particularly useful when working overseas or with people from foreign countries or with different ethnic and religious backgrounds here in the U.S.

In some cultures in the Middle East and Asia, handshaking and direct eye contact are not acceptable between men and women for religious reasons. This applies to many Muslims, Hindus, and Orthodox Jews.<sup5 In Islamic countries, offering your hand to a woman can be highly offensive.6 Fortunately, you can sometimes identify some of these people by their traditional garb. However, if you unknowingly extend your hand to someone who finds this convention inappropriate, they will usually graciously decline to shake your hand with a simple statement such as, "Handshaking is not permitted in my culture." In that case, simply drop your hand and smile and nod. There is no need for embarrassment.

Although people from the Japanese culture traditionally did not shake hands, it is a more common practice for Japanese people to shake hands today. Those from most Asian countries may use a softer handshake with less direct eye contact, with the exception of those from the Philippines where more direct eye contact is the accepted norm. It is considered rude in China, Korea, and Japan to maintain long eye contact with a person. It is regarded a bit like staring. Again, always consider cultural differences rather than assuming that someone is not sincere or is not confident.

Many cultures in Asia are adopting the American style of handshake when being introduced or in conducting business. As with the Japanese, it is common for many people from India to shake hands with Westerners today. However, for those of strict Hindu background, there may be no physical contact with members of the opposite sex (other than a close family member ) permitted.

Those from most European countries commonly use the handshake in work-related situations. Some European men of an older generation are accustomed to shaking hands with other men and kissing a woman’s hand. So if you are a woman, don’t be offended by this gesture. Consider the source. Many European men will wait for a woman to extend her hand first to shake. In Europe, the handshake is used more frequently than in America. As an example, a colleague who served in the Peace Corps related that some European teachers accused the American Peace Corps volunteers of being rude because they did not shake hands with them every time they met!

In Latin American countries like Mexico, a firm handshake is common in workplace situations or with individuals who are not close friends. Men are more inclined to shake hands than women, and men will often wait for a woman to extend her hand first.

In South American countries, it is traditional to use a firm handshake with men and woman.

People from Australia and New Zealand use a quick, firm shake usually at the beginning and end of a meeting — whether business or social. Those from Scandinavian countries also use a quick, firm shake, and will traditionally shake hands with a woman first when in mixed company.

Canadians shake hands firmly in business situations but less often in social situations. French Canadians are more inclined to frequent handshaking in the European tradition.

American Indians prefer a light handshake, but may accommodate other Americans by using a firm handshake.

So many international variations on the handshake exist that entire books have been written on the subject. You do not need to know and understand them all. You simply need to be aware that the American way is not the only way and be sensitive to other customs.

People with disabilities

Just because someone has a disability doesn’t mean you should bypass the traditional handshake. This convention is important with people who are disabled and who are often marginalized or treated differently. As nurses, we have a responsibility to be role models for greetings and behaviors that are respectful and appropriate for all people, especially those with a physical or mental disability.

If someone is visually impaired, you might ask, "May I shake your hand?" and then bring your hand to meet his or hers. If someone has a missing or nonfunctioning right hand or limb, offer your left hand to shake. Likewise, if someone offers the left hand first for whatever reason, meet it with your left. If someone has limited use of both limbs, extend your right hand anyway close to his or her right hand. People with a limitation will usually make an effort to meet your hand in some capacity. If shaking isn’t possible, a nod of the head or a light touch on the hand is appropriate to acknowledge the person.7

When to shake hands

Now that you know the proper way to shake hands, when is it appropriate to shake? A handshake should always be used —

• Upon meeting someone for the first time
• To greet someone you don’t see on a regular basis
• At the start and end of an interview, even if you know the person well
• When parting company with those you just met and/or don’t see often
• After a meeting or conversation to show agreement or solidarity
• Whenever someone offers his or her hand to you
• When you are welcoming people into your home, your office, a meeting, or a class or presentation

Shaking hands with children once they are of an age to understand proper greetings is just as appropriate. The gesture promotes respect, socially acceptable behavior, and a feeling of being acknowledged. It is a good idea to teach children to shake hands and to practice with them.8

Troubleshooting

Even with the best of intentions, there are often obstacles and stumbling blocks to something as seemingly simple as a handshake. For example, if you can’t shake hands because of recent hand surgery or severe arthritis, you might politely say something like, "Forgive me for not shaking your hand but I have recently had hand surgery."

If you have cold hands, shake anyway. The receiver is probably much less aware of the temperature of your hand than you are. Don’t apologize for your cold hands and draw attention to them. Of course, if you know beforehand that you will be greeting someone and shaking hands, you can rub your hands together when no one is looking.

If you have sweaty palms, keep a handkerchief in your pocket and use it discreetly, if possible, just before shaking to dry off your hand. If that’s not feasible, shake hands anyway. The act of shaking hands is more important than the fact that your hand is sweaty or cold. If you refuse to shake, people may assume that you are unfriendly or do not respect them. Refusing to shake someone’s extended hand is insulting unless you offer an acceptable reason, such as religious proscription or physical limitation.

If you extend your hand to someone to shake, and he or she does not respond, presuming they saw your extended hand, simply drop your hand to your side and carry on. Who knows what his or her motivation is. Just don’t take it personally.

If your hands are full when someone approaches you to shake hands, put down the things in your right hand if possible or shift them to your left hand. You can also extend your left hand, if necessary, in a pinch. Again, make every effort to shake hands when the situation presents itself. The gesture and its significance supercede inconvenience or other obstacles.

If you meet someone in cold weather and you are wearing gloves, it is appropriate to remove your glove before shaking unless it is completely impractical.

Some nurses express concern about spreading germs through handshakes. However, germs are spread in a lot of ways. Eliminating handshaking from your day is unlikely to significantly reduce the spread of disease, especially with the amount of handwashing most nurses perform in a day. If you’re that concerned, carry a container of waterless sanitizer for discreet use as necessary.

At networking and social events, carry a drink in your left hand so you are prepared to shake hands when necessary. Of course some circumstances make it impossible or inconvenient to shake. In those cases, a smile and nod will suffice.

Why do nurses need to shake hands?

If you want to be taken seriously as a nurse, you need to start shaking hands. Proper handshaking will enhance your credibility and put you, along with the entire profession on a more equal footing with other professions in healthcare and society.

It is particularly important for nurses to shake hands with their patients and patients’ families when appropriate. It might not be appropriate to shake hands during emergency or crisis situations when immediate medical attention is needed. As caregivers, nurses are licensed to have physical contact with others that goes beyond what is usually socially acceptable. Therefore, initially shaking hands with a patient during an introduction is a respectful way of starting the caregiving relationship. It is also a good chance for the patient and nurse to start creating a bond of trust.

Likewise, a nurse should shake hands with family members, physicians, and other healthcare professionals as well as their peers. And while you wouldn’t shake hands regularly with the staff you work with every day, you would shake hands with other colleagues that you do not see on a regular basis such as those you see at meetings and conventions. This would apply to those from your own institution as well as others.

Professional introductions are an important part of a nurse’s image and self promotion. As Suzanne Gordon and Bernice Buresh state in their book From Silence to Voice — What Nurses Know and Must Communicate to the Public, "A firm but cordial handshake is an essential part of a professional introduction and provides the opening for nurses to state their names and credentials." 9

Proper handshaking conveys confidence, trust, and openness. The gesture demonstrates respect and acknowledgement of another and serves as a universal greeting. People who shake hands are perceived as more credible and are more memorable. If you already have a good, firm handshake and use it regularly, you’re ahead of the game. If not, start practicing to perfect your grip and begin using your newly acquired skill. I look forward to shaking your hand.

References

1. Cardillo D. Your First Year as a Nurse. New York; Three River Press; 2001.
2. Tuckerman N, Dunnan N. Amy Vanderbilt Complete Book of Etiquette. 15th ed. New York, NY: Doubleday; 1995.
3. Chaplin WF, Phillips JB, Brown JD, Clanton NR, Stein JL. Handshaking, gender, personality, and first impressions. J Pers Soc Psychol. 2000;19(1):110-117.
4. Handshakes, sensitivity boost doctor-patient rapport. The Atlantic Journal Constitution website. Available at: www.ajc.com/health/content/sharedauto/healthnews/bhvr/605385.html. Accessed October 8, 2007.
5. Morrison T, Conaway WA, Borden GA. Kiss, Bow, or Shake Hands. 2nd ed. Holbrook, MA: Bob Adams; 2006.
6. Post P, Post P. The Etiquette Advantage in Business. 2nd ed. New York, NY: HarperCollins ; 2005.
7. Fox S, Cunningham P. Business Etiquette for Dummies. Foster City, CA: IDG Books Worldwide; 2000.
8. Post EL. Emily Post’s Etiquette. 17th ed. New York, NY: Harper Collins; 2004.
9. Buresh Bernice From Silence to Voice — What Nurses Know and Must Communicate to the Public; Ithica, NY; Cornell University Press 2000.

Bibliography
Mitchell M. The Complete Idiot’s Guide to Etiquette. 3rd ed. New York, NY: Alpha Books; 2004.
Pachter B, Brody M. Complete Business Etiquette Handbook. Englewood Cliffs, NJ: Prentice Hall; 1995.
Copyright Nursing Spectrum Nurse Wire (www.nursingspectrum.com). All rights reserved. Used with permission. This material can be used to earn 1.0 contact hour of continuing education by calling (800) 866-0919 or going to http://www.nurse.com/CE/CE307.