Introduction

'First impressions count' is an important NHS initiative and has been adopted by several NHS Trusts with Karen Lynas of the NHS Leadership academy stating that 'people assess you within the first seven seconds'.1 The NHS Institute for Innovation and Improvement published a '15 step challenge' toolkit in which it states the importance to patients of 'acknowledgement on arrival, eye contact and greeting'.2 Focus group research involving patient feedback has indicated that patients like to be greeted and for the clinician to introduce themselves but there has been minimal research into patient preferences regarding this greeting.

Patients attending teaching hospitals are in a unique position in that they receive treatment by clinicians at varying stages of learning and competence, ranging from undergraduate dental students to consultant grade clinicians. Previous research on patient preferences for greetings in a healthcare environment have been undertaken in general practice, inpatient settings and ambulatory settings, but no specific studies have been undertaken to assess how patients attending teaching hospitals prefer to be greeted, or if they would like to be made aware of their clinician's training grade.

The generational theory has been used to make assumptions as to how individuals of different ages interact in social settings. These assumptions are based on the theory that people born within an approximate 20-year period inherit collective attitudes and attributes according to the intensity and pace of shared social and political experiences during that time period.3 The current generations encountered in adult healthcare are the 'Silent Generation' (pre-1943), the 'Baby Boomers' (1943-1960), 'Generation X' (1961-1981) and the 'Millennial Generation' (1982-2003).4

Generational theory publications have suggested that younger generations are much more informal in terms of attitudes and the wearing of formal attire than earlier generations, and this includes the automatic use of first names during social interactions. Older generations are more likely to use formal terms of address and title and it is therefore theoretically possible that a patient of an older generation may think it is 'rude' or 'discourteous' to be greeted by their first name, whereas a young clinician may feel that this is an appropriate form of greeting. If the patient's initial impression is that staff in a clinical setting are 'rude' or 'flippant' by the way they have been greeted, this could have a negative effect on the patient's healthcare experience.

No research has been conducted into whether different generations have strong preferences as to how they are addressed and greeted or if first impressions are considered to be vital to patient satisfaction in healthcare, as such the authors felt it was appropriate to conduct a pilot study to explore this.

Objective

The objective of this study was to determine how patients want to be greeted by clinicians on a first encounter in the clinical setting.

Materials and methods

A questionnaire was designed in conjunction with the clinical effectiveness team at the Royal Liverpool and Broadgreen University Hospitals Trust (RLBUHT). This was based on previous questionnaire formats which had been approved and validated for use within the Trust when collecting patient related information. The team had previously discussed the use of questionnaires with the Ethics committee who confirmed that ethical approval was not necessary as the data did not record information of a confidential nature and completion of the questionnaire was entirely voluntary. A statistician was consulted who advised that no statistical analysis of the data would be required, and that the results could be stratified by generational cohort and compared to assess if there was an association between the findings and the generational theory.

In order to ensure that distribution of questionnaires was entirely random they were left on the reception desks on each of the three floors of the dental hospital and the reception clerks were asked to distribute one to each patient attending over a ten-week period. The outpatient clinics included in the study were the Restorative, Oral Surgery, Oral Medicine and Special Care Dentistry departments. The patients were requested to complete the confidential, ten-question, tick-box questionnaire while seated in the waiting area before their appointment (Fig. 1). It was stipulated that they should give their preferences for a first patient encounter with the clinician. The patients placed the completed questionnaires in a box left on the reception desk and these were collected on a weekly basis.

Figure 1
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Patient Questionnaire

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The patients were asked to complete the questionnaire before their consultation with the clinician to ensure that there was no bias introduced by the actual encounter.

The aim was to establish what the patient would prefer rather than elicit comments on what had actually happened.

The study collected prospective data from 450 adult patients (16+ years of age) who attended an outpatient clinic at Liverpool University Dental Hospital between mid-November 2015 and February 2016.

The data was stratified into the following generational cohorts: the 'Silent Generation' (pre-1943), the 'Baby Boomers' (1943-1960), 'Generation X' (1961-1981) and the 'Millennial Generation' (1982-2003).

Results

Demographics

Of the 450 patients, 249 were female and 201 were male. The distribution within the generational cohorts is displayed in Table 1.

Table 1 Number of patients per generational cohort
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Patient preferences according to the questionnaire

Q1 At your first meeting with a member of clinical staff how would you prefer to be addressed?

It was found that 42.7% (n = 192) of all patients preferred to be greeted by their first name at a first encounter (eg John), 36.9% (n = 166) didn't mind how they were addressed, 11.6% (n = 52) preferred to be greeted by their full name (eg John Davies) and only 8.9% (n = 40) of patients wanted to be addressed by their surname and title (eg Mr Davies).

Patient preferences within the generational groups are displayed in Table 2.

Table 2 Q1 At your first meeting with a member of clinical staff how would you prefer to be addressed?
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Q2 How would you prefer the members of staff to introduce themselves to you?

A higher proportion of all patients (38%, n = 171) didn't mind how the clinician introduced themselves, 26.2% (n = 118) preferred them to use their first name, 18.2% (n = 82) preferred a full name introduction and only 17.6% (n = 79) preferred the surname and title (eg Dr Jones).

Patient preferences within the generational groups are displayed in Table 3.

Table 3 Q2 How would you prefer the members of staff to introduce themselves to you?
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Q3 Would you like the clinician to shake hands with you on the first meeting?

It was found that 43.8% (n = 197) of patients would like the clinician to shake their hand as a greeting at their first encounter. 15.1% (n = 68) did not want to shake hands with their clinician and the remaining 41.1% (n = 185) were indifferent.

Patient preferences within the generational groups are displayed in Table 4.

Table 4 Q3 Would you like the clinician to shake hands with you on the first meeting?
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There was an obvious trend within the generational groups, whereby a higher proportion of older patients preferred to shake hands with the clinician compared to younger patients, as seen in Figure 2.

Figure 2
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Q3 Would you like the clinician to shake hands with you on the first meeting?

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Q4 How important is it to you to know the grade of staff member you are seeing?

The majority of patients (50.9%, n = 229) thought that it was helpful but not essential to know the grade of the staff member providing treatment, 29.3% (n=132) of patients thought it was very important to be aware and the remaining 19.8% (n = 89) thought it to be irrelevant.

Patient preferences within the generational groups are displayed in Table 5.

Table 5 Q4 How important is it to you to know the grade of staff member you are seeing?
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Q5 Do you understand what all the titles of grades of staff mean?

Almost 60% (n = 266) of patients didn't understand what all the titles of grades of staff meant.

Patient answers within the generational groups are displayed in Table 6.

Table 6 Q5 Do you understand what all the titles of grades of staff mean?
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Q6 Would it be helpful to display a sign in the waiting room explaining the different grades of staff?

The majority of patients (65.8%, n = 296) thought it would be helpful to display a sign in the waiting room explaining the different grades of staff, with 19.1% (n = 86) stating that it wouldn't be helpful and the remaining 15.1% (n = 68) finding it to be irrelevant.

Patient preferences within the generational groups are displayed in Table 7.

Table 7 Q6 Would it be helpful to display a sign in the waiting room explaining the different grades of staff?
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Q7 Would it be helpful if staff of the same grade wore the same colour uniform?

Again, the majority of patients (59.1%, n = 266) thought it would be helpful for staff of the same grade to wear the same colour uniform, 22.7% (n = 102) thought that it was irrelevant and the remaining 18.2% (n = 82) thought that it wouldn't be helpful.

Patient preferences within the generational groups are displayed in Table 8.

Table 8 Q7 Would it be helpful if staff of the same grade wore the same colour uniform?
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Discussion

The study found that a higher proportion of patients wished to be addressed by their first name which is in-keeping with the increasing informality in social interactions currently observed within society. This result was found to be consistent with other research in the field and it has been suggested that calling a patient by their first name is a positive step towards putting patients at ease and breaking down barriers between patients and their clinicians.5,6,7,8,9,10 In contrast to this, an informal greeting could result in the patient feeling patronised, vulnerable and less in control of the situation, which would be particularly detrimental in a dental setting as patients are often anxious about the prospect of dental treatment.5 The generational theory states that older individuals such as those in the 'Baby Boomer' generation place an emphasis on title-based recognition whereas patients in 'Generation X' and the 'Millennial Generation' cohorts identify with the blurring of traditional boundaries and a preference for informality in their social interactions.11,12 There was no observed trend within this study, and both older and younger patients showed a preference for informal interactions either via a first name greeting or had no particular preference.

It was found that a higher proportion of patients didn't mind how the clinician introduced themselves with the second most frequent preference being for clinicians to introduce themselves by their first name only, further reinforcing patient preference for an informal doctor-patient relationship. This finding contradicts other research in the field which found that patients prefer clinicians to introduce themselves by their title and surname (eg Dr Jones) or full name and title (eg Dr Mark Jones).5,7,9,10 It has been argued that clinicians introducing themselves by title encourage professional paternalism and risk establishing an unequal relationship and difference in status between the patient and clinician. This could result in the patient becoming dependent on the clinician and less involved in making decisions and taking responsibility for their healthcare decisions.13 Some authors advise a symmetrical mode of greeting to address this issue, whereby if the patient is greeted on a first-name basis so then should the clinician introduce themselves in a similar manner, which could help to avoid an unequal doctor-patient relationship.6 Patients within the 'Generation X' cohort are reported to place an emphasis on equality, independence and a shift away from authority figures, however, the study was unable to establish a trend between the generational cohorts.11,14

A higher proportion of patients wanted to shake hands with their clinician which is in-keeping with similar research in the field.3 This act of physical contact could help to break down barriers further and may put anxious patients at ease, however, clinicians should try to act upon non-verbal cues as some patients could dislike hand-shaking or oppose it for cultural and religious reasons.

There was an observed trend between the generational cohorts whereby a higher proportion of older patients preferred to shake hands with the clinician compared to younger patients, and this could support the assumption that patients in older generational cohorts prefer more formal social interactions.

Almost 60% of patients didn't understand what all the titles of grades of staff meant, however, the majority of patients in all generational cohorts thought that it was either very important or at least helpful to know the grade of staff member providing treatment.

The majority of patients in all generational cohorts stated that they thought it would be helpful to display a sign in the waiting area explaining the different grades of staff, and a majority also showed preference for staff of the same training grade to wear the same colour uniform such that they were identifiable. Previous studies in the field have found that patients believe that dress-code is important as it instils confidence in the clinician's professionalism, and it was found that patients were often unable to distinguish between clinicians and other members of the public based on their attire. This was subsequently reported to increase patient anxiety due to concerns for patient safety and security, which could negatively impact on a patient's healthcare experience.15

Conclusions

This study has found that consideration should be given to addressing patients informally by their first name, however, asking a patient about their individual preference at the first encounter before making assumptions is likely the safest and most respectful strategy. Clinicians should consider shaking hands at a first encounter, particularly with patients in older generational cohorts, however non-verbal cues should be identified and acted upon. Patients believe that it is at least helpful to know the training grade of the clinician providing treatment and this should be disclosed routinely to facilitate a transparent healthcare system. The majority of patients do not understand the difference between training grades and as such consideration should be given to providing patients with an explanation via a sign in waiting areas, and ensuring staff of the same training grade wear the same colour uniform to enable them to be identified and to avoid confusion.

These recommendations could be provided at trust or practice inductions as part of staff training, and could also be taught in undergraduate dental training to ensure that the greetings undertaken in clinical encounters fulfil patient preferences.