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Communication 4: the influence of appearance and environment

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This article, the fourth in a six-part series on communication skills, discusses unintentional communication produced by factors such as our appearance and environment


Most people are able to detect dissonance between unconscious actions and conscious words. Nurses – like anyone else – sometimes transmit unintended messages. This can happen in many ways, such as through body language, tone of voice, a crumpled uniform or untidy desk. This article, the fourth in our six-part series on communication skills, explains how unintended messages are transmitted by personal appearance and the work environment.

Citation: Ali M (2018) Communication 4: the influence of appearance and environment. Nursing Times [online]; 114: 3, 46-47.

Author: Moi Ali is a communications consultant; board member of the Scottish Ambulance Service and of the Professional Standards Authority for Health and Care and former vice-president of the Nursing and Midwifery Council.


Unintentional communication can occur through the tone, pace, volume or pitch of your speech, and non-verbal communication such as posture, eye contact, facial expressions and gestures (Ali, 2018; Borg, 2013). It can also stem from your appearance, such as a crumpled uniform; and through environmental factors such as an untidy nursing station. All these factors can send out positive, negative or neutral messages to patients. Fig 1 illustrates how nurses can inadvertently communicate a different message to the one they believe they are transmitting.

fig 1


We have control over aspects of personal appearance, such as hairstyle, but not over others, such as skin colour. Prejudices can affect how we are regarded and how we regard others, and unfair assumptions may be made about status and intelligence using factors such as appearance, ethnicity, gender or age.

People are often judged by their appearance: smart or casual, well-groomed or untidy. How we look can be a powerful transmitter of intentional and unintentional messages. Think about how you respond to other people’s appearance. Do you automatically make judgements based on what someone looks like?

Practitioners who wear uniforms may convey power and authority that eludes them when in normal dress. Uniforms may also evoke deference and compliance in some patients. Be conscious of your appearance and how others may react to it. What does it say about you? If you do not wear a uniform what message are you trying to convey with your appearance?

An appropriate appearance for your professional role will help you establish credibility and avoid unintended negative messages (Anderson, 2010).

Environmental factors

A waiting room with out-of-date magazines, a drab consulting room, or dimly lit hospital corridor can convey unintentional negative messages. Even where care is first-class, poor surroundings may leave a perception with patients that it is less than good. Conversely, a thoughtfully designed environment can have a positive impact on patients’ wellbeing. Small touches such as potted plants, restful colours and a pleasant fragrance can have a big impact, because they communicate that your organisation cares.

The environment can be designed to anticipate what patients might need. For example, is there somewhere for them to hang their clothes, and a mirror to check their appearance before emerging from a cubicle after dressing?

Room layout

Room layout is important for effective communication and thoughtless arrangement of furnishings may make patients feel unimportant and contribute to nervousness and anxiety. A desk can create physical and psychological barriers between a nurse and patient. If you have to sit at a desk, can the room be laid out so that patients sit at a right angle to you rather than across the desk from you? Could the use of a pedestal table improve information sharing? (Ajiboye, 2015).

Standing or sitting in an elevated position transmits a message about status, which is not conducive to effective communication. Ensure that you sit at the same height as patients who are in bed, sitting or using a wheelchair. This makes it easier for patients to hear you and for you to hear them; this conveys that both they and the conversation are important to you.

Position yourself where the patient can see your face and facial expressions clearly, especially when speaking to those who cannot move their head, or their eyes, or need to lip-read.

Auditing your environment

Consider conducting a workplace audit to identify unintentional communication. Do not rely solely on your own perceptions; ask patients for their views. Use suggestions and comments boxes, questionnaires and focus groups. Find out what patients’ first impressions were of your clinical area. There are several issues that you could explore – these are described below.

Patient information materials

Examine the words, images and ease of use. Wordy, jargon-laden text conveys negative messages; patients want clear, plain English communication. What messages do the photographs or illustrations convey? Is a cross section of the community represented?

Notices and signs

Sometimes notices and signs can let down an otherwise caring organisation. Officious, unfriendly signs communicate negative messages. Check that yours do not hector, lecture or order – for example, “Mobile phones not allowed”. These may be legitimate messages but they should be expressed in a positive, helpful or explanatory way (“Please wash your hands” rather than “Now wash your hands’’). Remove unnecessary or out-of-date notices as they suggest you are an out-of-touch organisation.


Check standard letters to see if they communicate unintentional messages. Are they officious, impersonal and lacking the human touch? Could they make patients feel that you do not care, or do not see them as an individual? Can they be improved? See case study in Box 1.

Box 1. Unintended communication

Grace Crouch, aged 52, recently had a DEXA scan to measure her bone density for suspected osteoporosis following a wrist fracture. A letter arrived from the local hospital inviting her to an appointment to discuss the results and possible treatment. Ms Crouch became very upset when she read the letter; it came from the department for healthcare of older people. She had not considered that she had a condition associated with ageing. She raised this with her specialist nurse and the team are reviewing their standard letter.


What does your workplace look like from outside? What message do patients receive before they get through the door? Once inside, is your clinical area comfortable and welcoming?


It is important to be personally aware of your appearance, how your workplace looks and the messages that this imparts to your patients. By becoming aware of your own unintentional communication, you can avoid transmitting negative messages 

Key points

  • Unintended messages can be transmitted through the tone, pace, volume and pitch of speech and body language
  • The appearance of staff, such as an untidy or dishevelled uniform, can have a negative effect on patients
  • The environment, including the layout of furniture, can put patients at ease or create barriers to communication
  • Out-of-date and poorly presented written information can undermine patient confidence
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