Over the past six months, through work in the US and ongoing collaboration with healthcare organisations and their vendor partners, I found myself noticing something I had not expected to matter quite as much as it did.
Across both in-person settings and virtual conversations, there was a visible range in how people chose to present themselves. Executives wore jeans with dinner jackets or open-collar shirts. Senior leaders leaned towards chinos, golf shirts and running trainers. There was still hierarchy, but it felt more subtle and more fluid. You could sense who was at the top table, but it was not defined by a uniform.
Coming from the NHS, the contrast felt stark.
In many NHS settings, professionalism still carries a relatively narrow visual identity. Suits, ties and a fairly fixed idea of what leadership is supposed to “look like”. Step outside of that and there can be a subtle sense that you do not quite fit.
What surprised me was not the difference in clothing. It was how quickly clothing became linked, consciously or unconsciously, to assumptions about credibility and capability.
I have previously been described as “laid-back”. Not because of my work, my output or what I have delivered, but because of how I present myself. Earlier in my career, I was also asked, half-jokingly, whether it was “dress down day”.
The comments were usually framed lightly, but they revealed something deeper. Appearance was being used as a shorthand for seriousness.
As someone with ADHD and autism, I have always found that slightly difficult to reconcile. Clothing is not a neutral choice for me. Comfort affects focus. Focus affects performance. A well-fitted, comfortable outfit allows me to concentrate fully on the task at hand. An ill-fitting or overly formal one often does the opposite.
There have been moments where I have considered whether adapting how I present myself would make leadership easier, even if it felt less aligned with how I prefer to work.
That raises an uncomfortable question. If what I wear can influence how effectively I work, why are organisations still more concerned with how it influences perception?
Over time, I began to view this through the lens of authentic leadership, particularly the idea that credibility is built through consistency between values, behaviour and openness with others.[1,2] The tension for me was not whether professionalism matters. Of course it does. The tension was whether professionalism and conformity had quietly become interchangeable.
Leadership is not only expressed through strategy or decision-making. It is also experienced through the environments leaders create, and the signals they send within them.[2]
Those signals are often subtle. They sit in the background of organisational life and are rarely discussed openly, yet they shape how people experience inclusion, authority and belonging.
I have found myself navigating these expectations in real time, often making small, almost unconscious decisions about how to present myself depending on the setting and audience.
For neurodiverse individuals in particular, ambiguity can increase cognitive load. Effort spent interpreting unwritten norms is effort not spent on thinking, contributing or leading.
This extends beyond neurodiversity. Individuals from underrepresented backgrounds, including women and colleagues from ethnic minority groups, often experience similar pressures to align with established expectations of what leadership “looks like”.
These expectations are not neutral. They are shaped by history, culture and power. Healthcare leadership developed within historically hierarchical and paternalistic structures, where authority was closely associated with formality, status and professional distance.[3,4] While healthcare has evolved significantly, many of those signals remain deeply embedded within organisational culture.
In discussing this topic with senior colleagues, there was broad recognition that perception does play a role in leadership. As people become more senior, they inevitably become more conscious of how they are perceived and how this affects influence.
Andy Callow, Executive CDIO at Nottingham University Hospitals NHS Trust, reflected on this tension through his own experience. Earlier in his career, he challenged rigid dress codes that did not align with the realities of the work and successfully introduced more flexible expectations without any impact on delivery or performance.
As he became more senior, he recognised that perception becomes part of the leadership landscape. However, his underlying view remained unchanged – that credibility is ultimately built through delivery rather than appearance.
He summarised it far more bluntly than I ever could:
“If the organisation can’t cope with a few pairs of jeans, how will it cope with wholescale service transformation?”
That line stayed with me because it gets to the heart of the issue.
Transformation is often discussed in terms of technology, strategy and operating models. But cultural transformation is usually much quieter. It sits in the signals organisations reward, tolerate or discourage. It appears in who feels comfortable speaking up, who feels pressure to conform, and who quietly concludes they need to change parts of themselves to be taken seriously.
Professionalism matters. But professionalism and conformity are not the same thing.
Healthcare rightly talks far more now about inclusion, psychological safety and authentic leadership. Yet those concepts are difficult to sustain if credibility remains tied to inherited and often unspoken expectations about appearance.
Leaders signal constantly. Through behaviour, language, visibility and environment. The signals may seem small, but their impact often is not.
Because leadership is not only what we say or do.
It is also what we quietly reward.
References:
- Avolio BJ, Gardner WL. Authentic leadership development: Getting to the root of positive forms of leadership. The Leadership Quarterly. 2005;16(3):315-338.
- Walumbwa FO, Avolio BJ, Gardner WL, Wernsing TS, Peterson SJ. Authentic leadership: Development and validation of a theory-based measure. Journal of Management. 2008;34(1):89-126.
- West M. Compassionate leadership in the NHS. The King’s Fund; 2020.
- Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. Harper & Row; 1970.
Author
Tom Boyle
Tom is Head of Telecommucations at Sheffield Teaching Hospitals NHS Foundation Trust and works across digital communications, contact centre transformation and healthcare technology leadership. He also undertakes advisory and consultancy work across the wider healthcare sector, including collaboration with US healthcare organisations and vendors. Tom has academic interests in authentic and transparent leadership, particularly in relation to organisational culture, communication and inclusion within healthcare.
Declarations of Interest
No interests to declare