International Retention Toolkit

Actions employers can take to ensure internationally recruited staff will want to stay, thrive and build lasting careers in the NHS.

15 May 2024

This toolkit aims to support a reduction in turnover of international staff in the NHS by enabling them to stay, thrive and build lasting careers.


It is for line managers and employers and should be used alongside the International Recruitment Toolkit and the Improving Staff Retention Guide to support your overall approach to recruiting and retaining international and domestic staff. The good practice principles and examples throughout can be applied to all professions.


As employers focus on growing and sustaining ethical recruitment pipelines for internationally recruited staff, it is equally important that we retain as much of this workforce as possible. In the six months to September 2023, almost half of new nursing registrants in England were trained overseas and of the doctors who joined the UK workforce in 2021, 50 per cent were international medical graduates. However, a UK systematic review suggests international nurses face challenges in integrating into their roles when recruited to work in the UK. These challenges are not exclusive to international nurses and may be experienced by other international staff groups in the workforce. 

Based on a framework of four pillars, this toolkit brings information, good practice examples and resources together in one place and focuses on what organisations, systems and regions are already doing to create the conditions for all international staff to thrive in the NHS. These four pillars align with the four key actions for internationally recruited staff set out in NHS England’s Equality, Diversity and Inclusion (EDI) Improvement Plan. The end of each section provides an opportunity to reflect on what you have read and consider how you or your team will play your part.

The four pillars

This resource has been produced by NHS Employers, in collaboration with NHS England, employers, staff and stakeholders from across the sector.

NHS Long Term Workforce Plan

The NHS Long Term Workforce Plan (NHS LTWP) is the first comprehensive workforce plan for the NHS, putting staffing on a sustainable footing and improving patient care. It focuses on retaining existing talent and making the best use of new technology alongside the biggest recruitment drive in health service history.

It builds on the NHS People Plan and the NHS People Promise which commits to creating compassionate and inclusive cultures in organisations and systems. 

The EDI Improvement Plan supports the NHS LTWP by improving the culture of our workplaces and the experiences of our workforce, to boost staff retention and attract diverse new talent to the NHS. Leaders and managers should continue to encourage cultures that champion the experience and voice of all staff and ensure a focus on listening, learning and compassion. 

The People Promise logo with the seven icons of the Promise.

The role of leaders in retention

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Getting started

There is no single action that will improve retention. Retaining staff is a result of the combined actions that are taken by an organisation or system at each stage outlined in this toolkit, aligned to the People Promise and the NHS LTWP. As an integral part of your international recruitment process teams, organisations and systems should work collaboratively to support retention activities and share good practice.

For systems working towards a collaborative approach to international recruitment, this toolkit provides resources to initiate and support preliminary discussions. For further information on working across systems, go to the International Recruitment Toolkit for advice on where and how to start, and see a useful checklist on how to become a lead recruiter from overseas in your region or system.

It may be useful to consider how you can use your workforce data to learn more about the experience(s) of international staff currently working within your organisation. 

Our self-assessment checklist below will enable you to check your progress against the key factors that are known to support the retention of international staff.

Understanding your data

The NHS LTWP highlights the opportunity for organisations to make better use of national tools to more regularly use employee engagement metrics to inform improvement plans. 

NHS Staff Survey data has been aligned to the seven People Promise elements and two themes: staff engagement and morale. This provides a comprehensive overview of employee experience and is consistent across the NHS in England. The results dashboard can be broken down to provide results for international staff. You may wish to use this data to spot trends and follow up on what your staff are telling you. 

How to find the data breakdown:

  • Access the NHS Staff Survey website.
  • Click interactive results.
  • Using the local or national dashboard option, click on the ‘Breakdown – scores’ or ‘Breakdown – questions’ tab.
  • On the ‘Select breakdown’ dropdown menu, click ‘Recruited from outside UK (International recruitment)’.

The NHS Staff Survey interactive dashboard allows users to filter data by two demographics simultaneously at a national, regional and ICS level. For example, nurses and doctors recruited from outside of the UK. 

The People Pulse allows access to more frequent data to identify experiences of colleagues who were recruited from outside of the UK. Additionally, if organisations use the People Pulse as their data collection method for the National Quarterly Pulse Survey, they will also benefit from the breakdown of employee engagement scores by internationally recruited staff, on quarterly basis.

The Workforce Race Equality Standard (WRES) report 2022 highlights the experience of black and minority ethnic (BME) people working in the NHS (which may include a high proportion of internationally recruited staff) and will enable you to compare your organisation’s performance with others in the region and can support collaboration and improvements locally or regionally.

Make use of tools such as the Electronic Staff Record (ESR) to collect data on career progression rates for your international staff and compare with domestic staff. Are there any disparities? ESR has also refreshed the exit interview questionnaire, which allows staff who are leaving to self-report their reasons and state what, if anything, would have kept them in the organisation. 

Local workforce data may hold information on the experience of international staff in your organisation and can potentially help you to identify and tackle any issues they may face.

  • Locally designed surveys or conversations with existing international staff can highlight any issues or challenges and ensure they are addressed early.
  • If international staff do decide to leave, seek honest feedback either as part of your normal leaving process, or have specific discussions on their experience to improve the experience of existing and future international staff.

Insights from employee listening methods, whether they are led nationally or locally, should be maximised to gain an insight into employee experience in a holistic way. See the Listening Well Guide, which provides organisations with a blueprint for developing a comprehensive employee listening strategy.

​​​​​Other tools

See Understanding your data in the Improving Staff Retention Guide for further guidance. 

NHS England has developed an interactive and practical Civility and Respect Toolkit with a framework for organisations to help tackle bullying and harassment and to create a civil and respectful workplace culture.

Organisations are encouraged to use the Violence Prevention and Reduction Standard, to look at how they address violence against our workforce.

NHS England’s NHS Health and Wellbeing Framework includes a diagnostic tool to self-assess your organisation and provides a high-level culture change toolkit aimed at health and wellbeing staff, human resources (HR) and organisational development (OD) staff, and anyone with an interest in health and wellbeing.

In addition NHS England’s team health and wellbeing guide, a range of simple activities designed to enable teams to look after their own health and wellbeing more effectively.

NHS Employers’ eight elements of positive staff experience, created in collaboration with health and wellbeing, staff experience, HR and equality, diversity and inclusion (EDI) leads, outlines the critical steps and considerations for achieving a robust and sustainable staff experience programme/initiative to support people to stay well in work.

Survey of existing international nurses


Our self-assessment checklist below will enable you to measure how well your organisation is currently supporting international staff and where you might need further information or to take action. The questions are based on research by the University of Huddersfield on the factors that are known to support the retention of international nurses but can apply to all professions in your internationally recruited workforce.

It is important to be as open as possible when completing the survey, as this will provide you with an idea of where your organisation may need to focus. Where you identify areas for further development, please visit the relevant section in this toolkit for more information, helpful tips, practical good practice examples, and signposts to useful resources.


  • Red - We have not addressed this area in our organisation or system.
  • Amber - We need to do further work in this area in our organisation or system.
  • Green - We have addressed this area effectively in our organisation or system.

Self-assessment questions

  1. We have a robust approach to understanding our international data in our organisation, which gives us useful insight into the experience of international staff, including reasons for leaving. (Go to Understanding your data)
  2. We proactively engage with new international staff in the months before they arrive in the UK to understand their motivations for migration and provide pre-arrival information and support. (Go to Creating strong foundations)
  3. We acknowledge and recognise the depth of experience that international colleagues bring to our organisation and consider this when considering their starting salary.  The NHS terms and conditions of service handbook, Annex 23 Point 11 relates to starting salary.  However, Annex 23 Point 17 and Section 12.2 states that ‘employers have the discretion to take into account any period or periods of employment outside the NHS, where these are judged to be relevant to NHS employment’. (Go to Creating strong foundations)
  4. We have a comprehensive approach to welcoming new international staff so that they feel settled in their new role and local community. (Go to Making new recruits feel welcome)
  5. We understand cultural differences and celebrate the cultures of our international staff, so they feel a sense of true belonging within our organisation. (Go to Building belonging)
  6. We acknowledge the depth of experience that international staff bring to our organisation and actively support their personal and professional growth (Go to Maximising personal and professional growth)

While this self-assessment focuses on retaining internationally recruited staff in the NHS, other tools are available to complement retention strategies across your whole workforce:

  • NHS Employers Improving staff retention web resource contains an interactive traffic-light tool to help you understand where you might want to focus your efforts first.
  • NHS England’s nursing and midwifery self-assessment tool supports you in retaining your nursing and midwifery staff and encourages trusts to develop and implement local evidence-based retention improvement plans.
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Pillar one: Creating strong foundations

The first pillar focuses on creating strong foundations in the months before your new recruits arrive in the UK. First impressions are important for anyone starting a new job, but consider how internationally recruited colleagues might feel as they prepare to leave behind friends and family, familiar surroundings, language, and cultures to start a new life in a different country.

Review your recruitment timeline to consider where and when your organisation can offer support. The International Recruitment Toolkit contains a useful recruitment timeline for overseas nurse and midwife recruitment and overseas doctors.

As well as the support you offer locally, diaspora groups can also provide the pastoral and professional support your international nurses and midwives will need. A list of diaspora groups can be found in the International Recruitment Toolkit  and can be shared with your new recruits so they can find out about the support available to them before they arrive.

How to create strong foundations

A diverse group of healthcare staff looking at a computer.

For international staff

Maintaining contact

You should engage with new recruits early and often. This could include a one-to-one pre-arrival welcome call to get to know them personally, identify what support they may need, and to introduce them to key colleagues they will be working with. Getting to know their reasons for coming to work in the UK at this stage will help to support their personal and professional development, build trust and their attachment to their job, team, organisation, and the life they are seeking in the UK. 

Welcome packs

It is good practice to provide your new recruits with a welcome pack. These can be shared prior to arrival and could include information about the UK, the organisation, local area and dialect, how to register with a GP and emergency contacts (including information for if things go wrong). You can also include details of staff networks, diaspora groups and how your new recruits can access support if they observe or experience bullying or harassment or need support with their own health and wellbeing. 

Go to the International Recruitment Toolkit to use our welcome pack checklist.

Map skillsets and qualification

Research shows 78 per cent of international nurses had been qualified for over five years, and nearly half (48 per cent) had been qualified for more than ten years prior to migrating. On joining the NHS, many are placed on the first pay band for registered nurses and assigned to work in areas overlooking prior skills and experience. A University of Huddersfield study of international nurses’ experience shares how acknowledging previous expertise would improve their experiences of working and living in England. 

It is important to consider the number of years an internationally recruited colleague has been qualified as part of your recruitment process and where possible, to take this into account with their starting salary as per the guidance in the NHS terms and conditions of service handbook. Meet with them to understand the skills and experience they have gained from working in international healthcare settings. Placing them in their preferred clinical area acknowledges their experience and will support their growth and help them feel valued. If this isn’t possible, open and honest discussions about next steps and the possibility of internal transfers should be initiated.

Furthermore, encouraging mutual learning by understanding prior experience and approaches to healthcare used around the world enhances integration and collaboration within teams. 

Cost of living

The University of Huddersfield study of international nurses’ experience of working and living in England describes feelings of surprise or shock at the cost of living related to tax, rising inflation and the cost of fuel and food. Consider providing short-term solutions such as discounts and vouchers or subsidised food. Providing long-term solutions through your employment package can provide stability, reassurance, shows your commitment and will contribute to retaining valuable talent.


It can be complex and challenging for new recruits to independently find suitable and affordable housing. Consider your local accommodation offer and/or work as a system to find suitable accommodation for people before they arrive.  Some organisations with limited accommodation have found it beneficial to make links with local university accommodation providers. 

Internally, engage with staff to find out if any can offer a spare room in their home. Those who can help may be eligible for the government’s rent-a-room scheme, which lets people earn up to £7,500 per year tax free from letting out furnished accommodation in their home.

Motivations for migration

For leaders, managers and the wider workforce

Manager guide

A managers’ guide can help to prepare managers and team members for working with overseas staff and can include information that will help your new recruits transition smoothly into their new roles. Take a look at the Managers Guide for Overseas Nurses produced by the Capital Nurse international recruitment consortium. You might find it a helpful resource to support the objective structured clinical exam (OSCE) preparation and pastoral support of your international nurses.

Engage existing staff

Encourage your existing international staff to share their lived experience of relocating to the UK with new recruits. They will also have a unique understanding of the support new recruits may need to adapt to the cultural and working differences of the NHS and can provide you with key insights as you develop your support offer.

Acknowledging previous experience

Good practice examples

  • Manchester University NHS Foundation Trust (MFT) starts the onboarding process for new international medical graduates (IMGs) before they arrive in the UK. A dedicated HR team meets with them virtually to discuss their expectations about working in the UK, travel options and to troubleshoot any queries they have. A peer buddy is also assigned to welcome and support the new IMG at this early stage.

    On arrival, MFT ensures new IMGs are integrated well into the organisation and the local community. To help settle them into their new department, education supervisors and mentors who have been specifically trained by the trust to support and supervise IMGs are assigned and their peer buddy continues to support them as they settle into life in the UK. 

    Once the IMGs have settled in their department, enhanced career support guidance and dedicated training days are provided. The induction extends beyond the initial two-day induction and weekly half day sessions are run for three months to further enhance the onboarding experience. MFT has also developed a network of IMG and locally employed doctors (LED) representatives which are a bridge between senior clinical leaders, educators, managers and the wider trainee workforce to improve communication, engagement and morale. They provide live feedback and can voice any concerns directly to the medical staffing, Guardian of Safe Working and British Medical Association (BMA) representatives at the junior doctor’s forum and the local negotiating committee (LNC). 

    To support all of this activity, MFT has a dedicated postgraduate team hub to support LEDs and IMGs in the organisation and has developed a bespoke online SharePoint platform, an online hub which provides guidance, policies, information and resources in one easily accessible place for IMGs and LEDs.

  • West Yorkshire Allied Health Professional (AHP) Faculty has developed a manager’s guide which sets out the recruitment process (including Health and Care Professions Council (HCPC) registration) and information that managers can share with new international AHP recruits to support them when they arrive in the UK. A welcome booklet has also been developed with international recruits who have previously migrated to the UK to provide information a new recruit may need to prepare them for the first few weeks of living in the UK. This includes information on accommodation, opening a bank account and accessing nearby facilities. To support their transition, a booklet designed by dietetic students at the University of Teesside on British cuisine is also shared to raise awareness of the British diet and cultural food stores in West Yorkshire. A pastoral lead for international AHPs works across the system to ensure international AHPs and managers are supported. See this housing webinar for international AHPs in West Yorkshire for an example of the support offered by the faculty. 

  • Leeds Community Healthcare NHS Trust provides 12-weeks free accommodation to internationally educated nurses. By building a relationship with Leeds University, student accommodation is used to house them during this 12-week period. This accommodation is within reach of local transport, making it easy for internationally educated nurses to attend the OSCE training centre, supermarkets, town centre and places of worship. To manage expectations, the moving out date is shared with the nurses before their arrival. To support them to find longer term accommodation, the trust proactively shares rental guides, local agent’s information, and rental prices in different areas of the city but acknowledges that housing has become a real challenge. The trust’s international recruitment team supports them to find accommodation online and books viewings. Internationally educated nurses are allotted time for viewings and guided on how to get a house quickly. The team also accompanies them to house viewings, shares information on bills, taxes and provides employer references. It also helps to share the address details of where the nurses will be based so they can begin looking for accommodation near that base as soon as possible. 

  • The University Hospital Birmingham NHS Foundation Trust (UHB) was awarded the Best International Recruitment Experience award at the Nursing Times Workforce Summit and Awards 2022. The trust considers each candidate’s CV and full months of registered nursing experience to determine their starting salary. The interview and selection panels are pooled to reduce unconscious bias, and candidates are appointed to a practice setting based on their skills, knowledge, and post-registration experience. Candidates can request certain sites as the trust recognises that many have friends and family in the West Midlands. After completing the OSCE or adaptation programme all applicants are enrolled in UHB’s preceptorship programme and can apply for the accelerated development programme for internationally educated staff. The School of Nursing, AHPs, and midwifery teams deliver bespoke specialty-based training in the practice setting, along with access to external education via apprenticeships and higher education. The preparation programme is six weeks from UK arrival, and candidates do not start in their practice setting until their seventh week in the UK. This allows for a supportive induction to both the NHS and a pastoral and cultural integrated support programme. Five out of eight of the OSCE preparation team are internationally educated nurses, and the administration team and pastoral officers are all colleagues who were originally from outside the UK, making the team very representative. The trust works closely with the other four NHS providers in the ICS to pool resources, share good practice and quality assure processes. By December 2023, the team delivered the programme to 651 new employees.

  • Through effective ICS working, Surrey Heartlands identified that affordable accommodation was one of the key barriers to access for international nurses and launched a pilot project in July 2022 using an online platform designed to improve access of international nurses to affordable accommodation. Staff at Surrey Heartlands can advertise spare rooms available for rent in their property, with room prices capped below the area average to ensure affordability. As of February 2023, the pilot has provided affordable accommodation for 112 nights and continues to grow. The next phase of the project is to launch a free mobile app designed to increase the access of international nurses in Surrey Heartlands to pastoral, bespoke coaching, mentoring, mental and psychological support, signposting to affordable accommodations and services and information to support integration and improve personal sense of belonging in the workplace.

Tools and further reading

  • This NHS Employers Working and Training in the NHS Guide can be shared with IMGs as part of your recruitment and induction material.
  • See NHS England’s tools to support managers with onboarding international AHPs and NHS Employers’ page of useful resources to support international AHPs. 
  • The Chartered Society of Physiotherapy provides professional support and information for internationally trained physiotherapists about working in the UK. 
  • The Royal College of Occupational Therapy has an international recruitment hub to enable good practices and processes for international recruitment of occupational therapists. 
  • The British Dietetic Association has information for employers and overseas applicants who have undertaken recognised training in nutrition and dietetics outside the UK.
  • This NHS Employers page provides a collection of national resources and guidance to support your international nurses and midwives.
  • The overseas nurses and midwife recruitment section of the International Recruitment Toolkit has further information on UK professional registration requirements.
  • UK ENIC (European Network of Information Centres) is the designated national agency for the recognition and comparison of international qualifications and skills. NHS trusts in England can register two staff per trust who will be able to check staff member’s international certificate/s through ENIC. To register up to two members of staff to use the service please email
  • NHS Employers cost of living hub draws together resources and good practice to support employees with the rising cost of living. NHS England also provides resources and signposting to support colleagues with financial wellbeing.
  • For information on the registration process and associated timescales of the relevant professional regulator see the International Recruitment Toolkit.
  • For further information on repayment clauses should your international recruits decide to leave employment early, please see the International Recruitment Toolkit

How will you play your part?

Reflect on what you have read and consider how you or your team will play your part.

I/we will…



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Pillar two: Making new recruits feel welcome

The second pillar is about ensuring new recruits feel welcome when they arrive by helping them settle into their new communities and pointing them towards local services.

Consider what they will need during their first few months in the UK to establish themselves to live, work and beyond, such as bank accounts, national insurance numbers, registering with a GP, somewhere to live, UK sim cards, access to shopping, schools, navigating public transport and other amenities. Helping them with these arrangements will make a big difference to how well they ease into life in the UK. Introducing some coordinated social activities can also prove very helpful in encouraging integration into teams.

This supportive approach during the recruitment and onboarding stages means you are more likely to retain staff.

How to make new recruits feel welcome

Nurse smiling

For international staff

Pastoral support

It is important to provide pastoral care for your overseas staff as soon as they arrive to support them as they adjust to a new culture. You should continue this offer as they move beyond their initial induction period.  

As part of your pastoral care, check in with colleagues and offer them a wellbeing conversation to explore how they are feeling. Your existing international staff are often best placed to provide this support as they know first-hand how hard it can be to adjust to living in a new country. You should also build relationships with local community groups and share details with new recruits to enable them to build social support networks outside of work. Continue to signpost your new recruits to diaspora groups to supplement your current support offer. A full list of diaspora groups can be found in the International Recruitment Toolkit. Your staff networks can also provide a safe space for your international staff to share ideas, raise awareness of challenges and provide support.

A detailed checklist to assess your pastoral offer can be found in the International Recruitment Toolkit as well as further tips, good practice examples and a checklist for more pastoral support ideas. 


A buddy can help build relationships between your new international staff and existing staff and help them to feel more settled. Existing staff with lived experience of relocating to the UK could become a buddy for a new overseas recruit. Your local trade union representatives may also be able to help set up peer networks in the workplace.


Your organisation may already have a well-established corporate induction programme, but it is worth considering what additional support or information might be beneficial for your new international staff. For example, introducing a programme of social adaptation will help your overseas staff to learn about the NHS and the cultural and working differences. A programme like this will also enhance English language levels, particularly in areas such as typical local dialect and phrases. You could also consider designing a bespoke induction programme based on country of origin, such as a comparison of commonly used medications in home countries. Other support offers can include role preparation, for example supernumerary time or OSCE preparation. It is also important to familiarise new international recruits with HR processes bespoke to working in England and the NHS and to share information on pay, terms and conditions and contracts. 

Consider incorporating the induction support available from professional regulators, professional associations and trade unions such as the Royal College of Nursing (RCN), British Medical Association (BMA), the Chartered Society of Physiotherapy, the Royal College of Occupational Therapy, the British Dietetic Association, UNISON, and Unite, and via the Occupational English Test (OET). The General Medical Council (GMC) runs a free workshop for overseas-trained doctors designed to help them settle into medical careers in the UK (see tools and further reading below for more information).

For leaders, managers and the wider workforce

Welcome event

Many organisations hold welcome events or celebrations throughout the year to celebrate the arrival of new international colleagues or to congratulate individuals or groups who have passed their OSCE for example. You may wish to consider working in collaboration as a system to organise events, which would allow for sharing of resources but also would introduce internationally recruited staff across organisations. Including existing international staff, ward or department teams, local faith leaders and senior leaders can help them to feel included, welcomed and supported in your organisation. Your communications team can also get involved in sharing the good news of international staff through internal news stories or newsletters, although it is important to be aware of the Code of Practice red and amber list of countries. 

Health and wellbeing offer

As part of your induction, signpost new recruits to the health and wellbeing offer provided by your trust and/or system and encourage completion of an associated occupational health assessment or risk assessment where required. You should signpost and encourage new recruits to seek support when needed and offer advice on how to do so. You can also encourage them to make links with professional and personal networks and diaspora groups to support their wellbeing and create friendships and peer networks.

Many NHS organisations have introduced networks of health and wellbeing champions to support the health and wellbeing of colleagues across the organisation. NHS Employers’ health and wellbeing champions webpage has guidance for health and wellbeing leads on what they need to do to introduce wellbeing champions as part of the NHS People Plan.

Link with your local HR and OD teams to find out how champions have been introduced, and how you can signpost recruits to access the champions network, an online community of practice, accessible through the NHS Futures site. If you’re managing a team, NHS England’s Looking after your team health and wellbeing guide can help you identify how to best support your team and identify areas of need. 

Flexible working

Line managers are encouraged to discuss flexible working with direct reports during your regular health and wellbeing conversations, appraisals, or via one-to-one discussions. The NHS Staff Council has worked collaboratively with NHS England and Timewise to develop two new guides to support NHS line managers and staff to work more flexibly.

Robust induction and manager support

Good practice examples

  • The University Hospitals of Derby and Burton has developed a robust induction plan for internationally educated nurses with two bespoke inductions, one as they arrive in the country and another after they have undertaken their OSCE test. Additional sessions have been included in both inductions based on what nurses have previously found challenging as they integrate into the clinical areas. Additional sessions are:

    • introduction to the UK culture
    • fundamentals of care (in recognition of the potential differences in how nursing is practiced in international nurses' home countries and to ensure that they feel equipped in delivering patient care)
    • accountability and delegation.

    A new learning approach called nesting has also been introduced. Nesting is a facilitated learning experience and a way of introducing the internationally educated nurses to the clinical area during their supernumerary period by briefly placing them in a nesting ward. It focuses on two main activities: observations and reflections, under the overall guidance of a facilitator. Nesting promotes learning, collaboration, and effective partnerships to different clinical areas in supporting and nurturing new staff. A simulation has also been included in the trust’s second induction programme to provide opportunities for internationally educated nurses to establish their confidence in escalation and handover before they are allocated shifts as a registered practitioner.

  • Frimley Health NHS Foundation Trust’s (FHFT) bespoke peer to peer buddy scheme, Frim Buds pairs newly arrived international nurses with more experienced international nurses for guidance, advice and socialisation. A software called Padlet is used to publish details of Frim Bud's volunteers with the aim of easy accessibility, enhancing transition while in bootcamp training, providing non-clinical support, fostering social inclusion and building wider community. Newly arrived colleagues have fed back that they were able to adjust smoothly, expand their social circle in a new environment, enabling opportunities to connect to other colleagues and access valuable information and support. Senior or experienced internationally educated nurses were also able to develop their leadership and interpersonal skills with opportunities to share knowledge and experience. This programme reflects FHFT's nursing and midwifery strategy values: support, develop and achieve.

  • West Hertfordshire Teaching Hospital NHS Trust has partnered with a local charity providing services to the community. Through its community volunteer buddy scheme, the charity and the trust work together to provide one-to-one support to their international nurses. A nurse buddy helps international nurses to get to know the local area, find local services, day trips, and offer support and guidance. Before joining the trust, international nurses are asked whether they would like a buddy (via a brief questionnaire) and then the trust works with the charity to pair them up with one. The nurse buddy will contact the new recruit once a week in a way that best suits both parties. The trust received NHS England’s Pastoral Care Quality Award in 2022 for the quality of care and support provided for international nurses and midwives joining the trust.

  • Norfolk and Norwich University NHS Trust has an international recruitment buddy network. All buddies are volunteer international nurses who have obtained their NMC registration. New international nurses joining the trust receive information on the buddy network in their welcome packs. The network is supported by the professional nurse advocate team and Freedom to Speak Up Guardians. Volunteer buddies are notified of international nurse arrival dates and new nurses’ details are exchanged. The buddies will email the new nurses to welcome them to the trust and may also meet them at the airport when they arrive, at their accommodation or at their induction. The trust was awarded NHS England’s Pastoral Care Quality Award in 2022 in recognition of the quality of pastoral care it provides to internationally recruited nurses and midwives.

  • In 2022 Newcastle upon Tyne Hospitals NHS Foundation Trust established an international medical graduate (IMG) office to coordinate the work of inducting and supporting IMGs. It revised the induction process so that every IMG, regardless of which directorate they join has the same experience. The induction covers a variety of key touch points starting from when an IMG is offered a role and sets out to give them as much information as possible from the outset.

    • First day kit: the trust developed its first day kit for IMGs to provide information specific to the trust and local area. A link to the kit is sent to new IMGs before they start so they can familiarise themselves before they arrive.
    • Virtual meeting: this is an opportunity for the IMG office to get to know the IMG on a personal level and what support they will need on arrival.
    • IMG buddy scheme: directorates are asked to identify a buddy for new IMGs, preferably someone who is an IMG who can help with some of the practicalities of settling into the UK. 
    • Induction day: new IMGs attend a face-to-face induction day which includes a welcome to UK practice programme from a GMC representative.  
    • Education supervisor: each IMG is allocated an education supervisor that meets with them within their first two weeks to start career discussions.
    • WhatsApp: a WhatsApp group offers an informal space for IMGs to get to know each other and build their network.

Tools and further reading

English Language Testing and OET webinar

How will you play your part?

Reflect on what you have read and consider how you or your team will play your part.

I/we will…



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Pillar three: Building belonging

Pillar three focuses on building belonging. This relies on cultural sensitivity and an awareness of how it feels to be working and living in a different country.

Research shows that having English as a second language can impact on an international nurse’s sense of personal and professional belonging. Accents, abbreviations, local turns of phrase and conversational speeds can result in international staff feeling left out of workplace small talk or deskilled despite years of professional experience. Enabling your international staff to build social networks, to share stories and solutions to these challenges can help to reduce feelings of isolation and support them to bring their passions, culture, and personality to their role. You should also consider the role of leaders, managers and the wider workforce and what support or training they will need to raise awareness and support their international colleagues with these challenges.

How to build belonging

Thanking doctor

For international staff

Safe spaces

Establish active shared decision-making councils, international recruit forums or staff networks to listen to the voices and experiences of international staff. These safe spaces can become a driving force for change and improvement as international staff feedback on their experiences and develop solutions to any barriers or challenges they may be facing. 

Personal integration

A study of international nurses’ experience of the first two years working and living in England found that personal integration and life outside of work is just as important as professional integration. 

Overseas staff arriving in the UK with their families will need further support and signposting to increase integration into the wider community. Identifying and building relationships with local faith leaders, schools, colleges, and services to provide support will be key to making the transition to a new culture easier for the whole family. Equally consider those who have been separated from their families due to financial constraint or visa processing issues. Adjusting in a different culture without family is known to be one of the most difficult factors of migration. 

Professional integration

Professional support from line managers, clinical educators and mentors is also key to successful integration and can help ease uncertainty and anxiety. Ensuring international nurses have access to restorative clinical supervision by professional nurse advocates will support them to feel less stressed and isolated, increasing their confidence to develop personally and professionally.

Additional support

Consider signposting staff to support available from the relevant professional regulators, professional associations and trade unions, such as the Royal College of Nursing (RCN), the British Medical Association (BMA), the Chartered Society of Physiotherapy, the Royal College of Occupational Therapy, the British Dietetic Association, UNISON, and Unite the union.

Cultural challenges

For leaders, managers and the wider workforce

Cultural awareness training

Cultural awareness is an important skill for existing staff and managers of internationally educated staff. It increases awareness of different cultural norms, enabling teams to communicate more effectively, avoid misunderstandings, and build stronger relationships with colleagues from different cultures to their own. Where possible you should undertake learning about the cultures of international colleagues. This could be through a social event or more formal training. 

Cultural awareness is also important in both the recruitment and disciplinary process to prevent unconscious bias impacting decisions and outcomes. NHS England has developed online training with Culture in Health for the line managers of internationally recruited staff. The training will help line managers to build and improve the skills they need to better recognise, understand, and meet the needs of their international colleagues. To find out more about the training and other resources which are available, visit the Culture in Health website


Acknowledging cultural holidays and events celebrated by international staff, or celebrating their achievements, can help to build a sense of belonging and connection to your organisation and enables them to share their culture and traditions with colleagues.

Health and wellbeing conversations

Line managers should have regular supportive health and wellbeing coversations or check-ins with all of their team, including international staff as they settle into living and working in the UK. Health and wellbeing conversations are regular, supportive, coaching-style one to one conversations that focus on the health and wellbeing of staff. By encouraging organisations to embed health and wellbeing conversations across their system, staff feel heard and valued, and in which diversity is respected. 

Health and wellbeing conversations should consider the whole wellbeing of an individual and identify areas where the individual may need support, signpost them to that support, and regularly monitor their health and wellbeing over time.

NHS Employers’ health and wellbeing conversations webpage has some ideas for things you might consider to ensure that quality health and wellbeing conversations and plans that best meet the needs of our diverse workforce are embedded within your organisation.

See the health and wellbeing section of the Improving Staff Retention Guide for more information on supporting workforce wellbeing.  

Good practice examples

  • Scouse School is an initiative of Liverpool University NHS Foundation Trust to support internationally recruited nurses, AHPs and doctors gain better understanding and appreciation of Liverpool’s rich history, culture, people, colloquialism, and local and regional accents. Initially planned as a warm welcome and a means of helping recruits widen their networks within the organisation, the programme has developed into an activity that:

    • makes recruits feel more comfortable and accepted, facilitating their integration into their local communities
    • makes recruits feel more supported and valued during their transition to their new city thereby promoting retention
    • showcases the diversity of their new city which could lead to a more inclusive culture which is important for attracting and retaining talents.

    Co-produced by managers, educators and international recruits, participants receive certificates and are treated to a lunch of scouse and other UK food favourites. 

    There have been four cohorts since the introduction of the programme, and it will continue to run every other month. Participants have rated it highly, feeding back that it has helped them to understand terminologies and colloquialisms, improve familiarity with accents and meet new colleagues.

  • James Paget University Hospitals NHS Foundation Trust ensures that international staff joining the trust feel a part of it by placing a strong emphasis on listening to their feedback through a variety of engagement activities. Staff engagement sessions enable staff to feedback on their experience in an open and safe space. At a senior level, trust executives take part in an in your shoes programme which enables them to experience a day in the life of a member of staff. The trust is also trialling a reverse in your shoes programme where staff can also shadow executives. Ward-to-board sessions and non-executive director sessions held on the wards enable senior leaders to meet staff and hear what they have to say.

  • The Leeds Teaching Hospitals NHS Trust has introduced cultural awareness training for leaders and managers of internationally recruited nurses. The training is designed to raise awareness of the importance and impact of culture in creating a sense of belonging as well as how this awareness can bring about positive outcomes. This training is delivered in conjunction with race equity masterclasses offered to nursing leaders and managers across the trust.

  • #StayAndThrive is a research-in-action programme that began as a pilot in the North East and Yorkshire and South West regions, and launched nationally in November 2022 and has membership across all seven regions. 

    Through a series of learning events, a community of action was formed with a collective mission to create the conditions where internationally educated colleagues feel a strong sense of belonging and can thrive in their personal and professional lives while progressing in their careers. An analysis in March, April, June and November 2023 supported by the NHS regions in the programme, revealed a shift towards more positive experiences and fewer negative experiences of international retention and recruitment throughout the year as participants gained more experience of implementing the positive deviance approach though the programme. This approach identifies that solutions to problems already exist within communities, and that identifying, understanding, and sharing these solutions enables improvements at scale. The programme won the award for Best Employer for Staff Recognition and Engagement at the Nursing Times Awards 2023. The #StayandThrive bundle of interventions have also formed the four pillars of this toolkit.

    Making a difference video

  • The Mid Yorkshire Teaching NHS Trust (MYTT) has launched Stay and Thrive to improve the experience of internationally colleagues. The trust commenced its international recruitment campaign in August 2020 with 366 internationally educated nurses joining the organisation. The trust also supports the recruitment of internationally educated midwives, AHPs and medical staff. MYTT’s internationally educated nurses recruitment journey mirrors the four pillars set out in this toolkit. 

    • Creating strong foundations: MYTT has invested in dedicated resource to improve pastoral and educational support for internationally educated nurses. OSCE bootcamps have reduced the time from arrival to taking the OSCE exams by 50 per cent. 
    • Making new recruits feel welcome: anonymous surveys gather baseline data about internationally educated nurses recruitment experience and overall experience at MYTT. They are then invited to listening events which provide a psychologically safe space to share their accounts and experiences.
    • Building belonging: a buddy system complements the pastoral support. Buddies introduce new internationally educated nurses to staff networks and a voluntary social media forum. 
    • Maximising personal and professional support: building on the feedback from internationally educated nurses it was clear that support was needed on pathways to progression, application, and interview process. Regular forums are conducted with clinical supervision and coaching offers. MYTT has also commissioned an internationally educated nurse leadership programme and to-date 130 internationally educated nurses have completed it.

Tools and further reading

  • NHS England’s report The expectations of line managers in relation to people management includes a new framework for line managers which creates a clear view on the expectations of line managers in the service in relation to people management and the implications for provision of people services.
  • NHS Employers’ health and wellbeing hub provides advice and guidance on stress, sickness absence and financial wellbeing for NHS provider organisations. The health and wellbeing network is free to join and enables health and wellbeing leads to connect, share good practice and find out what’s happening across NHS wellbeing.
  • NHS England has a number of health and wellbeing programmes for NHS staff signposting to support for a range of health and wellbeing needs.
  • NHS England’s NHS Health and Wellbeing Framework can support you in creating a wellbeing culture in your organisation and also has information on supporting our NHS people.
  • NHS England’s guidance on health and wellbeing conversations provides good practice advice and guidance on having safe and effective health and wellbeing conversations. 
  • Keep up to date with interventions and practical solutions on NHS England’s retention hub.
  • NHS England’s resource on combatting racial discrimination against minority ethnic nurses, midwives and nursing associates is designed to help them recognise and challenge racial discrimination and by doing so, it supports staff wellbeing, physical and psychological safety. It also supports those in leadership roles to be inclusive leaders.

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Pillar four: Maximising personal and professional growth

The fourth pillar is about maximising personal and professional growth to ensure that all internationally recruited staff can fully realise their potential. 

Research shows that a common driver for international nurses to migrate to the UK is career progression and professional development. However, analysis reveals that progression is slower and less frequent for international nurses than for domestic nurses at all bands. The WRES 2022 report also highlights that just 44.4 per cent of BME NHS staff (which may include internationally recruited staff) believe their trust provides equal opportunities for career progression or promotion. 

Consider the skills and prior experience of your international staff. Once they have transitioned to working in the NHS, implement processes and opportunities to facilitate and accelerate their development. 

Your retention strategy should focus on enabling all international staff to achieve their career aspirations. Their ongoing personal and professional development will also lead to job satisfaction and in-turn a feeling of being valued by their employer. International staff should have access to the same personal and professional development opportunities as your UK workforce and should be tailored to each individual’s preferences and career aspirations. As part of this process, they should be offered an annual personal development review, and a personal development plan should be agreed.

Maximising personal and professional growth of internationally-educated colleagues

How to maximise personal and professional growth

Student nurses talking in a corridor.

For international staff

Career conversations

Line managers should hold regular career conversations with international staff to understand future aspirations and how they can be supported through clear career pathways. Holding career clinics with groups of international staff can widen their understanding of available career pathways, where to find roles, how to access education and successfully applying and interviewing for roles in the NHS. Also consider how to use interview feedback to support future applications.

Many international colleagues move to the UK with their spouses and families. There are many career opportunities within the NHS which may be suitable for spouses/partners/ family members of internationally recruited colleagues, and you may wish to make them aware of career clinics.


While managers play an important role in supporting the development of staff, professional coaching can be effective in providing the specialised training and expertise in career development, personal growth, and leadership that managers may not possess. Coaching can be tailored to the specific needs and goals of the individual and does not replace day-to-day managerial support but complements it with longer-term career planning and self-development. See the Leadership Academy for further information and support.

Leadership programmes

Some organisations run leadership programmes to support career progression for international staff and to increase the number of those moving into management positions.

In 2022, NHS England provided funding through its Accelerated Development Transformation Fund to support trusts to scope and develop innovation and transformation projects that focus on ways to recognise prior experience of internationally educated nurses and midwives; provide ethical opportunities to directly recruit into Band 6+ roles; and to accelerate the development of international nurse/midwife talent identified within the workforce. 22 trusts and systems across the country successfully bid for this funding and are delivering these projects. Insights and case studies will be shared via NHS England’s Futures platform.

Financial wellbeing

Health and wellbeing includes financial wellbeing. After five years of living and working in the UK, international colleagues have the right to apply for indefinite leave to remain. This can be a costly process, particularly for colleagues with families. Having the right to stay can support feelings of belonging so it is important to support international colleagues through this process by directing them to where they can receive financial advice or support. Some organisations have developed a loan scheme for eligible staff applying for indefinite leave to remain, helping to ease the financial burden of this process. NHS Employers’ financial wellbeing web page supports you to develop a robust approach to support your staff with financial wellbeing in the workplace. 

Line manager supported career development

For leaders, managers and the wider workforce

Role models

Research shows that following successful career progression, senior international nurses use their positions to influence change and lead and inspire other international and domestic nurses to maximise their potential. Sharing these career success stories on a regular basis will inspire new staff, provide an opportunity to hear about their experience and challenges and showcase the career pathways available.


A mentor can support your international staff to develop and take their next career steps, by providing access to their networks and championing on their behalf.

Watch the video of Jeni’s story below to hear how, in her current role as international recruitment and ethnic minorities nurse adviser at NHS England, she has championed the ethnic minority workforce and been an inspirational figure for international recruitment.

Jeni's story

Good practice examples

  • The Royal Berkshire NHS Foundation Trust’s (RBFT) Aspiring Band 6 Development Programme is a six-month programme delivered using a blended approach of on-line and face to face training. The aim is to recognise talent within the existing workforce and to empower these individuals to perform to their full potential.

    It offers a combination of facilitated self-reflection to gain insight into current leadership attributes and possible areas for growth, one-to-one coaching and action learning sets, leadership and management webinars and the opportunity to shadow senior members of the clinical team. For the duration of the programme, participants are allocated an experienced mentor who will provide support and guidance to enable them to gain strategic awareness and facilitate wider exposure to the leadership roles that internationally educated nurses and midwives aspire to. 

    From the pilot cohort of internationally educated nurses and midwives, between September 2022 to March 2023, 80 per cent of participants who completed the programme secured a Band 6 position within nine months.

  • The Hampshire and Isle of Wight (HIOW) ICS has developed a fellowship programme for internationally educated nurses and midwives. The programme began in March 2023 with six successful candidates from acute and community NHS trusts. It offers 22.5 hours per month to undertake the fellowship and mentorship from a senior nurse, midwife, and/or AHP. The fellows work with stakeholders across the system to focus on the recruitment and retention agenda, sharing their experiences at local and regional forums, and lead a quality improvement project. 

    In addition, HIOW ICS, in partnership with the Florence Nightingale Foundation and SimComm Academy, has developed an accelerated development programme for internationally educated nurses and midwives. The programme aims to enhance the leadership opportunities for internationally educated nurses and midwives within the system, recognising the experience and skills of the registrants to support progression into Band 6 and 7 roles. 

    The Florence Nightingale Foundation conducted a five-day leadership programme that focused on personality preferences and performance in teams, personal presence and impact by the Royal Academy of Dramatic Arts and stepping into authority and influencing change. The programme concluded with an award ceremony where participants shared their reflections and learning.

    SimComm Academy conducted a standalone workshop that was co-designed with the content developed by an internationally educated nursing fellow. The workshop was intended for recruiting managers supporting the recruitment of internationally educated nurses and midwives. The focus of the sessions was to raise awareness of the experiences including cultural barriers and biases within the recruitment process through simulation.

  • Herts and West Essex ICS identified that across the system, some international nurses were not progressing into higher banded roles or were unprepared for NHS recruitment processes despite having the necessary qualifications, skills, and experience. 

    Supported by NHS England funding, the ICS created a Band 6 development coach role to support the career advancement of international nurses. The purpose of this role was to ensure a holistic approach to the development of the international nurses’ experience, to help them to achieve their full potential, wherever that may be.

    The success of this role has led to the appointment of three further development coaches in Bedfordshire, Luton and Milton Keynes ICS, Suffolk and North East Essex ICS, and Norfolk and Waveney ICS. The coaches are all qualified domestic or international nurses or midwives who have worked in the NHS, and they provide coaching and mentoring support for international nurses at any stage of their career, including induction. They discuss career development and help to unblock career progression barriers such as a lack of confidence, writing job applications or interview technique, to support their career aspirations.

    In June 2023, following the success of the career development coach work to support the career advancement of international nurses, a mobile phone app – InterN - was created. The purpose of the app is to increase access to not just career development support but pastoral care for internationally educated staff by providing digitally driven information and resources all in one place.

    The content for the app grew from discussions with international recruits about their challenges and experiences of living and working in the UK.  It includes health and wellbeing, training and resources, housing and finances in addition to very local area trust information and contacts.

    The app has been launched across the East of England region and is available for any international recruit to download before they arrive in the UK or once they arrive and is also available on the Stay and Thrive FutureNHS platform

  • Torbay and South Devon NHS Foundation Trust offers tailored career progression support for its international nurses. The trust listened to feedback from international nurses who were already working in the trust to understand why some were not progressing in their careers. For new international nurses joining the trust, it was important to understand their motivations and how the trust could support them to achieve their goals. Using this feedback, the team identified three areas of focus: skills, knowledge and showcasing capabilities to support career progression. Some activities include:

    • promoting the update of CPD to build knowledge
    • developing leadership skills through the trust’s BME leadership programme, which is open to all staff groups across banding
    • delivering career progression workshops to discuss what roles are available in the NHS and share lived experience and career stories from existing international nurses.
  • Hull University Teaching Hospitals NHS Trust developed a ‘grow your own’ programme for international nurses in late 2020. The aim is to reduce workforce vacancies, promote the trust as a great place to work and develop career pathways for existing international healthcare support workers. The programme is supported from board to ward and helps the international healthcare support workers to qualify as registered nurses in the organisation. Six have now received their registered nurse status with more planned for in 2023.

Tools and further reading

  • NHS England’s Health Careers web page includes links to resources and support to help international staff to plan their next career steps. Hear from six internationally recruited nurses at different stages of their career about how the NHS has supported them to achieve their ambitions. 
  • Resources are available on the campaign resource centre for NHS and local authorities to help support the retention of internationally recruited nurses.
  • The Medical Workforce Race Equality Standard (MWRES) report 2021 identified that BME doctors have a poorer experience of medicine than their white colleagues, feeling less supported, less included and less able to prosper. NHS England has announced a First Five programme of priority domains intended to help tackle these racial disparities.
  • Direct your international nurses to the CNO Nursing Professional Development Programme, which is a central repository and signposting platform for information on national and regional nursing professional development programmes for all nurses. 
  • The RCN offers members a careers service with information and resources to support professional development.
  • The BMA offers overseas doctors a range of webinars, coaching courses, workshops and e-learning modules for professional development.
  • UNISON offers members a range of courses and workshops to support professional development.
  • Take a look at the Professional Development Guidebook produced by the CapitalNurse international recruitment consortium. You might find it a helpful resource to support the professional development of your international nurses.
  • NHS England’s report The expectations of line managers in relation to people management creates a clear view on the expectations of line managers in the service in relation to people management and the implications for provision of people services.

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International retention checklist

Below is a quick checklist to ensure your offer to overseas staff is as fulfilling as possible.

  • Review recruitment and onboarding offers for standardisation and transparency. 
  • Ensure policies respond to any form of inappropriate or discriminatory behaviour for all staff and services users.
  • Provide means such as culturally competent leadership training to ensure all managers and mentors feel equipped to compassionately support international staff with their unique personal and professional learning needs.
  • Implement ways to find out individual staff’s motivation for migration and why they have chosen to work in the NHS. Support them to actualise this to improve job satisfaction and fulfilment. 
  • Compassionate and inclusive pastoral support at organisational level should be a priority - recognising the unique learner status of overseas staff alongside acknowledging the invaluable positive contributions made are determinants of successful integration and acculturation.
  • The power of communities and cultural networks are fundamental to successful migration, and therefore the personal and professional lives of our international colleagues both inside and outside of work.
  • Provide support with local language idiosyncrasies promotes a sense of belonging.
  • Career progression, such as recruiting into relevant specialisms, should be prioritised and included in career discussions and as part of appraisal reviews.

The International Recruitment Toolkit includes a pastoral support checklist for you to consider the support you may offer to overseas staff prior to their arrival through to induction and beyond.

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International retention podcasts

To support employers, there are a number of audio resources that explore the subject of international retention. 

#StayAndThrive series

To support #StayAndThrive programme, the team has developed a podcast series exploring the experiences of internationally educated NHS professionals of transitioning to living and working in the NHS workforce in England.

Host, Katy McDonald, a former fellow for international retention at NHS England North East and Yorkshire region, speaks directly to international nurses, midwifes, allied health professionals, and to managers and team leaders trying to make those transitions as smooth as possible. The series highlights personal stories of challenges and triumphs, as well as offering advice on how we can all ensure everyone is truly able to stay and thrive.

You can find all episodes on the dedicated podcast website.

Stay and Thrive podcast
The Stay and Thrive podcast

As part of the development of this toolkit NHS Employers, working with NHS England, produced a podcast on the #StayAndThrive programme. The voices you’ll hear are members of the community of action, each bringing their own unique perspectives to the challenges international staff face in the NHS. You’ll hear advice on how often simple, practical actions can support international staff to stay and thrive and how working collaboratively has enabled the community to share knowledge and practice across different regions.

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Next steps

Now you’ve worked through this toolkit, you may find it helpful to refer back to the self-assessment checklist and consider what action or actions you will take forward locally or in collaboration with system partners.

Create your own action plan using the template on page 38 of our Improving Staff Retention Guide.

It is important to build your retention activity into the overall evaluation of your international recruitment work to measure impact and identify improvements. See the evaluation section of the International Recruitment Toolkit to get started (page 55).

More information and contact

If you have any questions about this toolkit or would like to share the approach of your organisation, system, or region to retaining internationally recruited staff, please get in touch with us:

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