International Retention Toolkit

Introduction

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. The Nursing and Midwifery Council’s (NMC) data report for 2021–2022 shows that almost half of professionals joining the NMC register were trained outside the UK. 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 your international nurses and may be experienced by other international staff groups in your workforce.

Based on a framework of four pillars, this toolkit brings information, best 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. 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.

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

The NHS People Promise

The NHS People Promise commits to creating compassionate and inclusive cultures in organisations and systems and as such, leaders and managers should encourage cultures that champion the experience and voice of all international staff and ensure a focus on listening, learning and compassion. 

Getting started

There is no single action that will solve 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. 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 (page 6), and see a useful checklist (page 7) on how to become a lead recruiter from overseas in your region.

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 will enable you to check your progress against the key factors that are known to support the retention of international staff.

Understanding your data

Your workforce data holds useful insights into the lived experience of international staff in your organisation and can help you to identify the issues you are trying to solve. For example, is there high or low turnover in particular areas? Are there issues specific to staff from overseas? How are internationally recruited staff represented at all levels in your workforce? What is their experience of harassment, bullying or abuse?

• The NHS Staff Survey data 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 latest Workforce Race Equality Standard (WRES) report 2022 highlights the experience of black and minority ethnic (BME) people working in the NHS (which may include 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. It allows the employee to self-report their reason for leaving and state what, if anything, would have kept them in the organisation.
• 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 in order to improve the experience of existing and future international staff.

​​​​​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.

The NHS Health and Wellbeing Framework includes a diagnostic tool to self-assess your organisation and provides guidance on how organisations can understand what good health and wellbeing looks like and what can be achieved. 

Self-assessment

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.  

Key:

• 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 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’)
4. 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’)
5. We acknowledge the depth of experience that international colleagues 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.

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 they 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 (page 61) and overseas doctors (page 89).

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 (page 75) 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

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 local area, dialect, the organisation, 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.

Go to the International Recruitment Toolkit to use our welcome pack checklist (pages 48-49).

Accommodation

The current cost-of-living crisis has led to a shortage of rental properties in some areas. 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. See the example from University Hospital Southampton NHS Foundation Trust in the International Recruitment Toolkit (page 47). Other organisations have used web-based searches and apps to find accommodation.

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.

Map skillsets and qualification

Research shows 78 per cent of international nurses had been qualified over five years and almost half (48 per cent) had been qualified for more than ten years prior to migration (University of Huddersfield (2022) International Nurses and their Initial Integration into NHS England’s Healthcare Workforce: A Population Analysis).

You should meet with your new recruits to discuss the skills and experience they have gained from working in international healthcare settings. It is important to recognise and make the most of their skillsets by placing them in their preferred clinical area, as this will support their ongoing progression and help them to feel valued. If this isn’t possible, have an open and honest discussion about next steps and the possibility of internal transfers, if and when a vacancy becomes available, and the process (if any) they would need to go through to be able to transfer.

Taking the time to learn about prior experience and approaches to healthcare used across the globe also encourages mutual learning and should be shared across teams to support integration.

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 CapitalNurse 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.

Good practice examples

Tools and further reading

• This NHS Employers Working and Training in the NHS Guide can be shared with international medical graduates (IMGs) as part of your recruitment and induction material.
• See Health Education England’s (HEE’s) tools to support managers with onboarding international AHPs and NHS Employers page for useful resources to support international AHPs.
• 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 (page 58).
• UK ENIC (European Network of Information Centres) is the designated national agency for the recognition and comparison of international qualifications and skills. HEE’s National Talent For Care team has fully-funded access to the ENIC database and offer an equivalency verification service for overseas qualifications, contact ENIC@hee.nhs.uk to access this service.
• For information on the registration process and associated timescales of the relevant professional regulator see the International Recruitment Toolkit (page 23).
• For further information on repayment clauses should your international recruits decide to leave employment early, please see the International Recruitment Toolkit (page 19).

How will you play your part?

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 by 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, GPs, somewhere to live, UK sim cards, access to shopping, schools, 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, and for this reason, we have included this information in this toolkit and the International Recruitment Toolkit.

How to make new recruits feel welcome

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. 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 a support network outside of work.

The International Recruitment Toolkit contains further tips, good practice examples and a checklist for more pastoral support ideas (pages 47-49).

A detailed checklist to assess your pastoral offer can be found in the International Recruitment Toolkit (page 62).

Preceptorships

Nurses newly joining the Nursing and Midwifery Council (NMC) register having trained overseas need training and support.

You should consider your existing preceptorship programmes and how these can be tailored to take into account their prior experience. The International Recruitment Toolkit shares an example from Whittington Health NHS Trust on how it developed a tailored preceptorship for its international nurses (page 72).

Social networks

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 (page 75). Your staff networks can also provide a safe space for your international staff to share ideas, raise awareness of challenges and provide support.

Buddying

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.

Integration visits

Helping your overseas staff to find their way around the local community is a good way of familiarising them with their surroundings. This could include taking them to local parks and supermarkets, the post office, tourist attractions, GPs, schools, helping them use public transport, and showing them the local places of worship.

Induction

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 on areas such as typical ward 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.

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), 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. 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. Consider working in collaboration as a system to organise events.

Health and wellbeing offer

As part of your induction, include an introduction to the health and wellbeing offer provided by your trust and associated occupational health assessment or risk assessment.

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.

Good practice examples

Tools and further reading

• The King’s Fund runs a free, short course to learn about the history of the NHS and how it all works and fits together.
• OET has the Living the Language resource to help new recruits overcome common communication challenges.
• This guidance document sets out minimum standards and detailed guidance for employers to provide an effective induction for IMGs entering the NHS. Access further information and resources on the NHS Induction Programme.
• The GMC runs a free workshop for overseas-trained doctors designed to help them settle into medical careers in the UK.
• The BMA has a guide to working in the UK for internationally educated doctors, including information about how the NHS works.
• Consider how working with groups such as the Academy of Medical Royal Colleges, can support international doctors should they choose to join as members.
• NHS England has established a national preceptorship framework for nursing which includes a core set of standards that constitute a minimum requirement for preceptorship programmes.
• The NHS Pastoral Care Quality Award is a scheme that supports NHS trusts to provide high-quality pastoral care to internationally educated nurses and midwives.
• NHS England has developed a number of bespoke support offers for diverse NHS staff, find more information on the NHS England website.  
• See the International Recruitment Toolkit for information on:
  • considerations if you are employing refugee healthcare professionals (page 22)
  • language support to prepare overseas recruits for their English language tests (page 40) and watch this NHS Employers webinar below for more ideas.  

How will you play your part?

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 (University of Huddersfield (2022) International nurses and their initial integration into NHS England’s healthcare workforce: a population analysis). 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

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.

Integration

Some overseas staff arrive in the UK with their families so will need further support and signposting to increase integration into the wider community. Identifying and building relationships with local faith leaders, schools, colleges and local services to provide support will be key to making the transition to a new culture easier for the whole family.  

Additional support

Consider signposting staff to support available from the relevant professional regulators, professional associations and trade unions, such as the RCN, the BMA, UNISON, and Unite.

For leaders, managers and the wider workforce

Cultural awareness training

It is important that existing staff and managers are aware that overseas staff will be used to different English terminology and cultural norms. Where possible they should undertake learning about the cultures of their colleagues. This could be through a social event or more formal training.

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. 

Cultural awareness is an important skill for managers of internationally educated staff. It increases awareness of different cultures enabling local leaders to support their international staff, increase understanding of equality, diversity and inclusion, and build stronger relationships with colleagues from different cultures to their own. To find out more about the training and other resources which are available, visit the Culture in Health website. 

Celebrations

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 wellbeing conversations or check-ins with their international staff to listen and understand their specific needs at a given time and signpost to the appropriate support. See the health and wellbeing section of the Improving Staff Retention Guide for more information on supporting workforce wellbeing.

Good practice examples

Tools and further reading

• NHS Employers’ health and wellbeing web pages have a variety of supportive materials around wellbeing.
• See NHS England’s NHS Health and Wellbeing Framework to support you in creating a wellbeing culture in your organisation and also information on supporting our NHS people.
• Keep up to date with interventions and practical solutions on NHS England’s retention hub.
• This resource is designed to help nurses, midwives and nursing associates 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.
• Watch Newcastle upon Tyne Hospitals NHS Foundation Trust's video (below) to see how the trust supported its internationally recruited staff with dedicated training.

How will you play your part?

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. 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.

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.

How to maximise personal and professional growth

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.

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 throughout 2023. Insights and case studies will be shared via NHS England Futures platform (log in required).

Ongoing health and wellbeing support

Looking after the health and wellbeing of your international staff should extend beyond their induction. Continue to signpost international staff to your health and wellbeing offer. Staff networks, forums or diaspora groups will play an important role in supporting the wellbeing of your overseas staff and can also support professional development.

In addition to trust-led health and wellbeing initiatives, NHS England has launched a coaching offer, Looking After You Too, for international nurses. It provides a safe space to focus on wellbeing and any pressures or challenges they may be facing. It aims to develop practical strategies in relation to their situation and is individually tailored and confidential. Coaches are from ethnically diverse backgrounds and can support people with a variety of challenges. For example, action planning, steps to support integration into the UK and the NHS, adjusting to a new role, decompressing, debriefing, difficult conversations, home pressures, interpersonal issues, workload pressures and stress. Having these conversations away from managers, peers or family members can help to offer a safe, non-judgemental space.

The coaching programme provided participants with an opportunity to focus on their health and wellbeing and take actions that supported them with decision making and building confidence to make positive career, personal and life changes. The coaching provided clarity with decision making and ensured that individuals were able to either make a career change or return to their home country.

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 (University of Huddersfield). 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.

Mentors

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.

Good practice examples

Tools and further reading

• NHS England has developed a web page with 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.
• These resources are system-facing and can be used by 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.
• Use NHS Employers’ health and wellbeing resources to support your ongoing health and wellbeing offer. This includes information on mental health in the workplace, burnout, stress management, menopause support, men's health guidance, personal safety and lone working, a communications guide and a wellbeing needs poster.

How will you play your part?

International retention checklist

International retention podcast

Listen to the NHS Employers 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.

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