Beyond Arrival: What Expat Doctors in Wales Can Teach Us About International Onboarding
Table of Contents
1. Linguistic challenges
1.1 The language used at work
1.2 Meaning Beyond Words
1.3 Using the right tone
2. Practical challenges: housing and immigration paperwork
2.1 Housing
2.2 Visas and work permits
3. Cross-cultural challenges at work
3.1 Unfamiliar working methods
3.2 Unclear hierarchy
3.3 Dietary needs
3.4 Social Isolation
3.5 Racism and prejudice
3.6 Limited cultural preparation
Practical reflection questions
Conclusion
Morris S, Haj Youssef M (2026;), "Cross-cultural adaptation in healthcare: examining expatriate doctors’ strategies and challenges in Wales". Journal of Work-Applied Management, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/JWAM-09-2025-0178
Introduction: Why international employee onboarding must go beyond arrival
Morris and Haj Youssef (2026) examined the cross-cultural experiences of 16 self-initiated expatriate doctors employed by an NHS health board in Wales. The NHS is the UK's public healthcare system. The researchers conducted semi-structured interviews and analysed the material thematically. This Research Highlight focuses on those challenges. It does not discuss the adaptation strategies identified in the study, which warrant separate consideration.
Healthcare is a particularly demanding setting because communication, professional judgement and patient relationships can carry immediate consequences. However, the underlying onboarding questions also matter outside healthcare. Effective expat onboarding must help international employees learn the formal requirements of their roles as well as the less visible conventions through which colleagues communicate, make decisions and build trust.
1. Linguistic challenges
Communication was one of the three main challenge themes identified in the study. Expatriate doctors described difficulties involving the language used around them, the meaning conveyed through expressions and humour, and the interpretation of tone.
1.1 The language used at work
This finding is specific to a bilingual Welsh setting, but the organisational issue is broader. A company may designate English as its working language while employees use another shared language in meetings or side conversations. For effective expat onboarding, HR should make working-language expectations explicit whenever international employees need to understand, contribute to or act on what is being discussed.
1.2 Meaning beyond words
The study also identified challenges of a paralinguistic nature. Beyond the exact words used, these challenges involved humour, local expressions and sarcasm. These are not simply advanced vocabulary problems. Their meaning depends on shared context, and newcomers have had less opportunity to acquire that context. The study describes instances in which participants understood the words but remained uncertain about what another person intended.
Language proficiency alone does not demonstrate that an employee will immediately understand local humour or culturally familiar expressions. Onboarding should therefore cover not only vocabulary and grammar but also meaning beyond the words themselves.
1.3 Using the right tone
The study therefore treats tone as a distinct communication challenge. The words themselves could be correct while the way they were delivered produced tension with patients or colleagues.
This issue can arise in other sectors when international employees give feedback, challenge a decision, manage conflict or communicate disappointing news. Written guidance is unlikely to be sufficient. Realistic examples, practice and feedback can help employees understand how their tone may be received while helping colleagues avoid attributing negative intent too quickly.
2. Practical challenges: housing and immigration paperwork
For the doctors interviewed, relocation brought challenges that shaped their first impressions of life and work in Wales. Some struggled with the quality or suitability of their accommodation, while others valued the community it offered. Visa refusals and uncertainty about work permits added stress, especially when important dates were approaching. These accounts invite employers to consider how they assess housing, explain administrative processes and prepare employees for potential delays.
2.1 Housing
Most participants initially lived in hospital
accommodation. Their experiences varied, but several considered the
accommodation or related services inadequate. Participants described rooms or
properties that were small, dirty, unsuitable for family life or affected by
maintenance problems such as dripping water and a lack of hot water. Some
compared the accommodation with student housing and felt that it did not
reflect their professional position.
The accounts were not uniformly negative. One participant valued the multicultural community created by the accommodation and felt that living there supported greater understanding of other cultures, including British culture.
Securing a property does not necessarily mean that the housing need has been met. Suitability also depends on condition, household composition, privacy, location and access to community. Global mobility teams and relocation providers should therefore assess the lived suitability of accommodation rather than treating placement as complete once a property has been found.
2.2 Visas and work permits
Participants also described stress, uncertainty and
limited organisational support concerning visas and work permits. One doctor
recalled the distress of having a visa refused when travelling to take an
examination. Another described needing to apply for a work permit while neither
the participant nor the people around them appeared to understand the process
clearly.
The study presents these experiences as examples of
the administrative burden carried by expatriate doctors during relocation and
the need for clearer organisational guidance.
Immigration requirements differ by jurisdiction, but the transferable global mobility issue is ownership. International employees need to know who explains the process, which dates are critical, what remains uncertain and where responsibility passes between the employee, employer and external provider.
3. Cross-cultural challenges at work
Most expat doctors in the study had received a largely administrative onboarding process, even though they experienced intercultural challenges such as unfamiliar working methods and hierarchy. In the few cases in which participants had received cultural preparation, it had been limited in scope.
3.1 Unfamiliar working methods
Several participants valued the interdepartmental communication and structure of the NHS, but they found the unfamiliar ways of working difficult. One example concerned how and when to involve a patient's family members in their treatment. These differences required more than technical knowledge. Participants had to understand where professional responsibilities began and ended within the NHS and how their roles related to those of other healthcare professionals.
The examples are healthcare-specific, but unfamiliar working methods can arise in any sector. An effective expat onboarding process should provide explicit guidance on role boundaries, decision rights, escalation routes and the points at which an employee's work intersects with other functions.
3.2 Unclear hierarchy
Many participants struggled with hierarchy. They were accustomed to a
more hierarchical system in their home countries than in the NHS, where the
hierarchy was perceived to be flatter. They mentioned challenges such as
adjusting to a new, more egalitarian team role and having to follow an extended
process to make a decision.
Hierarchy is relevant across industries and countries. Different ways of
collaborating and making decisions can be confusing for people from another
culture. Understanding how these processes work may be necessary for effective
collaboration.
A flatter structure is not automatically easier to navigate. It may rely on unwritten knowledge about influence, disagreement, initiative and shared responsibility. The practical lesson is not to teach national stereotypes about power distance. Instead, cross-cultural onboarding should explain how authority works in the specific organisation, team and role rather than relying on broad descriptions of national culture.
3.3 Dietary needs
Some expat doctors had difficulty maintaining diets connected with their
cultural, religious or personal practices. One participant from a vegetarian
family described the dietary challenges as considerable, while another was
concerned about having to change established meals or eating habits.
Dietary needs may appear peripheral to international employee onboarding, but they affect whether the organisation feels inclusive. Employers could ask about relevant requirements rather than expect international employees to raise them repeatedly on their own.
3.4 Social Isolation
Many expatriate doctors in the study, especially those from collectivist
countries, experienced a loss of connection. Many felt lonely and isolated
because they were far from their families and had little local community
support.
The study's findings indicate that relocation challenges extended beyond
logistics into emotional and social wellbeing. The researchers connected
unfamiliar accommodation, distance from family and limited social opportunities
with loneliness and difficulty adapting.
Social isolation can be a difficult part of relocating to any country
because people leave their families behind and may not know anyone in their new
environment. A lack of connection can produce loneliness that is difficult to
manage.
The participants' accounts show why workplace relationships, local support, community access and support for accompanying family members belong within the scope of expat onboarding.
3.5 Racism and prejudice
Some expatriate doctors in the study had encountered challenges related to aspects of their demographic background, such as immigrant status, language, gender and skin colour. This could make acceptance in the new environment more difficult.
Discrimination and prejudice can occur across industries and countries and have serious consequences for both the recipient and the organisation. Safe reporting routes, fair investigation, managerial accountability and action against discriminatory behaviour are essential.
3.6 Limited Cultural Preparation
Limited orientation and cultural preparation were prominent concerns. Twelve of the 16 expat doctors reported receiving no cross-cultural preparation. The expat doctors were unsure about cultural norms and expectations at work. Some specialist departments had provided limited cultural training, but more general departments had provided none. Several participants described their orientation as brief and largely administrative.
This is one of the study's most relevant findings for HR. Administrative induction answers questions such as where to go, what to sign and which systems to access. Cultural onboarding addresses how to interpret behaviour, collaborate, make decisions, communicate across difference and seek help when expectations remain unclear. The first does not automatically deliver the second.
Practical reflection questions
Based on this study, I have formulated 11 reflection questions that you and your colleagues can use in your organisation. The list is not exhaustive, but it can help you examine different aspects of international onboarding in your organisation and can be used immediately.
What working-language expectations are in place when employees use different languages, dialects or locally specific terminology?
Which expressions, humour, indirect messages or conversational conventions might international employees be expected to understand without anyone explaining them?
Which sensitive or high-stakes conversations should international employees be able to practise before misunderstandings affect trust, performance or safety?
How do you assess whether accommodation is genuinely suitable for the employee and household, rather than simply available?
Does every international employee know who owns each part of the immigration process, which deadlines matter and where to seek reliable help?
Which role boundaries, decision rights and everyday working practices are essential but currently left implicit?
How clearly do you explain how authority, consultation, disagreement and escalation operate within the receiving team?
How and when do you identify dietary requirements, and are these needs considered in temporary accommodation, the workplace and organised events?
What dependable relationships and relevant community connections are created after arrival for the employee and, where appropriate, accompanying family members?
Can international employees report discrimination safely, and do they know what the organisation will do after a concern is raised?
What does your onboarding teach international employees about functioning in the work culture beyond completing administrative tasks and gaining system access?