The National Guardian’s Office’s latest speak up review Listening and learning: Amplifying the voices of overseas-trained workers, found that overseas-trained workers often face unique barriers that prevent them from speaking up about patient safety concerns.
The NHS is one of the most diverse healthcare systems in the world, with a significant proportion of the workforce being overseas- trained. But when workers do not feel able to speak up, it is not just a workplace issue; it becomes a patient safety risk too.
Silence
The Speak Up review findings demonstrate that despite policies that promote openness and speaking up, overseas-trained workers are often less likely to raise concerns. Many worry about being misunderstood, dismissed, or even penalised if they speak up. Cultural norms, past experiences, and workplace dynamics play a huge role in this silence.
And when concerns go unspoken, patients are put at risk.
This silence among overseas-trained workers is not an issue to do with reticence; it’s related to organisational culture.
Diversity is often celebrated in posters and training modules, but when a real concern is raised about exclusion, microaggressions, or systemic bias, the organisation doesn’t always act to support the overseas-trained worker.
Equality, diversity and inclusion plans have become a way to signal progress without making people uncomfortable. In many healthcare organisations, diversity is measured but not meaningfully discussed. Equality, diversity and inclusion training is mandatory, but rarely transformative.
During the Speak Up review, many overseas-trained workers described speaking up as risky to them. In some organisations, leaders may want to help but they often lack the cultural intelligence and confidence to handle these difficult conversations.
Cultural intelligence
Cultural intelligence is a person’s ability to work effectively across different cultures. It goes beyond awareness and sensitivity – it’s about adapting your behaviour, communication, and leadership to be effective in diverse cultural settings. For NHS leaders and teams, this means recognising that:
- Not everyone views hierarchy and authority in the same way.
- Some staff may hesitate to speak up out of respect, fear, or prior experience.
- The “right” way to raise concerns may look very different across cultures.
When leaders develop cultural intelligence, healthcare organisations are able to bridge the gap between well-intentioned policies and real-world psychological safety. Healthcare institution policies may articulate values like inclusion, respect, and safety, but psychological safety depends on interpersonal dynamics and not just structural intent.
Without culturally intelligent leadership and staff, policies risk becoming performative rather than transformative.
Cultural intelligence equips individuals to recognise cultural norms and values in diverse interactions, regulate personal responses and biases in intercultural contexts and adapt behaviour effectively based on cultural cues.
Leader behaviours
If you’re a team leader, clinical supervisor, or senior executive, here’s how you can start fostering cultural intelligence in your team:
- Ask, don’t assume. Check in with staff from overseas backgrounds. Ask what barriers they face when raising concerns and listen with curiosity, not defensiveness.
- Model vulnerability. Share your own mistakes and learning moments. When leaders show it’s okay to be imperfect, others feel safer to speak up.
- Mentor inclusively. Pair new overseas-trained workers with culturally aware mentors who can help them navigate NHS systems and unwritten rules.
- Promote diverse champions. People speak up more when they see people like them in leadership roles. Representation isn’t just symbolic it’s structural.
- Invest in training. Cultural intelligence training isn’t a nice-to-have. It’s a patient safety imperative.
Vital
Everyone in the NHS regardless of their accent, background, or where they trained should feel empowered to raise a red flag when something doesn’t seem right. Healthcare senior leaders, managers and workers owe that to the patients and to each other.
Cultural intelligence plays a vital role in making this possible. There is a need to move beyond celebrating diversity to truly leveraging it for safer, more inclusive care.
If you’re working in healthcare leadership or workforce development, the National Guardian’s Office would love to hear from you:
- How do you support overseas-trained staff in speaking up?
- What barriers still need to be addressed in your organisation to ensure that overseas-trained workers feel confident to speak up?
Let’s share ideas and build a more culturally intelligent NHS, together.