Determinants of cross-cultural adjustment among self-initiated expatriate medical doctors working in Ireland

Abstract

Purpose

The last decade has seen a significant increase in self-initiated expatriation research across various cohorts; however, limited research exists on the self-initiated expatriation of medical doctors despite their high mobility rates. The purpose of this paper is to investigate the determinants of cross-cultural adjustment among self-initiated medical doctors working and living in a host culture.

Design/methodology/approach

A questionnaire was distributed to self-initiated expatriate (SIE) doctors working in Irish hospitals. In total, 193 valid responses were collected. Three linear regression analyses were conducted to explore factors influencing cross-cultural adjustment among SIE medical doctors, along with qualitative insight into their adjustment to working and living in Ireland.

Findings

This study found that age, marital status, cultural novelty, previous international work experience, length of time working in the host culture did not influence the cross-cultural adjustment of SIE doctors. However, gender, language ability and perceived fair treatment were found to influence their cross-cultural adjustment in the study. Specifically, female SIE doctors reported higher levels of general adjustment to that of SIE male doctors. SIE doctors' language ability was found to influence their work adjustment, and those who perceived unfair treatment in the host culture reported lower levels of general adjustment.

Originality/value

This paper contributes to the limited knowledge and understanding surrounding the self-initiated expatriation of medical doctors and their cross-cultural adjustment to the host hospital and host culture.

Citation

Nolan, E. and Liang, X. (2022), "Determinants of cross-cultural adjustment among self-initiated expatriate medical doctors working in Ireland", Journal of Global Mobility, Vol. 10 No. 3, pp. 289-311. https://doi.org/10.1108/JGM-01-2022-0002

1. Introduction

Expatriates can be defined as individuals who live or work outside of their own home country on a non-permanent basis (McGinley, 2008). The term expatriate can be broken down into two main categories, conventional expatriates (AEs) and self-initiated expatriates (SIEs). Over four decades of research exists surrounding the cultural adjustment of AEs (Vlajčić et al., 2019; Bhaskar-Shrinivas et al., 2005; Peltokorpi and Froese, 2009), and the cultural adjustment of SIEs has gained significant momentum in the past two decades (González et al., 2021; Lauring and Selmer, 2018; Nolan and Morley, 2014). AEs are individuals sent on an international assignment by their home organization, while SIEs are described as individuals who themselves make the decision to move and work abroad (Myers and Pringle, 2005; Harrison et al., 2004). The main difference between AEs and SIEs is that the SIEs decide themselves to relocate abroad for work, often doing so without organizational support. Cerdin and Selmer (2014) define SIEs as individuals who: (1) self-initiated their international relocation, (2) have regular employment intentions, (3) have intentions of a temporary stay in the host culture and (4) have skilled/professional qualifications. While research on SIEs has gained significant momentum in the last decade, upon reviewing existing literature on SIEs' cultural adjustment to that of AEs' cultural adjustment, it is evident that research surrounding SIEs' cultural adjustment is limited in comparison to that of AEs. This observation has been recently supported by González et al. (2021), McNulty and Brewster (2019) and Zakaria and Yusuf (2022). One group of SIEs that have received little attention in research is that of health care workers (Brewster et al., 2021; Zakaria and Yusuf, 2022). This is somewhat surprising considering the high mobility levels of doctors, nurses and care assistants globally. Of all highly regulated professions, medical doctors are among the most likely to independently seek work abroad, motivated mainly by a mix of developmental opportunities, rewards and work-life balance issues (Britnell, 2019). In line with Cerdin and Selmer's definition of SIEs, we classify these doctors as SIEs, as they are highly qualified individuals who self-initiate their own relocation to the host culture for a temporary stay, with the purpose of regular employment. The aim of this paper is to address the lacuna in research surrounding the cultural adjustment of SIE doctors working in a host culture. We replicate existing studies that investigate determinants of adjustment in order to test their validity in the context of SIE medical doctors. While numerous determinants of SIE cultural adjustment exist within literature and should be considered with future research (e.g. accompanied by family/spouse), we explore the following eight determinants of cultural adjustment in this study: age, gender, cultural novelty, marital status, previous international work experience, length of time in host country, language ability and perceived fair treatment. This research is relevant and offers several contributions to theory and practice. First, we contribute to the knowledge and understanding of SIEs in the health care sector, more particularly medical doctors, a cohort that to date has received limited attention despite having one of the highest mobility rates. Second, by assessing the determinants of SIE doctors' cultural adjustment, the current study offers insight to the recruitment bodies that could improve their SIE recruitment and retention process. Third, this study may add to the growing literature on SIE expatriation by providing new evidence on the validity of past determinates of cultural adjustment in relation to a specific medical SIE cohort, while highlighting determinants that may need to be explored more in order to establish a thorough understanding of their cultural adjustment.

The remainder of our paper is structured as follows. First, we discuss the self-initiated expatriation of doctors to Ireland. Following this, we explore the concept of cultural adjustment, more particularly Black's model of adjustment. We then discuss the eight determinants of adjustment included in the study and form hypotheses. Following this, we describe the methodology of the study along with presenting the findings. Finally, we discuss the findings while highlighting implications for both theory and practice.

2. Self-initiated expatriate doctors in Ireland

The World Health Organization (WHO) notes that over the past decade the number of doctors relocating to OECD countries for work has increased by 60%. This trend is not only set to continue but is likely to increase. It is predicted that by 2035 there will be a global shortage of more than 12.9 million doctors (WHO, 2013). Of all OECD countries, Ireland is experiencing the greatest doctor shortage. The mobility of doctors is a major issue in Ireland both in terms of the inflow and outflow of health professionals (Nolan, 2018). Ireland has been experiencing an acute shortage in the number of doctors servicing its nation's hospitals, with the vast majority of home-grown doctors leaving to work in Canada and Australia for better career advancement opportunities, increased pay and work-life balance (Humphries et al., 2019). In order to combat these shortages, Ireland has become increasingly reliant on non–EU doctors to service the Irish health care system (Bidwell et al., 2013; Nolan, 2018, 2022). These SIE doctors come to Ireland to occupy low or middle grade posts in provincial hospitals, which are often not attractive to the Irish workforce. It is estimated that currently 41.6% of all doctors working in Ireland obtained their medical degree from outside the country. To put this number in perspective, France reports as little as 3.1% of its doctors holding a medical degree from outside the country. In an attempt to combat the severe shortages, Ireland runs aggressive recruitment drives to attract new doctors to the country. The response of applicants from these recruitment drives has come from mainly outside the EU, resulting in a large proportion of non–EU doctors in Ireland (Nolan, 2018, 2022).

These non–EU doctors are SIEs who personally secure a post in Ireland and organize their relocation to the country independently of the host hospital. These SIEs have no organizational support with their transition to working and living in Ireland, this is in part down to the fact that they organized their own international recruitment, but it is also a reflection of the current state of the Irish Health Care System, where limited attention is paid to the successful transition of these doctors, presumably resulting from intense resourcing issues and time pressure (Nolan, 2018).

3. Cultural adjustment

Relocating across borders for employment can have substantial and sometimes unexpected effects on SIEs. While immersed in the host environment, SIEs become aware of the differences that exist between the host and home culture, leading them to become more susceptible to the variety of challenges such as culture shock and inability to interact effectively with host country nationals (HCNs). Cultural adjustment can be described as the degree of psychological comfort individuals perceive concerning a new situation or culture (Black, 1988; Nolan and Morley, 2014). It is a learning process through which individual's attain the new skills, cultural norms and appropriate behaviors to adjust to the host culture, both inside and outside the working environment. While several conceptualizations of cultural adjustment exist within literature (see Hippler et al., 2014b, 2015; Vromans et al., 2013; Ward and Kennedy, 1999; Zhang and Hussain, 2021), one of the most prominent conceptualizations of expatriate adjustment is that of Black (1988), Black and Stephens, 1989 and Black et al. (1991). Black (1988) conceptualized cultural adjustment as the degree of psychological comfort an individual has when living and working abroad. The model is multi-dimensional and consists of three domains in which expatriates need to adjust to; general, interaction and work adjustment. While this model is not without criticism, most notably surrounding the theoretical basis of the scale and the nature of adjustment (see Kubovcikova, 2016; Haslberger and Dickmann, 2016; Hippler et al., 2014a; Haslberger et al., 2013), it remains one of the most popular measurements and conceptualizations of adjustment within the expatriate literature and is supported by a series of empirical studies on expatriate adjustment (e.g. Black and Gregersen, 1991; Hechanova et al., 2003; Bhaskar-Shrinivas et al., 2005; Selmer, 2005; Nolan and Morley, 2014; Chen and Shaffer, 2018; Presbitero, 2020; Shah et al., 2022).

General adjustment can be defined as the degree of comfort and familiarity expatriates have with their general living conditions in the host country, these include non-work factors such as food, housing and national culture. The SIE doctors in this study are non–EU and will not only have to make sense of the organization's facilities, but also the foreign country that they have relocated to. This includes a different political and monetary system, different accents, norms, values and behaviors to that of their home culture.

Interaction adjustment can be defined as the degree of interaction expatriates have with HCNs and the perceived comfort expatriates feel interacting with supervisors, peers and subordinates in their host location. Black et al. (1991) note that interaction adjustment is the most difficult dimension of adjustment as differences in mental maps and rules (perceptions, beliefs and values) become evident when expatriates interact with HCNs. Different cultures generally have certain norms that guide the proper functioning of individuals within the society. As a result of these differences, the SIE doctors may experience conflicts and misunderstandings in the host culture with HCNs. In order for SIE doctors to adjust successfully, it is important that the uncertainties they may experience are reduced. HCNs are an important source of information regarding appropriate behaviors and consequences that can increase expatriates' efficiency in communication with others (Aycan, 1997; Mendenhall and Oddou, 1985). It is not surprising therefore that the meta-analysis by Bhaskar-Shrinivas et al. (2004) found that language ability and relational skills aided interaction adjustment among expatriates.

The third domain is work adjustment, which concerns itself with the degree of psychological comfort that expatriates experience with various aspects of the work environment and job role, e.g. managing authority relationships, job responsibilities and working conditions while in the host location. The theoretical framework of work adjustment emanating from Dawis and Lofquist (1984) and Nicholson (1984) suggests that adjustment to a new role is fundamental to subsequent outcomes in the role. According to Black et al. (1992), this is the easiest dimension of the three cultural domains, mainly because it is aided by the similarities of the role in the home culture.

In order for SIE doctors to adjust, it is important that they reach both cognitive and emotional levels of satisfaction with the values, norms and attitudes of the host location, which in turn can facilitate their integration to host environment. The assumptions that SIE doctors have about everyday encounters in Ireland may differ from their home culture, often leading to increased ambiguity and increased levels of stress. Cultural adjustment literature indicates that successful adjustment to the host culture decreases expatriates' uncertainties and intent to leave the job prematurely (Bhaskar-Shrinivas et al., 2005; Ones and Viswesvaran, 1997; Peltokorpi, 2008; Ramalu et al., 2010). Successful expatriate adjustment is linked to increased levels of job satisfaction and task performance (Bhaskar-Shrinivas et al., 2004; Bhaskar-Shrinivas et al., 2005; Bolino and Feldman, 2000; Kristof-Brown et al., 2005; Lee and Sukoco, 2008; Verquer et al., 2003; Vogel and Feldman, 2009). However, lack of cultural adjustment is viewed as one factor which accounts for some of the failure that occurs in international assignments (Black, 1988; Grainger and Nankervis, 2001; Selmer and Leung, 2003). The results of several expatriation studies (e.g. Tung, 1987; Black et al., 1991; McEvoy and Parker, 1995; Black and Gregersen, 1999; Bhaskar-Shrinivas et al., 2005; Takeuchi et al., 2002; Ramalu et al., 2010; Takeuchi, 2010) indicate that if expatriates do not adjust adequately, they are likely to depart prematurely. Of those who remain, their maladjustment has been associated with negative effects towards the job, such as poor job satisfaction and task performance (Kraimer et al., 2001; Shaffer at al., 2006). Therefore, adjustment is of significance to both the host hospital and to the SIE doctors themselves. From an organizational perspective, adjustment partially predicts performance and successful completion of an assignment. From an SIE doctors' perspective, adjustment can influence job satisfaction and psychological well-being.

Various determinants of cultural adjustment among expatriates have been cited over the last two decades. Factors such as age, gender, cultural novelty, marital status, previous international work experience, length of time in the host culture, language ability and perceived fair treatment are all said to impact on expatriate adjustment (e.g. Selmer et al., 2009; Okpara, 2016; McNulty and Hutchings, 2016; Lauring and Selmer, 2018; González et al., 2021; Froese, 2012). Drawing from the above, we explore if such determinants of cultural adjustment impact on the cultural adjustment of SIE doctors, a unique cohort of SIEs that to date have not been substantially investigated.

4. Determinants of cultural adjustment and hypotheses

While past research on SIEs' adjustment has controlled for the impact of some demographic variables (e.g. age and gender) on adjustment, Brewster et al. (2021) note in their systematic review that almost all of the top-cited papers have ignored the diversity of the SIEs group. They instigate future analyses to understand how SIEs with diverse characteristics (e.g. gender, age, international work experience) may adjust differently. In this paper we analyze, and subsequently discuss, these differences in relation to SIE doctors. We include the following eight determinants of cultural adjustment to determine their validity in relation to SIE doctors: age, gender, marital status, cultural novelty, previous international work experience, length of time in host country, language ability and perceived fair treatment. Each is discussed below in relation to cultural adjustment.

4.1 Age

Expatriates' age has been linked to cultural adjustment and adjustment outcomes (e.g. Isakovic and Whitman, 2013; Harrison and Hubbard, 1998; Okpara, 2016; Selmer, 2001; Selmer et al., 2009). However, the results tend to be mixed where age was found to have a negative influence on general and interaction adjustment, but a positive impact on work adjustment (see Hechanova et al., 2003). In contrast, Wechtler et al. (2015) found that age positively influenced all three facets of cultural adjustment, supporting Selmer's (2001) findings. While existing research has yielded varying results on the influence of age on cultural adjustment, we anticipate that older expatriates are likely to have more experience in dealing with the changes that emerge during the transition to a host culture (i.e. Black and Gregersen, 1991). SIE doctors who are older are likely to have more varied life experiences, which may equip them with deeper levels of knowledge and understanding about themselves and the world around them. In an expatriation situation, it is possible that they can draw from the knowledge gained through life experiences to guide them in new situations in the host culture. Therefore, we suggest that older SIE doctors' experience and knowledge gathered through life may aid their adjustment process by reducing stresses and uncertainties associated with the expatriation process.

H1.

SIEs doctors' age will positively influence their general, interaction and work adjustment.

4.2 Gender

Past research indicates that gender can be an important factor in determining expatriate success (Caligiuri et al., 1999; Okpara, 2016). Traditionally, the vast majority of expatriates were male: however, over the last decade, the role of female expatriates has increased significantly. However, past findings investigating the relationship between gender and cultural adjustment offer mixed results. Fisher and Härtel (2003) found that gender was not a determining feature of successful adjustment, while Lauring and Selmer (2015) indicated that there was no statistical difference between male and female adjustment to a foreign culture. These findings were supported by Eze and Awolusi (2018) who found that gender did not significantly influence cultural adjustment. However, Haslberger (2010) found that females adjusted better than males, and Cole and McNulty (2011) found that female expatriates often outperformed their male counterparts. Salamin and Davoine (2015) found that apart from general adjustment, female expatriates adjusted better to interaction and work adjustment than their male counterparts, while Selmer and Lauring (2011) found that females had greater interaction and work adjustment to that of males. It is important to note that while there has been an increase in research on female expatriates, they still remain an under-represented expatriate group (McNulty and Hutchings, 2016). Drawing from the most recent studies looking at and male and female adjustment, it seem plausible to suggest that female SIE doctors will report higher levels of cross-cultural adjustment to that of male SIE doctors. Therefore, we propose that SIE doctors' gender will impact their cross-cultural adjustment.

H2.

Female SIEs doctors will have higher levels of general, interaction and work adjustment, compared to their male counterparts.

4.3 Marital status

Past research indicates that being married is a key influencer of international mobility (Kim, 2015). Selmer and Lauring (2011) noted that marital status was likely to make a difference, as SIEs who were married encountered family issues (negative or positive), which could impact their decisions compared to unmarried SIEs (Lauring and Selmer, 2010; Meyskens et al., 2009; Yang, 2007). Within the expatriation literature, marital status has been consistently linked to cultural adjustment and work outcomes. However, the results are mixed. For example, an expatriate who is married can experience stress and lack of adjustment, resulting from the spillover effects of their spouse's dissatisfaction with the international relocation. On the other hand, past research has found that expatriates who are married fare better to those that are not married (Selmer, 2001; Van Oudenhoven et al., 2003; Selmer and Lauring, 2011; Lauring and Selmer, 2018). SIE doctors coming from developing countries are motivated to move abroad for career development and advancement opportunities (Nolan, 2018, 2022), which is something that they are aware of early on in their training. For dual career couples, only the SIE doctor recruited will be granted a working permit to work in Ireland. It is reasonable therefore to suggest that decisions relating to expatriation and time spent abroad for this cohort of SIEs are more likely to be joint and supported decisions between the married persons. As such, spouses are likely to provide support and stability to the SIE doctors, which in turn can reduce stress and aid cultural adjustment. Therefore, we anticipate that marital status will positively influence SIE doctors' cultural adjustment.

H3.

Marital status will positively influence SIEs doctors' general, interaction and work adjustment.

4.4 Cultural novelty

Recent research acknowledges that for health care professionals living and working in culturally diverse environments, with differing norms, values and beliefs to their own, can cause stress (Zakaria and Yusuf, 2022; Almalki et al., 2012; Va Rooyen et al., 2010). Such stresses can impact on SIE doctors' adjustment to working and living in the host location. As noted previously, the vast majority of SIE doctors working in Ireland are from outside the EU, mainly from Sudan, Pakistan and Egypt (Nolan, 2018). It is well recognized that these countries are culturally diverse to Ireland (see Hofstede, 2022). SIE doctors working in Ireland are challenged with adjusting to the various cultural differences that exist between their home and host culture. Past research indicates that cultural novelty negatively influences SIEs cultural adjustment (e.g. Isakovic and Whitman, 2013). The non-work factors of cultural novelty can be described as the cultural differences or cultural distance an expatriate perceives in relation to their home and host culture (Church, 1982; Isakovic and Whitman, 2013). We anticipate that the higher the cultural novelty of SIE doctors, the more difficult it will be for them to adjust to working and living in Ireland, a sentiment that is supported by past research on SIEs (e.g. Isakovic and Whitman, 2013).

H4.

Cultural novelty will have a negative relationship with SIE doctors' general, interaction and work adjustment.

4.5 Previous international work experience

Past research surrounding the influence of previous international work experience on expatriates' cultural adjustment is mixed. Isakovic and Whitman (2013) found no relationship between SIEs previous international work experience and the facets of cultural adjustment in their study, while other studies found a positive relationship between previous international work experience and adjustment (Bhaskar-Shrinivas et al., 2005; Lui and Shaffer, 2005; Mezias and Scandura, 2005; Okpara, 2016; Selmer, 2001). We anticipate that SIE doctors who have undertaken previous international work are likely have acquired transferable skills and acculturation tactics that can be utilized in their adjustment to working and living in Ireland, perhaps making their transition easier.

H5.

SIE doctors' previous international work experience will positively influence their general, interaction and work adjustment.

4.6 Length of time in host country

It is well acknowledged in research that cultural adjustment is a process that occurs over time. Oberg's (1960) U-curve theory indicates that it can take up to a year for expatriates to adjust to the host location. Thus, it is logical to conclude that the more time SIEs spend in the host culture allows for more learning time, which can aid adjustment (Lauring and Selmer, 2018). The more time SIE doctors spend in the host culture, the more time they have had to familiarize themselves with the social norms, values and cues of the host culture and work environment. This in turn is likely to reduce uncertainties and aid cultural adjustments in comparison to SIE doctors in the early stages of their expatriation. Drawing from this, we anticipate that SIE doctors' length of time in Ireland will positively influence their cultural adjustment.

H6.

SIE doctors' length of time in host country will positively influence their general, interaction and work adjustment.

4.7 Language ability

We include language ability within this study as past research on SIEs in the medical profession highlights the importance of language ability in adjusting to a new culture (Zhang and Hussain, 2021). SIE doctors are in constant communication not only with management and colleagues, but perhaps more importantly, with the patients they are treating on a daily basis in the host culture. Therefore, understanding how their ability to speak the host language can influence their adjustment seems pivotal. Past research indicates that the ability to speak the host culture language is important in relation to cultural adjustment (Haslberger and Dickmann, 2016) and has been consistently linked to expatriate adjustment (González et al., 2021; Tenzer and Pudelko, 2017; Zhang and Peltokorpi, 2016; Farcas and Gonçalves, 2016: Froese and Peltokorpi, 2013; Isakovic and Whitman, 2013). SIEs' difficulty speaking and understanding the host country language can result in reduced levels of interaction with HCNs, which can increase uncertainty. Understanding HCNs and being able to communicate effectively in the host language allows SIEs to make sense of the new culture which is likely to aid their cultural adjustment. As all SIE doctors in this research are required to pass an English proficiency exam prior to recruitment, and English was either a first or second language in their home culture, ability to speak English was not a factor that needed to be considered. However, we deemed it important to determine the ease at which they understood the Irish accent, due to the high level of remote hospitals these doctors are sent to in Ireland, where the Irish accent is stronger and perhaps more difficult to understand. We anticipate that SIE doctors' difficulty understanding the Irish accent is likely to increase uncertainties which may impact on their cultural adjustment.

H7.

SIE doctors' ability to understand the host language accent will positively impact their general, interaction and work adjustment.

4.8 Perceived fair treatment

Perceived fair treatment in a workplace setting is heavily dependent on the type of treatment individuals receive at work (Lind, 2001; Tyler, 1998). We focus on a form of interpersonal justice in this study which refers to the perception of how fairly others treat the employee in their workplace (Van Erp et al., 2011). Social exchange relationships can impact on SIEs' perceptions of fair treatment (Chen, 2010), and SIE doctors are likely to be involved in numerous social exchange relationships at work (e.g. relationships with their supervisor (leader-member exchange); seniors (hospital consultants); Irish colleagues (doctors); hospital staff in general who are not doctors; and indeed with their patient and patients' families). Lind (2001) and Tyler (1998) note that in order for individuals to feel a sense of belonging, they need to be treated with dignity and respect, failure to do so can result in individuals feeling excluded (Penhaligon et al., 2009). We deem this especially important when dealing with SIEs, whose uncertainties are likely to be high during the expatriation process as they are coming from different diverse cultural settings and backgrounds. Indeed, past research indicates that fair/equal treatment is of particular concern when it comes to fostering diversity (Shortland and Perkins, 2019; Rubino et al., 2018). Recent research indicates that SIE doctors working in Ireland are treated unfairly in terms of access to training and career advancement opportunities by comparison to their EU counterparts (Nolan, 2018, 2022). It is therefore important to understand more about their perceived fair treatment and how such perceptions can influence their cultural adjustment. Drawing from the above, we anticipate that SIE doctors' poor perception of fair treatment decreases their sense of belonging which is likely to negatively impact on their cultural adjustment.

H8.

SIEs doctors' poor perceived fair treatment will negatively influence their general, interaction and work adjustment.

5. Methodology

5.1 Sampling and data collection

Questionnaires designed to collect both quantitative and qualitative data were administered to SIE doctors working in Irish hospitals via the Medical Council Ireland newsletter and social media in the summer of 2019. In total, we obtained 193 useable questionnaires. Table 1 reports the demographic information about our respondents in terms of their gender, age and nationality distribution, as well as their marital status and motivations to move to Ireland.

5.2 Measures

5.2.1 Cultural adjustment

Cultural adjustment was measured using Black and Stephens (1989) adjustment model consisting of three dimensions; general, interaction and work adjustment. The scale comprised of 14 items on a seven-point Likert scale with anchors ranging from 1–very unadjusted to 7–very adjusted. General adjustment items included food, health care facilities, entertainment, living conditions, cost of living, shopping and housing conditions. Interaction adjustment items included interacting with host country nationals outside of work on a day-to-day basis and socializing with host country nationals. Work adjustment items included performance standards and expectations, supervisory responsibilities and specific job responsibilities.

5.2.2 Independent variables

Age was measured by asking participants to indicate their age group (1 = 21–30 years old; 2 = 31–40 years old; 3 = 41–50 years old; 4 = 51–60 years old; and 5 = 60 years old and above). Gender was determined in the questionnaire by asking participants what gender they identified as: male, female and other (please specify). Marital status was measured by asking respondents to choose from married (1), single (2), separated/divorced (3) and widow (4). Cultural novelty was assessed by asking respondents to fill out their nationality, SIEs home country was then assessed against the host country using Hofstede's cultural dimensions. The higher the degree of cultural diversity between cultures is likely to indicate a higher level of cultural novelty. As shown in Table 1, over half of our responding doctors were from Sudan (22.80%) and Pakistan (39.38%), while 16.58% indicated that they were from regions such as South Africa and North America. Thus, cultural novelty was coded into three groups (baseline: other nationality; Nationality_P: Pakistani; and Nationality_S: Sudanese). SIE doctors were asked to indicate their previous international work experience, they were asked if they had any previous international work experience prior to coming to Ireland, their response options were 0 = no and 1 = yes. Length of time in host country was poised as follows: please indicate how long you have been working in Ireland (1 = less than 6 months, 2 = 6–11 months, 3 = 1–2 years, 4 = 2–3 years and 5 = more than 3 years). In relation to language ability, SIE doctors were asked if they had any difficulty understanding the Irish accent (which can be very strong in certain regions of Ireland), and if so, how long did it take them to understand the Irish accent. Finally, perceived fair treatment was measured by two questions: Do you feel you are treated the same as Irish-trained doctors when at work? And if no, who do you think treats you differently to Irish-trained doctors?

5.2.3 Qualitative feedback

In order to gain further insight into SIE doctors' cultural adjustment to working and living in Ireland, the questionnaire asked SIE doctors to provide open ended written feedback on their experience of working and living in Ireland: “Please comment on any additional feedback you would like to give about your work and general experience of living and working in Ireland”. By adopting this approach we enhanced our study by being able to provide not only statistical evidence of the relationships found, but also rich qualitative insight on their experience of working and living in Ireland. 182 of the samples provided qualitative feedback amounting to a word count of 6,906 which was categorized and coded (general, interaction and work adjustment) using MAXQDA.

5.3 Measurement reliability and validity

We ran reliability analysis in SPSS 26 and confirmatory factor analysis (CFA) in SmartPLS 3 to test the reliability and validity of our focal variables: general adjustment, interaction adjustment and work adjustment. CFA results are shown in Table 2. As shown in Table 2, the composite reliability (CR) scores are all larger than 0.80, with average variance extracted (AVE) scores larger than 0.50. This secures the convergent validity. The squared roots of AVEs are all larger than the respective correlation coefficients (Table 3), confirming discriminant validity. The Heterotrait-Monotrait Ratio (HTMT) scores for all focal variables are all smaller than 0.85, further confirming discriminant validity (Henseler et al., 2015). The reliability (Cronbach’s alpha) for general adjustment was α = 0.81, for interaction adjustment was α = 0.85 and for work adjustment was α = 0.71. The combined reliability, referred to as overall cross-cultural adjustment, yielded a Cronbach’s alpha of α = 0.90. Taken together, the reliability analysis and CFA results show good reliability and validity.

6. Findings

6.1 Cultural adjustment

6.1.1 Quantitative findings

SIE doctors in the study reported an average of 4.66 out of 7 for general adjustment (M = 4.66, SD = 1.16), indicating that they were normal to somewhat adjusted to the general aspects of living in Ireland. SIE doctors in the study reported an average of 4.96 out of 7 for interaction adjustment (M = 4.96, SD = 1.32), indicating that they had slightly higher levels of interaction adjustment compared to the general adjustment they reported. Of the three facets of adjustment investigated, work adjustment was the highest for SIE doctors, with an average of 5.03 out of 7 reported (M = 5.03, SD = 1.20). This result suggests that SIE doctors were somewhat adjusted to working in Irish hospitals.

6.1.2 Qualitative findings

The qualitative responses collected from the sample support the quantitative findings in relation to SIE adjustment to living in Ireland. One SIE doctor said:

It's good to be here, lovely people in general, there is challenges in every work environment or among a new societies for a new person but with patience and wise work through every struggle can come to a good end. SIE216

While another indicated:

I am very pleasant to be in the Irish society. I widens my horizon and ideas. I am impressed by order of law and how all people obey the rules and laws regardless being Irish citizens or residents from overseas countries. SIE209

SIE doctors did note some difficulties in relation to their general adjustment to Ireland, such as difficulty finding accommodation and the price and availability of food from their region. One SIE doctor said:

Cost of Living, housing issues and immigration issues are main hurdles for life in general. SIE116

In relation to interacting in the host culture, one SIE said:

I find interacting with people are extremely helpful, nice and friendly. SIE74

While another SIE doctor echoed the above by saying:

Interaction with people and the overall environment in Ireland … they are friendly and helpful. SIE26

However, some of the SIE doctors highlighted some difficulties in relation to interaction adjustment, often indicating that they felt they were looked upon as different because they were from Africa, and sometimes found it hard to understand how to interact with Irish people. One SIE doctor said:

… I feel racism most of the time. SIE30

While another elaborates on this by saying:

In general I think the Irish have difficulty in dealing with foreign nationals is because Ireland is very new to new people moving in the country especially considering its neighbour which has a very long history of living with multiple nationalities. All in all, I think, even if Ireland is lagging behind in how to deal with these foreigners, the pace and direction of development in this area is very good hopefully with time the Irish people (who are already very tolerant I might add) will finally get used to us foreigners. Especially the ones with different skin colours. SIE54

While another notes:

sometimes I find it difficult to understand (Irish) people's emotions (labile emotions from day today and the double face) the way people look at you in some places. SIE48

Delving into the qualitative data to determine why these doctors felt only somewhat adjusted to working in Ireland, it became clear that the SIE doctors felt they were being underutilized within the workplace and were unable to reach their full potential.

One SIE doctor said:

Easy to integrate myself in and out the workplace … However, significantly difficult opportunities to progress in career compared to EU/Irish citizens. SIE217

While another two more state:

Working conditions are tough as a doctor, there is very little opportunity of career progression as a doctor. SIE 57

Work is good. Salary is good. The skills you learn are good. The only issue is lack of access to a training program. And lack of career progression to consultant positions. SIE5

6.2 Determinants of cultural adjustment

6.2.1 Regression analysis

We performed three linear regression analyses to analyze whether different characteristics (i.e. age, gender, marital status, cultural novelty, previous international work experience, length of time in host country, language ability and perceived fair treatment) of SIEs may influence their general, interaction and work adjustment. The results are reported in Table 4. No relationship was found between age, marital status, cultural novelty, previous international work experience and length of time in the host country in this study, thus rejecting hypotheses 1, 3, 4, 5 and 6. The results of the study indicate that gender, language ability and perceived fair treatment influence either general or work adjustment, partially supporting hypotheses 2, 7 and 8.

Gender is found to influence general adjustment (β = −0.26; p < 0.001). The results suggest that there is a significant gender difference in general adjustment. To further explore the gender difference, we performed a t-test analysis to explore if there is a significant gender difference in general adjustment. The results show that females exhibit higher levels of general adjustment (M_female = 5.14; SD = 1.11; M_male = 4.48, SD = 1.13, t = −3.74, p < 0.001) than their male counterparts. Thus, hypothesis 2 is partially supported.

Language ability is found to influence work adjustment (β = 0.24; p < 0.05), partially supporting hypothesis 7. The results suggest that compared to people with language difficulties, those with no language difficulties exhibit higher levels of work adjustment. While 41.61% of the 161 respondents indicated that they had no difficulty understanding English in Ireland, 41.61% indicated that they sometimes encountered difficulty, and 16.77% said that they definitely had difficulties in understanding English in Ireland. More specifically, 17 (8.81%) indicated that they had difficulty understanding the English of Irish doctors, 51 (26.46%) of Irish patients and 56 (29.02%) socially. Roughly, it took respondents less than 1 year to get used to the accents.

Perceived fair treatment is found to significantly influence general adjustment (β = 0.22; p < 0.01), partially supporting hypothesis 8. Among the 166 respondents who responded to the question of “do you feel you are treated the same as Irish trained doctors working in Ireland”, 72.29% indicated that they did not feel they were treated fairly. Specifically, a majority of respondents highlighted that they were treated differently mainly by consultants (57.51%), managers/supervisors (44.56%) and Irish trained doctors (38.34%). To illustrate how perceived fair treatment influences general adjustment, we performed a t-test in SPSS. The results show that people who perceive fair treatment report a higher level of general adjustment than those who do not perceive fair treatment (M_Fair = 5.04; SD = 1.07; M_Notfair = 4.48, SD = 1.17, t = 2.83, p < 0.01).

6.2.2 Qualitative findings

Language ability was a common theme that ran through the SIE qualitative feedback, with SIE doctors indicating difficulty communicating at first, despite their English fluency; however, these issues tended to dissipate over time:

Irish people need to know that people will have difficulties in communication when they first come and give them the opportunity to settle. SIE 13

As previously mentioned, Ireland recruits significant numbers of SIE doctors, mainly from outside the EU. These doctors are referred to as non–EU non-consultant hospital doctors in Ireland. Research indicates that these doctors are not offered training or career advancement opportunities while working in Ireland (Nolan, 2018, 2022), while their EU counterparts are offered such opportunities resulting in unequal treatment (Nolan, 2021). Drawing from the qualitative feedback provided by SIE doctors, perceived lack of fair treatment was reported in the vast majority of responses. One SIE doctor noted,

I wish the ingrained culture of discrimination in many hospitals improve. SIE25

While another SIE doctor said:

I feel I am judged sometimes for qualifying in Africa. SIE34

The qualitative research found that SIE doctors plan to work in Ireland for a few years to gain experience and then move to the UK or other European countries. This sentiment was echoed by several SIE doctors in the study. One SIE doctor states:

Ireland is a good place to start your career but don't waste more than two years here if you want career progression. SIE23

While another SIE doctor said:

I like the system here, but a lack of clear career pathways make you emotionally drained. … so many more see Ireland as a “training site” with a view of moving to UK. So while the system overall is good, but there are so many things that can be improved. SIE221

This sentiment is echoed by another SIE who said:

In general, Ireland is a welcoming country but career progression is difficult specially in surgery. You find many people leave to UK after they find themselves stuck to the same registrar job for years without progression. SIE148

However, one SIE doctor pointed out that despite the lack of career advancement and training opportunities, Ireland is a good place to live and work and they will continue to do so if given the opportunity.

I like working and living in Ireland but there is very little career progression, we are not considered to be taken in training posts due to non–EU … to be honest with you, I like working in Ireland and will continue if there is opportunity for me. SIE 202

Surprisingly, among the 181 respondents who responded to the question of “are you happy with your decision to come to Ireland to work”, the majority (56.91%) of SIE doctors were happy with their decision to come to work in Ireland, whereas 43.09% were not happy. One SIE doctor states:

I took the right decision by coming to work in Ireland, am not sure if it will be the right one to stay for a long time as it may effect my career progress. SIE155

7. Discussion

Decades of research acknowledges that the transition to working and living in a new culture can be a difficult one (Bhaskar-Shrinivas et al., 2004; Black et al., 1991; Harrison and Shaffer, 2005). While research on SIEs has gained significant momentum over the last decade, little is known about the self-initiated expatriation of medical doctors despite having one of the highest mobility rates of all professionals (Britnell, 2019). The aim of this study was to address the gap in research pertaining to the self-initiated expatriation of SIE doctors; more particularly we tested the validity of eight determinants of cultural adjustment (age, gender, marital status, cultural novelty, previous international work experience, length of time in host country, language ability and perceived fair treatment) to establish if they influence SIE doctors' cultural adjustment. The majority of SIE doctors in the study were male and the average age group lay between 31–40 years old. The top three home countries SIE doctors expatriated from were Pakistan, Sudan and Egypt, respectively. The main motivation for SIE doctors to relocate to work and live in Ireland was for career progression, followed by financial attractiveness and quality of life. Just over half of SIE doctors in our study were living and working in Ireland less than three years, with the remainder of SIE doctors living and working in Ireland for more than three years.

7.1 Implications for theory and practice

SIE doctors in this study reported being somewhat culturally adjusted to working and living in Ireland. They reported slightly higher levels of work adjustment to that of general and interaction adjustment. Drawing from past expatriation research (e.g. Selmer et al., 2009; Okpara, 2016; McNulty and Hutchings, 2016; Lauring and Selmer, 2018; Tenzer and Pudelko, 2017; González et al., 2021; Froese, 2012), we anticipated that age, gender, marital status, cultural novelty, previous international work experience, length of time working in Ireland, language ability and perceived fair treatment would impact on SIE doctors' general, interaction and work adjustment. However, our study found that the majority of these determinants did not influence SIE doctors' cultural adjustment. This research found no relationship between age, marital status, cultural novelty, previous international work experience and length of time working in Ireland, on the three facets of cultural adjustment.

Our research indicates that age does not influence SIE doctors' general, interaction or work adjustment. Past research has indicated that the influence of age on cultural adjustment has been varied and mixed (Wechtler et al., 2015), and as such, we add to the array of mixed results by finding that SIE doctor's age has no influence on their cultural adjustment to Ireland. Marital status has been linked to cultural adjustment in past research with research indicating that married expatriates tend to fare better than their single counterparts (Selmer, 2001; Van Oudenhoven et al., 2003; Selmer and Lauring, 2011; Lauring and Selmer, 2018). Despite this linkage in past research, our results indicated that the marital status of SIE doctors did not impact on their general, interaction or work adjustment. Additionally, in line with past research (e.g. Isakovic and Whitman, 2013; Bhaskar-Shrinivas et al., 2005), we anticipated that cultural novelty would negatively influence SIE doctors' cultural adjustment. However, this was not supported within our findings, suggesting that cultural distance between the home and host culture for SIE doctors in this study did not impact on their ability to adjust to working and living in Ireland. Previous international work experience was also found to have no impact on SIE doctors' cultural adjustment in this study. This finding supports Isakovic and Whitman (2013), which indicated that previous international work experience did not impact on SIEs' cultural adjustment in their study of academics. Additionally, SIE doctors' length of time in Ireland did not influence their cultural adjustment, suggesting that for this cohort of SIEs, the length of time in the host culture had no influence on their cultural adjustment. One possible reason for these findings could relate to the SIE occupational group in question. The determinants of SIE doctors' cultural adjustment may not be comparable to the determinants of other non-medical doctor cohorts of SIEs. This could be because SIE doctors have the largest mobility rate of all highly-skilled professions (Britnell, 2019). Due to such high mobility rates, it is possible that SIE doctors are geared towards the idea of expatriation throughout their training and career, thus making them more accepting of, and prepared for, expatriation during their career.

Drawing from the above, factors that influence SIE doctors' cultural adjustment may differ to that of non-medical SIEs. This highlights the importance of researching and understanding the SIE expatriation of various occupational groups (Fisher and Hutchings, 2013; Salem et al., 2017). SIEs are a diverse group of individuals working across various organizations, and we cannot assume that their expatriation experiences all mirror each other although they all fall into the SIE category of international talent. Therefore, it is increasingly important to assess SIE within different occupational groups, such as health care professionals (Brewster et al., 2021).

Interestingly, our study found that SIE doctors' gender, language ability and perceived fair treatment influenced their cultural adjustment. Female SIE doctors reported a higher level of general adjustment than their male counterparts in the study. This is partially in line with past studies on expatriate gender and adjustment where Salamin and Davoine (2015) and Selmer and Leung (2003), found that female expatriates had higher rates of adjustment to their male counterparts. This finding adds to the growing research surrounding female expatriation, which while steadily growing, is still under-represented in expatriation research (McNulty and Hutchings (2016).

Interestingly, over 58% of SIE doctors in the study reported difficulty understanding the Irish accent, with over 73% stating this issue was resolved within their first year in the country. However, the remainder of SIE doctors noted that it took between 1–3 years to understand the Irish accent, with close to 8% of SIE doctors indicating that they still had difficulty understanding the Irish accent. SIE doctors are in constant communication with management, colleagues and patients, therefore the ability to understand the host accent is pivotal for them to work successfully in their role. Our research found that language ability influenced SIE doctors' work adjustment. This finding is in line with past research indicating that the ability to speak the host language is important for adjustment (Haslberger and Dickmann, 2016; González et al., 2021; Tenzer and Pudelko, 2017; Zhang and Peltokorpi, 2016; Farcas and Gonçalves, 2016: Froese and Peltokorpi, 2013; Isakovic and Whitman, 2013).

The study also found that SIE doctors' perceived fair treatment while working in Ireland impacted on their general adjustment. It is interesting to note that such perceived fair treatment did not influence SIE doctors' work or interaction adjustment; rather, it would appear that perceived fair treatment at work influenced their general adjustment, outside of the working environment. One possible reason for this is that perceived fair treatment at work increased SIE doctors' sense of belonging, as suggested by Penhaligon et al. (2009) in relation to individuals' perceptions. This in turn is likely to have impacted on the SIE doctors' general adjustment to living in the host culture as they may be experiencing a higher sense of belonging within the new culture.

7.2 Limitations and directions for future research

This study is not without limitations. First, the use of subjective evaluation of cross-cultural adjustment may be problematic. We would recommend future research using more objective evaluation of cultural adjustment. Second, although SIEs provide a suitable context to examine cultural adjustment issues, collecting data from a single group, i.e. SIE doctors in the Irish context may prevent us from generalizing our results to other contexts. As a result, it is highly recommended that future research replicates our study in other contexts. Third, we only treated previous international experience as a binary variable (0 = no previous experience and 1 = with previous experience). It is recommended that future research operationalize this variable as a continuous variable. For instance, it could be useful to have more information about their previous international experience, such as the number of previous assignments or the time spent in previous international work experience. Fourth, we only explored certain characteristics of SIEs (e.g. age, gender and international work experience) in our study. Inevitably, other factors, such as spouse/family presence may also determine SIE doctors' cultural adjustment. Thus, it is warranted that future research should include additional variables in their own studies. Fifth, we acknowledge that our survey design is largely descriptive and could have benefited from supplementary interviews. Thus, we recommend future research adopting a mixed-method approach to provide a more in-depth look into our research issue. Finally, since a sizable proportion of SIE doctors' reported difficulty understanding the Irish accent for up to and over three years of being in the culture, we suggest future research investigating the impact of ability to understand host language accent on work related outcomes (e.g. task performance and job satisfaction).

8. Conclusion

The international migration of health care workers is becoming an increasing focal point of debate in global health care policy (Okeke, 2003). To date, limited research exists surrounding the self-initiated expatriation of health care workers, and in particular, self-initiated medical doctors despite the growing trends. Understanding their expatriation and cultural adjustment in their host culture is key to expanding the existent knowledge surrounding SIEs from different occupational groups.

Table 1

Demographic information

Feature		No.	Percentages (%)
Gender	Male	138	71.50
	Female	55	28.50
	Total	193
Age	21–30	33	17.10
	31–40	125	64.77
	41–50	25	12.95
	51–60	10	5.18
	Total	193
Nationality	Sudanese	44	22.80
	Pakistani	76	39.38
	Malaysian	9	4.66
	Indian	11	5.70
	Egyptian	18	9.33
	Nigerian	3	1.55
	Other	32	16.58
	Total	193
Length of time in Ireland	Less than 6 months	17	9.40
	6–11 months	13	7.18
	1–2 years	43	23.76
	2–3 years	21	11.60
	3+ years	87	48.06
	Total	181
SIE motivation to relocate	Financially attractive	34	18.78
	Career progression	96	53.04
	Quality of life	32	17.68
	Other	19	10.50
	Total	181

Table 2

CFA results

Variables and measures	Factor loadings	CFA indices
General adjustment
Please indicate how well you feel adjusted to …
Food	0.70	CR = 0.86 AVE = 0.50
Healthcare facilities	*
Entertainment/recreation facilities and opportunities	0.72
Living conditions	0.72
Cost of living	0.81
Shopping	0.64
Housing conditions	0.65
Interaction adjustment
Please indicate how well you feel adjusted to …
Speaking with host nationals	0.84	CR = 0.90 AVE = 0.69
Interacting with host nationals outside of work	0.89
Interacting with host nationals on a day-to-day basis	0.89
Socializing with host nationals	0.69
Work adjustment
Please indicate how well you feel adjusted to …
Performance standards and expectations	0.84	CR = 0.84 AVE = 0.63
Supervisory responsibilities	0.74
Specific job responsibilities	0.80

Note(s): ^*Item deleted due to low factor loading; CR: composite reliability; AVE: average variance extracted

Table 3

Correlation matrix

Variables	Mean	SD	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
1. Natioanlity_S			1.00
2. Nationality_P			−0.43	1.00
3. Marital			−0.17*	0.06	1.00
4. Age_G1	−	−	−0.09	0.10	0.13	1.00
5. Age_G2	−	−	0.05	−0.18**	0.20	0.52**	1.00
6. Age_G3	−	−	−0.11	0.05	0.12	−0.32**	−0.09	1.00
7. Gender	−	−	0.03	0.18*	0.15*	0.16*	−0.06	0.04	1.00
8. International experience	−	−	0.11	−0.01	0.13	0.04	0.22**	0.05	0.09	1.00
9. Length of stay in host country G1	−	−	−0.04	−0.03	−0.21**	−0.04	0.05	−0.10	−0.11	0.07	1.00
10. Length of stay in host country G2	−	−	0.10	−0.04	−0.14*	0.04	−0.14	−0.17*	0.01	−0.14	−0.30**	1.00
11. Language ability_G1	−	−	0.01	−0.08	0.15*	0.06	0.04	−0.07	0.08	0.03	−0.13	−0.01	1.00
12. Language ability _G2	−	−	−0.08	0.10	−0.07	−0.01	−0.09	0.03	0.03	−0.07	−0.10	−0.03	−0.53**	1.00
13. Fairness	−	−	−0.12	0.08	−0.07	−0.04	−0.07	−0.05	−0.18*	−0.10	0.25**	0.11	−0.15*	−0.13	1.00
14. General adjustment	4.66	1.16	−0.15*	−0.03	0.01	−0.08	0.05	0.05	−0.26**	−0.12	0.04	−0.01	−0.12	0.08	0.22**	1.00
15. Interaction adjustment	4.96	1.32	−0.17*	0.10	0.06	−0.01	0.01	0.01	−0.17*	−0.04	0.00	−0.04	−0.07	0.04	0.11	0.65**	1.00
16. Work adjustment	5.03	1.20	−0.06	0.08	0.05	0.04	−0.03	−0.01	−0.12	−0.03	−0.07	−0.07	0.01	0.13	0.04	0.61**	0.58**	1.00

Note(s): ^**p < 0.01; ^*p < 0.05

Cultural novelty: nationality_S: Sudanese; nationality_P: Pakistani; baseline: other nationality

Marital status: 1 = married, 0 = other status (widow, divorced, or single)

Age: 21–30 years old as the baseline group; Age_G1 = 31–40 years old; Age_G2 = 41–50 years old; Age_G3 = 51–60 years old

Gender: 0 = female; 1 = male

Previous international experience: 1 = yes, 0 = no

Length of stay in host country: 3+ years as the baseline group; Length of stay in host country G1 = less than a year; Length of stay in host country G2 = 1–3 years

Language ability: yes as the baseline group; Language ability_G1: sometimes; Language ability_G2: no

Table 4

Regression results

Independent variables	General adjustment	Interaction adjustment	Work adjustment
Nationality_S	−0.11	−0.12	0.03
Nationality_P	−0.06	0.05	0.08
Marital	0.02	0.06	0.02
Age_G1	0.02	−0.07	0.03
Age_G2	0.09	−0.05	−0.01
Age_G3	0.05	−0.05	0.01
Gender	−0.25***	−0.13	−0.16
Previous international experience	−0.13	−0.04	−0.05
Length of stay in host country G1	−0.04	−0.12	−0.13
Length of stay in host country G2	−0.03	−0.11	−0.13
Language ability_G1	0.04	−0.05	0.17
Language ability _G2	0.16	0.01	0.24*
Fairness	0.20*	0.09	0.12
R2	0.17	0.08	0.09

Note(s): ^*p < 0.05; ^**p < 0.01; ^***p < 0.001

Cultural Novelty: nationality_S: Sudanese; nationality_P: Pakistani; baseline: other nationality

Marital status: 1 = married, 0 = other status (widow, divorced, or single)

Age: 21–30 years old as the baseline group; Age_G1 = 31–40 years old; Age_G2 = 41–50 years old; Age_G3 = 51–60 years old

Gender: 0 = female; 1 = male

Previous international experience: 1 = yes, 0 = no

Length of stay in host country: 3+ years as the baseline group; Length of stay in host country G1 = less than a year; Length of stay in host country G2 = 1–3 years

Language ability: yes as the baseline group; Language ability_G1: sometimes; Language ability_G2: no