We spent twelve years working cross-culturally in East Africa, in a language development mission. Our organisation, SIL Global, was something so many of us were sold out for. “We are a global community rooted in local realities,” the mission said of itself. “Our activities in each place are guided by the cultures, priorities and partnerships of the people we serve.” We were there so that people could read and write in their own mother tongue, and so that communities could read the texts that mattered most to them in the language they understood best.
Each country had its own branch, and the number of people depended on the location and the need. Ours was a dual-country branch, Uganda and Tanzania, made up of around 100 international expatriates, predominantly from Western nations, and around 100 nationals stationed across the two countries. We worked alongside other missions and NGOs too, because the expatriate world is a small one and you come to know each other well.
I say all of this because I do not want to make it sound like something was wrong with our mission. The opposite is true. I was proud to serve with them. They were the most thorough I had seen, both in their cultural training and in their interpersonal training. And yet I watched so many good people leave. Not because they hated the work, and not only because the conditions were hard and foreign, though all of that added its own pressure. Mostly, we saw people leave because of interpersonal tensions and relationship breakdowns.
Among those 100 expatriates there were 15 different nationalities. Our organisation knew exactly what that meant, and it never stopped investing in the interpersonal and cultural awareness training its members needed. It was ongoing, not a one-off. It was treated as something that mattered, which was not what we saw in many of the missions and NGOs working around us.
The reason people leave is rarely the one you would guess
When mission agencies finally studied this properly, the findings matched what we had lived. In the 1990s the World Evangelical Alliance ran a study across 14 nations, published as Too Valuable to Lose.1 It found that missionaries were leaving the field at around 5 per cent a year, and that roughly 71 per cent of that loss was preventable.1 Preventable. Not the climate, not the danger, not the sheer difficulty of the work. Something that could have been addressed.
A larger follow-up, ReMAP II, surveyed around 600 agencies and nearly 40,000 missionaries across 22 countries, and was published as Worth Keeping.2 It shifted the question from why people leave to what keeps them, and the answer kept landing in the same place: the quality of relationships, and the care agencies put into supporting them. Conflict with colleagues, and breakdowns between team members and their leaders, sat consistently among the leading preventable reasons people walked away.2
Read that again, because it is the part that should stop a manager in their tracks. These were not disengaged people. They had uprooted their lives, raised their own funding, learned new languages and moved across the world on purpose. They were about as motivated and committed as a workforce gets. And still, what undid them most often was not the mission. It was each other.
Why “similar” people still clash
It would be easy to assume this is about vast cultural distance: the Westerner who cannot read a village, the new arrival lost in an unfamiliar country. It was not. Some of the sharpest friction I saw was between people who looked, on paper, like they should have understood each other instantly. A German and an American. An Australian and a Brit. People from “similar” Western nations who shared a language and a faith and still misread one another constantly, over directness, over how you raise a problem, over what a silence means.
Culture is not only nationality. It is the set of unspoken rules each of us carries about how people should behave, and those rules do not announce themselves. They simply feel like the normal way to be. When two people with different normals work closely under pressure, the gap usually shows up as a judgement about character. He is rude. She is cold. They are difficult. What is actually happening is two cultural scripts colliding, with neither person able to see their own.
The same story plays out on every healthcare team
If you run a healthcare team in Australia, you are running the same experiment, without the visas. Your floor brings together internationally trained clinicians and Australian-born staff, senior and junior, people who disagree in completely different ways about completely different things. We usually talk about cross-cultural skill as something for the patient interaction, how culture shapes communication at the bedside. But the missionary research points somewhere we tend to ignore. The relationships between staff are where people quietly decide whether to stay.
A nurse raised never to contradict a senior will not tell you she disagrees. She will go quiet, and eventually she will go elsewhere. A doctor trained to be direct will read an Australian colleague’s softened “maybe we could think about that” as agreement, and be blindsided when it was not. None of it is about competence. All of it wears people down, and worn-down people leave. In a sector already losing staff faster than it can replace them, that is not a soft problem. It is a retention problem, and an expensive one.
What actually keeps people
Here is what my mission understood that most workplaces do not. They did not treat cultural and interpersonal skill as something you cover once at orientation and then tick off. They treated it as a practice, returned to again and again, because the friction is ongoing and so the work has to be. This is the same case we make for moving beyond one-off training in healthcare. When an agency invested in that kind of ongoing support, its preventable losses dropped.2 When it did not, people left.
The lesson for healthcare leaders is uncomfortable but freeing, because it asks less for a new budget than for a new target. You are almost certainly already spending on orientation, on team days, on training. The question is whether any of it is pointed at the thing that actually drives people out.
What this means for managers
- Treat team culture as ongoing work, not an induction module. A single session at the start cannot carry a team through years of friction. Build cultural awareness into regular practice, not just the first week.
- Make the difference sayable. People manage what they can name. When a team can talk openly about directness, hierarchy and silence as cultural differences rather than character flaws, the friction stops being personal.
- Watch the quiet ones. The staff most likely to leave over relationships are often the least likely to tell you. Disengagement is not always loud. Sometimes it is just someone going still.
- Remember it runs both ways. This is not only internationally trained staff adjusting to Australia. Australian-born staff have a culture too, and it has to be learned in both directions.
- Ask your internationally trained staff what they need. They can usually tell you exactly where the friction sits, if you ask them and mean it.
The people who left our mission were not weak and they were not uncommitted. They were good people who ran out of road in their relationships before they ran out of love for the work. Healthcare is losing people the same way, and mostly we are not even measuring it.
If this is the kind of thing you are wrestling with in your own teams, I would like to talk. Have a coffee or a call with us, no pitch, just a conversation about what it could look like where you work.
References
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Taylor, W. D. (ed.) (1997). Too Valuable to Lose: Exploring the Causes and Cures of Missionary Attrition. Pasadena, CA: William Carey Library. ↩ ↩2
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Hay, R., Lim, V., Blocher, D. et al. (eds.) (2007). Worth Keeping: Global Perspectives on Best Practice in Missionary Retention. Pasadena, CA: William Carey Library. ↩ ↩2 ↩3
