Sign-on bonuses are costly for hospitals, and there is no evidence that this practice offers positive and long-lasting benefits. In my opinion, the practice of offering a sign-on bonus is, at best, a paradoxical nursing recruitment tool. We shouldn't need to pay nurses simply to come to work at our hospitals. The sign-on bonus is an ill-conceived practice to avoid fixing the real problems in recruitment and retention of a highly qualified nursing staff. Rather, we should promote and support a culture that values nurses and the contribution they make as an integral part of the healthcare team.

Many of those who leave their job do so because they don't feel valued and appreciated. Most employees leaving jobs report dissatisfaction with management and leadership. Leaders create the culture for an organization. Historically, hospitals have been hierarchical, "top-down" authoritative structures with oppressive rules and regulations for conduct, behavior, scheduling, dress, clinical practice, and attendance. These negative practices create a culture of distrust and erode morale among nurses. In this environment productivity declines and there are negative implications for both nurse and patient satisfaction. Eventually, as things deteriorate, nurses and patients go elsewhere for employment and care.

More efforts should be devoted to retaining excellent employees. A recruitment bonus is quickly spent, and just as quickly forgotten. Often, the initial payment is spent before orientation and socialization into the patient care team is completed. Meanwhile, resentment about the bonus by more tenured nurses is common. Thus, instead of promoting a loyal workforce, sign-on bonuses can actually have a negative effect on morale.

In place of the recruitment bonus, in my opinion, the following five strategies are more effective in sustaining an excellent nursing workforce over time. (1) Create a culture where nurses are valued for being caring, intelligent, trustworthy, disciplined, motivated professionals. (2) Develop, promote, and support an organizational philosophy of shared governance. (3) Allow nurses to direct and control their clinical practice where nurses and physicians interact as professional, respectful, and equal colleagues not just in the clinical setting but as members of hospital committees where decisions regarding patient care are made. (4) Encourage nurses to take responsibility for planning and producing their own work schedules. (5) Encourage and support nurses in critical performance improvement and patient safety activities. Through these five strategies, eventually every nurse becomes a leader and promotes your hospital as "the" place to work. Rather than compensate applicants just to join your hospital staff, consider retention bonus strategies. Demonstrate to a loyal, tenured workforce that they are respected, valued, and critical to the continued success of your hospital.

At my institution, the Human Resources Department has instituted "stay interviews." On a regular basis, the department director interviews nurses who "stay" for 5, 10, 15, or more years. A series of open-ended questions are used that allow current nurses to tell administrators why they chose to remain, what the leadership team could do better, what inhibits their practice, and what enhances longevity. There continues to be overwhelmingly negative responses to sign-on bonuses by our nurses. Instead, suggestions are consistently made for enhanced compensation for the most competent and tenured nurses. Recently, the clinical ladder was expanded to four levels. The registered nurse who advances from novice to expert, from Clinical Nurse I to Clinical Nurse IV, has an economic potential of 5% to 20% increase in salary. Our nursing turnover is an astoundingly low 8%.

Satisfied nurses who recruit others to work at the hospital can be given a "sign-on" bonus to acknowledge their recruiting efforts. Our data has shown that our employees are our largest single recruitment source. We rarely post job advertisements in the newspaper.

In my opinion, the single most important factor in retention is recognition. Recognition occurs as the leadership team publicly acknowledges and rewards contributions that individual nurses make to patient care and teamwork. The sign-on bonus is an expensive, short-lived tactic to "fill slots." Retention of high-quality, high-performing, and satisfied nurses makes more professional sense as a long-term effective strategy for promoting a positive patient care and nursing environment.