Quick-hire tactics may cause long-term problems

Sign-on bonuses and other perks can backfire

With the nursing shortage reaching almost-crisis levels, hospitals across the country are getting more aggressive in their efforts to recruit nurses to their institution.

Sign-on bonuses in the five figures, housing down-payment assistance, flexible working hours, and assistance with student-loan payments are just the tip of the iceberg when it comes to how far some systems feel they must go to fill vacancies.

"Ten years ago, it was $1,000 or $1,500 [sign-on bonuses]. In some critical areas, they went as high as maybe $5,000. Now, you are seeing sign-on bonuses of $10,000 - $20,000," says Brenda Nevid-jon, RN, MSN, associate clinical professor in health systems leadership in the outcomes division of the Duke University School of Nursing in Durham, NC.

But some nursing experts are warning hospitals that aggressive recruiting efforts are, at best, a short-term solution to the problem and may backfire if the institutions don’t have an equally aggressive plan in place to retain existing staff.

In fact, some hospitals don’t use sign-on bonuses at all because they feel they create inequality and resentment in the working environment.

"We do not use sign-on bonuses for newly hired nurses," notes Patty Puckett, RN, nurse recruiter for St. Jude’s Children’s Research Hospital in Memphis, TN. "We do not feel it is appropriate to reward newly hired employees over what we can give current employees who are working so hard and so professionally to care for our patients."

St. Jude’s nurse recruiting efforts emphasize the hospital’s unique clinical environment, and a very competitive starting salaries and benefit packages and have been very successful, she says. "We feel that sign-on bonuses may attract people who are mainly in it for the money, and that is not the kind of professional we hope to recruit here."

With nursing vacancies in hospitals estimated at 12% of capacity nationwide, an estimated 126,000 open jobs, the shortage of hospital nurses only is going to get more critical. As the baby boomers continue to age and retire, more and more vacancies will appear, Nevidjon says. Right now, the average age of full-time nursing faculty is 49 years, and one-third of nursing personnel nationwide are older than 50. And as has been the case for the past several years, fewer students are entering nursing schools and choosing health care as a career.

Hospitals need both short- and long-term solutions to the problem, say Nevidjon and others.

"If hospitals use the sign-on bonuses and premium packages to recruit new nurses, then they should see them as very short-term strategies," says Toni C. McKenna, RN, MSN, DNSc, senior director of the clinical leadership at VHA Inc., a nationwide network of community-owned hospitals and health care facilities based in Irving, TX. "Obviously, it has a lot to do with market competition. If other hospitals in the area are offering such incentives, I think many feel compelled to do it."

But these strategies work best when coupled with a longevity bonus for existing staff that is already in place, she adds.

"In places where it has been most successful, you see a sign-on bonus coupled with a recruiting bonus — so if a nurse brings a new nurse on board, not only will the new nurse get the signing bonus, but the recruiting nurse gets the same amount as well."

And though St. Jude’s does not offer sign-on bonuses for new nurses, they do offer recruitment bonuses for nurses who refer candidates for open positions there, says Puckett. "This has been a very effective program for recruiting the right nurses for our staff."

But hospitals hit by declining reimbursements from government and third-party payers are not likely to have the resources to keep up such bonuses to recruits and/or existing nursing staff for very long, admits McKenna.

Hospitals also should begin to look for other incentives, such as the type of working environment they provide to the nurses, she says.

Flexibility of work schedules, management responsiveness to concerns, autonomy for professional nurses, and whether the nurses’ clinical judgment is respected in patient care, are all factors that will influence whether a nurse decides to take or keep a job at a particular hospital, McKenna believes.

Recognition of differing levels of skills

Hospitals that are successful at recruiting and keeping nurses in the future are likely to be the ones that are more creative in the way they define roles for nurses in their organization, adds Nevidjon.

"Most organizations have a staff job description," she says. "But, some already have what they call clinical ladders where they do differentiate between the experience of a novice nurse vs. the experience of a more seasoned expert nurse."

A nurse who is 55 years old may not want to work all the way to age 65 on rotating, 12-hour shifts caring for patients, she explains. But that person still has a wealth of accumulated knowledge, wisdom, and expertise, she explains.

"They are our wisdom leaders; they are our experts. They are the ones whose intuitiveness at the bedside has saved many, many patients. So, there is a way to use that person with all of the new graduates coming out who cannot be up to speed because it takes time to work up to a level of competency," she says. "Maybe they are the nurse to the novice nurses."

Use of new technology to make the physical work of nursing easier also makes sense since most nurses are and will be in their 40s or older, she adds.

"There is a lot of room for more use of new stretchers, chairs, supports for moving people, etc.," Nevidjon says, adding that these supports would be beneficial for attracting and retaining nurses who are younger as well as older ones. "You can have a 25-year-old nurse pull a back muscle moving a patient."

Flexible work scheduling without as much mandatory overtime hours are very important to nurses, add both Nevidjon and McKenna.

Money rarely is the primary motivating factor influencing whether a nurse will remain at a given institution, she says. "For the most part, hospitals have to stay competitive, so salaries are roughly the same."

What will make the difference to today’s newer nurses is the ability to balance their professional and personal lives, says Nevidjon. "It is a generational thing. They are more mobile, they are less inclined to work for the same organization for 30 years, and they want to be able to spend time with their families."

However, flexible scheduling can be difficult to do in an already understaffed environment and can provoke discord if not handled carefully, she adds.

"Very key in this is your frontline managers because flexibility is very, very key. But, sometimes staff can interpret flexibility as preferential treatment," she explains. "You have to have very well-prepared managers to deal with all of those group dynamics."

Hospital administrators need to focus on getting the nursing managers the skills they need to manage these environments effectively, Nevidjon adds.

Empowerment and respect are essential

Nurses also want to work in environments where they feel their knowledge and skills are listened to and respected, says McKenna.

"Money is usually not the No. 1 issue," she notes. "It is whether the nurse is listened to, is he or she allowed to make decisions, does she have the support to have all of the resources she needs at her fingertips — whether it is equipment, enough hands on board, etc."

Good physician-nurse interaction, in particular, can be essential in retaining quality nurses, she notes.

A recent study conducted by physicians and nurses at VHA hospitals, which make up 26% of the nation’s community hospitals, found that "disruptive physician behavior" and the institution’s response to it significantly affected nurse morale and was a key factor in many nurses’ decision to leave the profession.

The survey of 1,200 physicians, nurses, and health care executives, published in the June issue of American Journal of Nursing, found that 30% of nurse respondents knew at least one nurse who resigned because of physician behavior.

For the study, disruptive behavior was defined as "any inappropriate behavior, confrontation, or conflict, including verbal abuse to physical and sexual harassment."

Overall, 92% of respondents said they had witnessed disruptive physician behavior.

Use of assistive personnel

Hospitals also need to look at different models of using both licensed RNs and unlicensed assistive personnel, Nevidjon advises.

Although RNs in the past may have been resistant to the hiring of unlicensed aides — because they have often been seen as substitute for more highly trained RNs — this does not have to be the case.

Many RNs younger than 40 have always worked on all-RN staffs and are not used to working in conjunction with the other providers, she explains. But older nurses usually have worked with aides and licensed practical nurses.

"You don’t want to get your ratio low (between the number of registered nurses and unlicensed personnel) — that would not be good for patient care," she says. "But, you can really develop a care model where you can use some assistive personnel."

Nurses, particularly nurse managers, need to become familiar with the state practice laws to understand the appropriate scope of practice for other caregivers.

New law may provide new options

However proactive hospitals are with recruitment and retaining strategies, they won’t be very successful without help from state and federal governments, say both McKenna and Nevidjon. Major public-policy efforts are needed to encourage people to enter nursing schools, reform outdated practice requirements that discourage nurses from staying in the profession, and pursue other sources of professional nurses, such as nurses from other countries who want to work here.

A new law currently before Congress has the potential to begin to remedy the problem, says McKenna.

The Nurse Reinvestment Act, introduced by Sen. Barbara Mikulski (D-MD) on Dec. 20 and passed by the Senate on the same day, will amend the Public Health Service Act to initiate an scholarship program to pay for the education of nurses who agree to practice in critical areas for a certain period of time, set up a grant program to award funding to institutions that set up effective nurse recruiting and training programs and career-ladder programs for nurses, and establish grants for funding public awareness and education campaigns aimed at the public.

"This new bill would help a lot, particularly since it contains the provision to repay student loans if a nurse agrees to work a certain period in a needed area," McKenna advises.

The Senate bill was sent to the House on Jan. 23 and has been referred to the House Committee on Energy and Commerce’s subcommittee on health. n


  • Brenda Nevidjon, RN, MSN, Duke University School of Nursing, DUMC Box 3322, Durham, NC 27710.
  • Toni C. McKenna, RN, MSN, DNSc, VHA Inc., 220 E. Las Colinas Blvd., Irving, TX 75039.
  • Patty Puckett, RN, St. Jude Children’s Research Hospital, 501 St. Jude Place, Memphis, TN 38105.