Career & Finances | Hospitals | Leadership

Understanding the Nursing Hierarchy: Where Do You Stand?

  • In most healthcare institutions, it is common to find a nursing hierarchy. 
  • Although it is normally left unsaid, this form of organization outlines and establishes the roles and responsibilities of everyone within the institution.  
  • Looking to advance your career? Wondering how far away you are from the top of the hierarchical structure? We have the answers you’re looking for!  

NCC News & Content Team

November 12, 2021
Simmons University

In most healthcare institutions, it is common to find a nursing hierarchy. 

Although it is normally left unsaid, this form of organization outlines and establishes the roles and responsibilities of everyone within the institution.  

Looking to advance your career? Wondering how far away you are from the top of the hierarchical structure? We have the answers you’re looking for!  

Let’s dive into understanding the nursing hierarchy! 

The Nursing Hierarchy

In this breakdown, we will go from the bottom of the structure to the top.  

However, it is important to note that regardless of the positioning of each role, all are essential in successful healthcare facilities. The illustration below was created solely for informational purposes and to outline the individual roles and responsibilities of each career. 

 

nursing hierarchy graph

Staff Nurses

Registered Nurses (RNs)

RNs are typically a patient’s first point of contact upon entering a healthcare facility.  

They are the ones who are assessing and addressing health conditions alongside a physician. 

From providing hands-on care to educating patients and their families on available treatment plans and potential complications, the work of an RN is essential to a healthcare team. 

To become an RN, one must attend a four-year college program and receive a Bachelor of Science in Nursing (BSN) degree, followed by a passed NCLEX-RN examination score.  

From there, the sky is the limit! As a result of the ongoing nursing shortage, RN positions are in high demand nationwide with ample opportunities to specialize!  

Licensed Practical Nurses (LPNs) and Licensed Vocational Nurses (LVNs)

LPNs and LVNs are direct collaborators with RNs. For example, they will commonly assist patients with repositioning, showering, dressing or changing wounds, and various other hands-on forms of care.  

Although the requirements needed to fulfill this position can vary from state to state, in most cases, one will need to earn a diploma in practical nursing, which normally takes about a year to complete.  

nurse practitioncer with pediatric patient

 Nurse Practitioner (NP) and Advanced Practicing Registered Nurse (APRN)

The roles of an NP and APRN are commonly confused, and understandably so!  

Simply put, you cannot become an NP without becoming an APRN first. The main difference between the two is how heavily specialized one can be. 

Typically, an NP will specialize (women’s health, for example) and an APRN will remain in general health.  

Nonetheless, both are essential and now more than ever! As a result of the COVID-19 pandemic, there has been a significant shortage in practicing physicians, so more nurses are pursuing advanced degrees in order to practice independently.  

Nurse Manager/Supervisor

From playing an active role in the development of both recruitment and retention programs to overseeing and critiquing care delivery processes from providers, nurse managers (or supervisors) are an essential role in the healthcare environment.  

Think of this role as one part nurse, one part administrator. 

Nurse managers and supervisors wear many hats and serve as a liaison to the nursing staff and administrators. Additionally, those in this role can also continue to provide hands-on care to patients, especially when staffing rates are low and help is needed.  

Of course, a BSN degree with an RN licensure is required for this role, however, earning a Master of Science in Nursing (MSN) or a Master of Health Administration (MHA) is highly encouraged for anyone interested in applying for the position.  

nurse administrators

Director of Nursing (DON)

On top of the duties of a nurse manager or supervisor, a DON holds many of their own responsibilities that can impact not only the nursing staff, but the institution or facility as a whole.  

Now, you might be thinking, “Well of course, a DON is almost at the top of the nursing hierarchy, but how do you get there?” Let’s break it down.  

As one would expect, the higher up the ladder you go, the more educational expectations there are for candidates. In this case, DONs must hold a BSN degree with a nursing license, and it is recommended that they earn an MHA as well.  

Additionally, any leadership experience leading up to applying for the role is encouraged; it can’t hurt a resume to have it anyways, right? 

From overseeing nursing leadership and staff activities, collaborating with the chief nursing officer (CNO) on various budgeting plans, and ensuring that all protocols and procedures are in line with both state and federal regulations, DONs carry a lot of weight over the healthcare team and facility. 

And as the famous line goes, “With great power, comes great responsibility,” and this is no different for one looking to fulfill the role of a DON.

Chief Nursing Officer (CNO)

We have reached the top of the nursing hierarchy at CNOs.  

Although the title can seem misleading, a CNO is a non-clinical administrator that works alongside various healthcare executives and represents the nursing program in its entirety. However, it is common for CNOs to maintain their nursing license in the event that returning to the bedside is needed (in a code black scenario, for example).  

A CNO can modify and re-implement new care plan procedures and processes to enhance patient experiences, oversee recruitment and retention programs, manage budgeting and employee compensation, and so much more! 

The climb to reach this position can be quite a long one, both experientially and educationally and requires a BSN as well as a master’s level degree (MSN, MHA, or Master’s in Business Administration [MBA]). 

For one looking to land a position as a CNO, it is exceptionally beneficial for them to take on any leadership opportunities that become available to them throughout their career, whether it is from an RN or DON role.

Although there is so much more to be said on the nursing hierarchy, please do not think that your role is any more or any less important than another’s.  

Everyone within a nursing program deserves recognition, because it truly takes a special person to be able to do what they do day in and day out.  

We hope that this break down has given you insight as to how far one can take their nursing career!  

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