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Traditional healthcare settings, including hospitals, operate under a hierarchy of nursing to define the structures of order and organization.  Nurses are ranked according to levels of license and education, and by years of experience. This can be kind of confusing to the new nurse walking into the hospital (“Uhhhh he just told me he was the DON and I don’t really know what that means…) , so I’ve outlined a typical hierarchy of nursing below.

Traditional healthcare settings, operate under a hierarchy of nursing to define the structures of order and organization. Let's look at the hierarchy....

Understanding the Hierarchy of Nursing

Chief Nursing Officer (CNO) The CNO, also known as the CNE or the chief nursing executive, is found at the top of the hierarchy pyramid, and reports directly to the chief executive officer (CEO) or the hospital or agency. The CNO functions in both administrative and supervisory roles and is responsible for the delivery of all nursing services across the hospital or healthcare unit. A CNO or CNE will generally have a minimum of a master’s degree and previous experience in nursing leadership positions.

Director of Nursing (DON) The director of nursing acts as an administrator, providing leadership for the department and/or service line, which ultimately directs patient care. They can be a director of the entire hospital, service line, or single department, depending on the size of the facility.  As an administrator, duties may include budgeting, record keeping, decisions on how different educational requirements are met, dealing with regularly issues, working with physician groups and other departments nursing works with, and so forth. Related positions at this level may include director of nursing services or director of patient care services. A DON will generally have a minimum of a master’s degree.

Nurse Supervisor or Nurse Manager Nurse supervisors and nurse managers function as a part of a leadership team, taking responsibility for various units. A nurse manager may be the manager for one nursing unit, or a group of them.  They are the step between administration and the bedside staff, and communicate changes back and forth.  They typically are holding or coordinating staff meetings to update the employees they are responsible for, as well as attending facility leadership meetings to touch base with who they report to.  Generally, they arrange for nursing care to be provided to patients (however that may look at the facility), in addition to many (and I mean many) other tasks including hiring, scheduling, and budgetary needs of the unit, . The nurse supervisor or nurse manager will typically be required to have a bachelor’s degree, and a master’s degree is recommended.  The nurse manager typically is not providing direct patient care, but rather coordinating things for the nurses who are.

Advanced Practice Registered Nurse (APRN) An APRN offers treatment services and patient care, typically in direct collaboration with a physician. However, in accordance with the laws of each state, they actually may practice independently with complete authority, and without a physician’s collaborative agreement. (Pretty awesome, right?) They may diagnose and treat patients, and in some environments, be the primary healthcare provider to their patients. There are four different types of APRN’s, including: Nurse Practitioners (explained below), as well as Certified Nurse Midwives (CNM), Certified Registered Nurse Anesthetists (CRNA), and Clinical Nurse Specialists (CNS). An APRN must currently hold a master’s degree and their specialty training in one of the four aforementioned areas, but many APRNs are seeking terminal degrees (DNP, PhD).

Nurse Practitioner (Certified Registered Nurse Practitioner, CRNP) A CRNP, or more frequently abbreviated as a NP, is a type of advanced practice registered nurse.   A nurse practitioner may work with patients of all ages and their families, providing useful and important information to help in decision making regarding lifestyle and healthcare. The nurse practitioner practices in accordance with the Nurse Practice Act, as prescribed by the state in which they work. The majority of nurse practitioners chose an area of specialty in which to be nationally certified.  The areas of specialty recognized by the American Nurses Credentialing Center are: Acute Care, Adult Gerontology, Emergency, Family, Neonatal, Pediatric, Psychiatric, and Women’s Health.

Staff Nurse or Bedside Nurse (RN) A staff or bedside nurse is typically a registered nurse providing direct patient care, by directly assessing, monitoring and observing patients as the first point of contact. They coordinate care for the patient within the entire health care team.  Today, to practice as a registered nurse one must pass the NCLEX-RN after graduating from a diploma or associate’s degree program. However, many hospitals and other employers, however, now require a bachelor’s degree to comply with the IOM’s recommendation for the nursing workforce to be 80% bachelor’s prepared by the year 2020.

Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) An LPN/LVN will often provide basic medical care and assistance, however depending on the facility and state, the LPN/LVN may provide care in a very similar scope to the RN with the exception of a few tasks (like hanging blood, for example). These tasks may include dressing changes, catheter insertions, administering oral medications, obtaining vital signs and so forth. Most LPN/LVN-prepared nurses work in the long term care setting, but can work in many different areas. To be an LPN/LVN, one typically completes 1-2 years of training and takes the NCLEX-PN exam.

Other Nursing Positions and Career Growth

The nursing hierarchy includes many roles and titles not listed here. Johnson & Johnson’s website Discover Nursing lists 104 areas of specialty positions in nursing, describing some great employment opportunities.

Nursing career development potential is highlighted by the growth and size of the profession. Nursing employment is projected to grow 16 percent by 2024, which, according to the Bureau of Labor Statistics, is much faster than the average for all occupations.

“Nursing is the nation’s largest health care profession, with more than 3.1 million registered nurses nationwide,” says the American Association of Colleges of Nursing. “Nurses comprise the largest single component of hospital staff, are the primary providers of hospital patient care, and deliver most of the nation’s long-term care.”

Pursuing Nursing Opportunities

So many advanced career opportunities are available for nurses and can advance the quality of patient care. Alvernia’s online RN to BSN degree Completion Program prepares students for management-level positions and other nursing specialties. The program offers a convenient and flexible online learning environment, accommodating the personal and work schedules of students. Alvernia also offers a Post-Master’s online DNP Clinical Leadership Program. Check out Alvernia University for more information on nursing hierarchy.


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