The Unspoken Nursing Hierarchy and Why It’s Garbage

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Who You’ll Hear

Kati Kleber, MSN RN – Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, and speaker.

Chelsea Klekamp, BSN RN – Experienced bedside nurse, Nurse Residency Program Coordinator. 

Amber Nibling, MSN, RN, NE-BC, NPD-BC, AMB-BC – Experienced bedside nurse, former Clinical Director of Education, current Senior Director of Clinical Learning at Orlando Health

What You’ll Learn

• Make your nurse heart sing
• More than ICU and NP’s
  • Research
  • Certifications
  • Home Health
  • Community Health
  • Education
  • Leadership

The Unspoken Nursing Hierarchy and Why It’s Garbage

What we leave nursing school thinking…

• You should be striving to work with the highest acuity patients.
• You are finally a successful and accomplished nurse once you become a Nurse Practitioner.

The truth is…

• It’s OK if you don’t want to work in the ICU.
• It’s OK if you don’t want to become a Nurse Practitioner. 
• It’s OK to not know what you want to do right away!

Do what makes your nurse heart sing.

• It’s something unique to you– no one else can tell you what the answer is. 
• When considering a career move
  • Ask yourself: is this something I really want? Or is this something I think I’m supposed to want to do?
  • Do some self-reflection to discover what you truly have a passion for and where your strengths lie. 
  • Figure out what you want your ideal day-to-day to look like (schedule, amount of patient contact time, etc.)
  • Practical considerations of different career paths (cost of education, job market, etc.) 
• If you don’t want to work in a hospital at the bedside, that’s OK! Nursing is such a diverse field, you can make an impact in a variety of different ways.
• There is no area of nursing that is greater than or less than the others.

There is more than just the ICU and nurse practitioners!

• Research
  • As a new nurse, you can join the shared governance council at your facility or conduct performance improvement projects on your unit
  • Terminal degree would be a Ph.D. to work as a Nurse Scientist at a facility or doing research at the university level
• Certifications
  • Examples: Sexual Assault Nurse Examiner (SANE), Trauma Nurse Specialist (TNS), Med-Surg (CMSRN), Critical Care (CCRN)
  • A way to dive deeper into your area without investing the amount of money required to go back to school 
• Home Health or Hospice
  • Very individualized, one-on-one care
  • Going into patient’s homes, working with them and their family, often frequently and for an extended period of time
• Community Health Nursing
  • Caring for a whole community
  • Big projects with nursing/healthcare as the foundation 
  • School nursing
• Nurse Librarian
  • Helps students or staff find research articles for papers, projects, or policy development
  • APA extraordinaire 
• Patient safety and quality of care
  • Ensuring regulations and requirements are being followed/met so that the organization gets reimbursed correctly
  • Preparing the organization for Joint Commission or DNV evaluations
  • Monitoring the use of restraints or suicide precautions and ensuring proper documentation
  • Evaluating incidences of HAPIs, CAUTIs, CLABSIs, etc. and ensuring preventative measures are being implemented and documented appropriately
  • Keeping up to date on state regulations and facility policies
  • Track incident reports finding trends that may require a systems-level solution
• Education
  • Master of Science in Nursing Education, or can teach with MSN, DNP, or Ph.D. in Nursing
  • A clinical instructor or academic professor
  • Unit educator
  • Nurse residency program coordinator or coach
• Leadership
  • Unit supervisors and managers
  • House supervisor/administrator
  • Director of Nursing (DON) or Chief Nursing Officer (CNO)

Final thoughts

• Even if you know you want to do something other than bedside nursing, there is still value in doing 1-2 years of bedside nursing to learn and gain experience. It also gives you a foot in the door to explore nursing opportunities within your organization. 
• When you take a new job, give that job time. Two weeks, or even two months, is not enough time to determine whether a job is a good fit. 

Remember that once you’ve graduated nursing school, you’ve made it to the beginning of the journey that is your nursing career. Don’t feel pressured to find your #1 perfect dream job right away! All the experience you gather on the way to your dream job is valuable.

• The Hierarchy of Nursing Fresh RN Blog
• Anatomy of a Super Nurse
• What’s Next