The Hierarchy of Nursing

This post was updated on January 1, 2020

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.

Understanding the Hierarchy of Nursing

Now, please keep in mind that this “hierarchy” is structured in a way in which you begin with positions requiring the least amount of formal education and experience who have the lowest number of responsibilities, and as you work your way “up” each level requires more education and/or experience, and is typically provided more compensation. For example, a chief nursing officer will earn substantially more than an LPN, however they will also carried significantly more responsibilities.

Nursing is a bit unique in that you do have different tracks of hierarchy. You can get into hospital administration and work your way up there, or get into academia, or in roles providing direct care to patients. (There are more, but let’s stick to these for now!) It does get confusing, so hang in there.

To simplify, I’ve split this into three levels based on education requirements and pay scales:

• L1: the LPN and RN
• L2: Nurse Manager, Nurse Educators, Nurse Practitioners
• L3: Directors of Nursing
• L4: Doctorate-Prepared Nurses, Chief Nursing Officers

Truly, I am over-simplifying a very complex field – so please take this structure of the hierarchy with a grain of salt. I mean no offense in “ranking” but it is helpful to understand what’s required of people who are at higher pay scales.

Also, while there are levels, it doesn’t mean that people have to want to “climb the ladder’ to be considered successful. Every RN doesn’t have to aspire to be a nurse manager, and every bedside nurse does not have to aspire to become a CNO or a nurse practitioner. Only each individual knows which role will fulfill their unique professional goals. This chart and explanation is not meant to say one is better than another, rather than to explain our field and the many options we have to pursue our passion.

L1: Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN)

To obtain your LPN/LVN license, one will typically complete 1-2 years of formal education and must pass the NCLEX-PN exam. The LPN/LVN scope of practice varies from state to state in the US.

Some states allow the LPN/LVN to do practically everything an RN can do, with the exception of certain medications and procedures (like hanging blood, IV push meds, etc). However, many hospitals prefer to hire a registered nurse (RN) rather than an LPN/LVN for the majority, if not all, of their patient care roles. With an LPN/LVN license, you may find yourself limited to non-acute care roles (like outpatient clinics, home care, nursing homes, and so forth).

An LPN/LVN is often limited to direct-care roles in these settings, and one would need to obtain further education to advance to any leadership positions. If you’re an LPN/LVN, but not sure if getting your RN is worth it, this is a great article to read that brings up some very valid points.

While the LPN/LVN is still a crucial member of the health care team, the long-term outlook of the position is uncertain. The LPN/LVN is a quick and cost-effective way to get nurses as the bedside as the grip of the nursing shortage begins to tighten across the country. However, the LPN/LVN has mainly shifted to the outpatient setting. In fact, from 1984 to 2005 there was a 47% reduction in LPN roles in the hospital setting (source).

Simply put, if you want to work in a hospital as a nurse or if you ever want to work in a leadership role, you’ll have to obtain your RN.

L1: Staff Nurse / Bedside Nurse (RN)

To obtain your RN, you’ll need anywhere from 2-4 years of formal education and must pass the NCLEX to obtain your license. An Associates Degree in Nursing (ADN) is obtained with typically two full years of school (but often takes longer), or approximately 70 credit hours. A Bachelors of Science in Nursing (BSN) is typically obtained after completing four years of full time school, or approximately 120 credit hours (source).

Here is a great video describing the difference between the two:

With either degree, you are a registered nurse. Whether you get you ADN or BSN, you take the same licensing examination. However, some hospitals only hire BSN-prepared nurses, but those are typically in larger urban areas in which they can have those kinds of requirements and still fill their positions. According to the Institute of Medicine’s recommendations that came out in 2010, they are pushing for 80% of the nursing workforce to be BSN-prepared by 2020.

Some states pushing for this have already begun enacting legislation to support these educational recommendations. In December 2017, New York State signed a bill that requires all newly licensed nurses with their Associates Degree in Nursing (ADN) to obtain their Bachelors of Science in Nursing (BSN) within 10 years of their initial licensure.

If you’d like to get my thoughts on this legislation, I wrote an article about it that you can read here.

Registered Nurses (RNs) can work in a plethora of roles… you can take care of critically ill patients in specialized ICUs, you can become a flight nurse, work as a school nurse, help deliver babies in labor and delivery, work in clinics, in procedural areas, and many, many more…

Most RNs are working in direct patient care roles in various settings. Registered nurses often report to their nurse manager, who is responsible for many (anywhere from 20 to 100+) RNs.  More on nurse managers next!

Many health care organizations offer opportunities for RNs to get more involved in professional development without leaving the bedside.

This includes opportunities like:

• Specialty certifications – here’s a podcast episode explaining certifications, and a blog post about the critical care certification
• Sitting on various committees like Shared Governance or Magnet to address identified needs on nursing units
• Climbing the clinical ladder – here’s an example of one at a pediatric hospital
• Participating in research projects
• Precept nurses new to your unit
• Mentor new nurses
• Train to be a charge nurse – this means you’d be in charge of coordinating the patients coming into and going out of your unit, deal with customer service issues, and essentially run the unit for the shift

Many RNs work decades at the bedside. However, if you want to work in a leadership position, or at a nursing school, in research, or other make a major jump in the pay scale, you will need to go back to school.

L2: Nurse Manager

A nurse manager is the person who is responsible for an entire nursing unit of staff nurses. In some cases, they may be responsible for multiple units or are in charge of an entire facility’s bedside staff. Ideally, a nurse manager is an experienced bedside nurse with exceptional leadership skills and also has their Masters of Science in Nursing.

Nurse managers are not only responsible for the staff nurses, but any nursing assistant/patient care technicians, medical unit receptionist, or anyone else who may have a position on that unit. They are in charge of hiring, firing, scheduling, maintaining the budget, performance evaluations of all of their staff, communicating change, and making sure the bedside staff knows about any changes from the administrative level of the hospital – as well as many other things.

Nurse managers are like the person who connects the bedside staff with hospital leadership. Nurse managers typically report directly to the Director of Nursing (or possibly the Chief Nursing Officer, depending on the size of the organization). As a bedside nurse, you’re responsible for yourself and possibly a CNA or two – as a nurse manager, you’re responsible for many nurses (anywhere from 10 – 100+).

Typically, nurse managers do not provide direct patient care unless circumstances are dire. They are coordinating and managing the nursing staff who provides the care. Naturally, this person must have more education and experience, and carries quite a bit of responsibility so they have a higher pay scale than a bedside nurse.

One who would excel in this role would be someone who can lead others well, has a high degree of emotional intelligence, is very organized, knowledge of how to create and manage a budget, and how to navigate the many personalities of both those who report to them and the leader(s) they would report to themselves.

L2: Nurse Educator

Nurse educators can work in hospitals, nursing schools, or other health care organizations. To be a nurse educator, you typically must have your Master of Science in Nursing (MSN), ideally with a focus in education. (This is the degree I hold!) Some states require any staff member of a nursing department at a nursing school to have their MSN.

If the educator is working in a hospital, they may be assigned to a specific unit, a service line, or the entire hospital. For example, you may have a nurse educator dedicated specifically to the pediatrics department… or they may have the entire pediatrics and women’s health service line (pediatrics ICU and floor, labor and delivery, postpartum)… or they may have the entire hospital.

If you’re working at a school, you could work specifically in the clinical environment, in the classroom, or both.

Nurse educators typically do not work with patients directly. They are responsible for learning about new educational requirements from various accrediting bodies (fore example JCAHO or CMS) or as directed by the administration of the hospital or leaders on the nursing program, creating that education and delivering it to the staff or students. They also track various numbers (also called nursing-sensitive indicators) like central line infections, catheter-associated urinary tract infections, pressure ulcers, and many more and create/deliver/evaluate education to help improve those numbers. If they’re an educator at school, they’re tracking things like NCLEX pass rates, job placement, drop out rates, and more.

One who would excel in this role must have a passion to teach and encourage current and/or prospective nurses. It is not the educator’s job to manage the nurse, rather to provide the necessary education to enable the nurse to provide safe care. Exceptional nurse educators also inspire nurses to want to become the best versions of themselves with a continued thirst for knowledge and to refine their practice.

(I could talk about nursing education all day… let’s continue on though, shall we?)

L2: Nurse Practitioner (NP)

Ok, here is where it begins to get really confusing! Hang in there with me. Nurse Practitioners are someone who is above the level of the staff nurse in terms of responsibility, educational requirements, and liability. However, NPs are not typically employed by a specific nursing unit. Organizationally speaking, they’re working under a physician and in most cases that person would be their one-up, not the nurse manager.

For example, if you have a cardiology nursing floor and it has 20 nurses on it, the nurse manager oversees them. If this cardiology floor has two cardiologists who have two NPs, the NPs do NOT report to the nurse manager. They report to the cardiologists. Does that make sense? So while the NPs work together with the bedside staff, they’re not reporting to the same person.

Educationally speaking, they’re more in line with the nurse managers and educators.

A nurse practitioner (NP) is someone who has completed a graduate degree (it can be a Masters or Doctorate) which enables them to go from providing direct patient care to being a provider. This means they have the ability to place orders for medications, procedures, monitoring, and so forth. Some states allow NPs to function independently, while others require them to work under a physician. You can work in the outpatient setting or inpatient setting as an NP.

The NP’s responsibility, liability, and scope is much larger and heavier than the bedside nurse. As an NP, there is a whole new world of billing, coding, and documentation that the bedside RN is not evaluated upon. So, you’re going from giving the medications to deciding which medications to give!

Depending on where the NP works, their day can vary widely. Here are a few quick comparisons. (Please note, this is not reflective of ALL people who work in these environments, they are general explanations.)

A quick ICU bedside RN to acute care NP comparison:

• The ICU bedside RN’s day consists of getting report on anywhere from 1-3 patients. They provide care to those specific patients for the entirety of the shift; monitoring, assessing, administering medications, documenting, etc. They communicate with the NP and physician closely throughout the shift to alert them of any changes or needs, implementing orders appropriately as they are received.
• The ICU NP may work closely with the intensivist and round on the entire unit. They would see each patient, look closely at their chart, decide on any new orders and changes to the plan of care, collaborate on their thoughts with the physician, and then enter the orders and write a progress note. The ICU nurse would implement the orders. The ICU NP may also insert central lines, arterial lines, perform thoracentesis, paracentesis, chest tube insertion, and many more very advanced and invasive procedures. The ICU nurse would assist with this, but would not perform the procedures.

A quick comparison of the outpatient RN to the outpatient NP:

• The outpatient RN’s day would consist of assisting the NP/PA or physician with procedures, speaking with patients on the phone and determining the best course of action (imagine doing an entire assessment without actually seeing the patient!), updating patients via phone about their labs/scans/diagnostics and plan of care while answering questions, speaking with insurance agencies, and so forth.
• An outpatient NP would have a list of appointments for the day of patients coming to see them at designated times. Someone else will check the patient in, get them in the room, gather necessary documentation, and then the NP would see the patient. They would assess the patient, come up with a plan of care, write any necessary orders (med changes, scans, labs, consultations with other providers), perform procedures, and document everything.

To get your NP, you must complete a nursing graduate program such as an MSN program or doctorate program (DNP). You can’t just complete any MSN or DNP – it must have the nurse practitioner portion as well. Not all MSN or DNP programs are created equal. The NP portion is a specialty certification added to the graduate degree.

Here is a (non-exhaustive) list of the many acronyms NP’s can have:

• NP = Nurse Practitioner
• APRN = Advanced Practice Registered Nurse
• CNS = Clinical Nurse Specialist – differs from an NP, but professionally prepared at a similar level with a graduate degree, specialty certification, and license
• CRNP = Certified Registered Nurse Practitioner
• CPNP = Certified Pediatric Nurse Practitioner
• NNP = Neonatal Nurse Practitioner
• FNP = Family Nurse Practitioner
• AG = Adult-Gerontology
• BC = Board-Certified

For example, I have an MSN in Nursing Education but I do NOT have my advanced practice certification. So, while I do have an MSN I cannot practice as an NP.

Therefore, with the MSN (or DNP) and NP certification you can work as an NP but you don’t have to. You have that graduate degree, so if you wanted to work in education you absolutely could!

Plus, there are different kinds of NP programs to choose from…

This is an important distinction:

• Family (Primary Care) = all patients of all ages across the lifespan (FNP)
• Adult = only adult aged patients

Additional specializations options include:

• Pediatric
• Neonatal
• Gerontological
• Psychiatric
• Women’s
• Oncology
• Emergency care
• Midwifery

Currently, you can still get your MSN and be an NP (it’s shorter and costs less), but that may change. Some larger, more prestigious NP schools have already done away with their MSN option for the NP.

Check out this awesome infographic explaining the NP options, created by Sean Dent, MSN ACNP CCRN.

Ok, now that we’ve got the management/leadership, education, and patient care graduate-level tracks covered – let’s move on up!

L3: Director of Nursing

A director of nursing works at a hospital. Remember how the nurse manager was in charge of many staff nurses? Well, the Director of Nursing is in charge of multiple nurse managers. While the staff nurses don’t directly report to the director, they are under their jurisdiction – so to speak.

Directors of Nursing typically are responsible for an entire service line, rather than one unit. So instead of just the pediatrics manager (and subsequently all the staff nurses who report to that nurse manager), they may also be responsible for the nurse managers of the pediatric emergency department, pediatric ICU, and NICU. Essentially, the higher you go up the hierarchy, the larger the amount of responsibility on your shoulders.

Directors of Nursing are working with other leaders of the health care organization, often people who are overseeing and in charge of non-nursing related areas. Nurses in these roles are the representative for nurses in the boardrooms when higher level decisions are made about the organization. For example, let’s say to cut costs one of the top level executives at the hospital wants to go down to only having one in-house pharmacist at night rather than two. The Director of Nursing is the one at the table of those high-level decisions to say,

“Whoa whoa whoa whoa here. The nursing staff frequently utilizes the pharmacist for medication needs overnight – whether that be clarification of drug compatibility, safe substitutions, troubleshooting, etc. The pharmacist already must approve all meds that come though and removing one would substantially slow the time in which meds are approved, which in turn would slow how fast they can be administered. While this makes sense on paper and may save us money up front, practically it most likely will result in many late meds and puts us at high risk for safety events. It may cause some serious pharmacy and nursing staff dissatisfaction, and ultimately cost more than we’d save while putting patients at risk.”

It is crucial to have nurses in these roles to advocate for us, because there are many people making decisions that impact nursing care directly who have never touched a patient. It is these nurses in the manager, director, and CNO roles who advocate for us on our behalf.

Generally, someone who is in the Director of Nursing role should have a Masters of Science in Nursing; or something similar, ideally with a focus in health care administration. Organizations may now prefer nurses in these roles to have their DNP as well.

L4: Doctorate-Prepared Nurses

There are two terminal degree nurses can pursue: The Doctorate of Nursing Practice (DNP) and the Doctor of Philosophy.

To oversimplify these two roles:

• The DNP-prepared nurse is educated to prepare nurses to work at the highest level of practice. They translate and analyze research and apply it to practice. Generally, this is a more clinically-focused degree. You’d be a “practitioner” in this role.
• The PhD-prepared nurse is educated to actually create the research. This is a degree heavily focused on research. You’d be a “researcher” in this role.

With both of these, you can work in a health care organization or nursing school. Because fewer people go into the PhD role and it is a longer and more involved process, naturally it is in more demand – especially in academia. While this may be unspoken, a PhD is typically viewed with more prestige when candidates apply to these higher level positions (CNO, Director, Nursing Program Director, etc.).

If you’ve got a terminal degree (meaning, you cannot obtain a higher degree in the same field), then you should command more compensation and responsibility.

A note about NP’s with the DNP degree: As mentioned before, the educational winds are shifting to require NPs to have a DNP. While that is the goal, it’s not yet come to fruition. However, a DNP does not mean you must work as an NP. You can choose to work in leadership or educational positions as well.

(I chose to place NP in L3 and doctorate-prepared RNs in L4 because currently one can work as an NP with an MSN. One could argue this either way.)

L4: Chief Nursing Officer (CNO) 

The top of the hierarchy in a health care organization from a nursing perspective is the Chief Nursing Officer (CNO, or may also be the Chief Nursing Executive/CNE). All nursing directors would report to this person.

To recap:

• Bedside nurses report to nurse managers
• Nurse managers report to directors of nursing
• Directors of nursing report to the CNO/CNE
• Badda-bing, badda-boom

The CNO is ultimately responsible for the nursing care at a health care organization. This role requires the most experience and education, and carries the most responsibility. Therefore, the CNO is most likely the person with the highest pay scale. They typically have at minimum an MSN (ideally with a leadership background); ideally also an MBA because they are not only responsible for the direct nursing care itself but facilitating it from a financial perspective in a sustainable way.

If the CNO believes that the organization needs to allot for more nurses on a specific service line, create a new educational program, substantially change an existing nursing process, then they have to be able to justify it to the other higher up/stakeholders from both a financial and practical standpoint.

People in the CNO role have typically been in the field of nursing for many years and obtaining the position is the culmination of many years of clinical work, holding various leadership positions, and completing a graduate degree.

The unspoken hierarchy

One thing I felt as a nursing student was the unspoken hierarchy or nurses. It felt like everyone was supposed to go back to get their NP… that you have to start out in med-surg, progress to the ICU, eventually flight nursing, and then get your NP and work with the sickest patients possible to be considered the best.

Well – that’s just completely ludicrous.

(Please note, I’m using every ounce of strength not to make an early 2000’s rap reference here.)

The truth is, there are so many different options within the field of nursing. After a few years in practice, I realized that I had no desire to become a nurse practitioner – I loved education. Why should I spend all that time and money to pursue a degree and get a job that ultimately was not my professional passion?

I wanted to wake up and be excited about work each day. I knew that if I went for the NP option, I wouldn’t feel that way. So, while some may think every nurse should want to climb this hierarchy, I’m not buying into it.

At the end of the day, it’s your life, your time, and your money. (And these days, it is a lot of money. It would be wise to spend that large sum pursuing a degree that you have a specific plan for.)

Only you know what provides you with joy and professional satisfaction. The key is not getting complacent.  Many look to the next step because once we feel that boredom or complacency, we assume we’re supposed to want to do the next step on the ladder.

If you’re finding that you feel bored and need a new challenge, before embarking on a major financial and life commitment – consider the day to day of what your life would be like once you obtained that degree. Consider if the time and financial investment are worth it. If you’re not sure, consider digging into some lateral challenges and responsibilities in your current role and you figure out what’s best for you.

Nursing is an outstanding profession with many options and a promising outlook.

If you’re considering being a nurse, I highly recommend it. I started nursing school in 2007 and am so glad that I did.

If you’re an experienced nurse looking for a new challenge, check out my book, What’s Next: The Smart Nurse’s Guide to Your Dream Career, published by the American Nurses Association.

More resources

• How to Become a CNS: 6 Realistic Steps
• If you’re looking to land a nursing job, I’ve got a free nurse resume template that you can download here.