What is the nursing hierarchy?
The nursing hierarchy refers to the structured levels of nursing roles within the healthcare system. While “nurse” is a broad term, it includes multiple licensed positions that differ in skills, education, experience and authority. Each role plays a specific part in patient care, and higher levels typically involve greater clinical responsibility, decision-making authority or leadership expectations.
When hiring nurses, understanding how these roles differ allows employers to match patient needs, staffing requirements and regulatory standards with the appropriate level of nursing expertise.
“Each nursing role plays an important function within the context of the medical team, but the roles may involve different duties and tasks that they can perform. It is important to determine the distinctions between these roles so that you can make effective hiring decisions.”
—Michelle Hensley, DNP, APRN, CPNP-PC, PMHS
Some common levels of the nursing hierarchy, listed from entry-level roles to advanced practice positions, are:
Licensed practical nurse (LPN) or licensed vocational nurse (LVN)
Licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) typically complete a one-year diploma program, after which they can sit for the National Council Licensure Examination for Practical Nurses (NCLEX-PN) and earn their credentials. LPNs are trained to perform basic medical care, with common duties including taking vital signs, administering oral medication, inserting catheters and assisting with basic patient care such as dressing and bathing.
Each state may designate the LPN’s scope of practice regarding the duties they can and cannot perform. For example, certain states might limit the ability to insert intravenous (IV) therapy or require additional training and certification to perform this task. State rules might also determine the types of medication that LPNs are able to administer.
Registered nurse
Registered nurses (RNs) typically choose to complete their education through either a two-year associate degree program or a four-year Bachelor of Science in Nursing (BSN) program. After completing their education, they may be required to pass the NCLEX-RN exam and apply for RN licensure within their state.
RNs spend the most time with patients, so they often communicate with physicians to help create the plan of care. They can specialize in certain areas or departments, such as the ER, critical care, oncology and labor and delivery. They might be called staff nurses or bedside nurses, and handle the bulk of direct patient care, including treatments and medication administration.
Advanced practice registered nurse
The advanced practice registered nurse (APRN) is the highest-level position for a nurse in clinical practice, separate from leadership and administrative roles. APRNs encompass roles including nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists and certified nurse midwives.
APRNs provide patient care through diagnosing conditions, prescribing medications and developing treatment plans. Some states allow APRNs to have complete authority to practice independently without a collaborating physician overseeing treatment and care.
The minimum education for an APRN is a master’s degree, but many earn a doctoral degree. The master’s option typically takes an additional two to three years to complete, while the doctoral path takes three to four years.
Nurse supervisor
Supervisory positions might be called a nurse manager or nurse supervisor. Nurses in these leadership roles oversee LPNs or RNs. Nurse managers typically have a minimum of a bachelor’s degree, although master’s degrees are often preferred and sometimes required, especially within larger healthcare organizations.
A nurse supervisor or manager typically oversees nurses in a specific department and does not usually provide direct patient care. They manage staffing, organize unit policies, manage day-to-day operations and facilitate unit budgeting. Supervisors and managers are often involved with hiring and organizing training for new nurses.
Director of nursing
The director of nursing is an executive administrative role within the nursing hierarchy, responsible for providing leadership and directing patient care. This position requires at least a master’s degree. A director of nursing rarely works with patients and instead focuses on high-level decisions that broadly influence patient care. They often work with the chief nursing officer on issues, such as budgeting and policies.
Chief nursing officer
Some healthcare organizations have a chief nursing officer (CNO) who oversees all nursing services for the facility. In a hospital, that means the CNO is responsible for the nurses in all departments of the hospital. It’s an administrative position that usually requires at least a master’s degree, but a doctoral degree may be preferred or required.
FAQs about the nursing hierarchy
Do nurses have to progress through every stage?
Nurses typically don’t have to progress through every stage of the nursing hierarchy. They may choose to enter the field as an LNP or an RN. Most RNs enter the medical field with that credential and never start as an LPN. Some nurses stop at the LPN or RN level, while others pursue advanced degrees or supervisory roles.
Before a nurse can pursue an APRN degree, they need to have a bachelor’s degree in nursing, an RN license and work experience in nursing, so this would require an individual to work up through the ranks. Nurses working in administration begin as staff nurses and then move up through leadership positions.
Who supervises nurses?
Nurses with more experience or seniority may be hired or promoted into roles to supervise the nursing staff. For example, charge nurses are experienced nurses who manage a particular shift in a specific department in the healthcare facility. Nursing managers or supervisors directly oversee staff nurses (RNs) and charge nurses in a specific department while also managing administrative tasks for that unit.
APRNs are typically managed separately by an APRN manager, a clinic manager or a physician, depending on the type of facility they work for. Higher-level nursing administrators, such as directors and chief nursing officers, oversee all nurses, but they don’t typically provide direct supervision for nurses on a day-to-day basis since they deal with administrative tasks.
Are there related positions that don’t require a nursing license?
Some healthcare roles support nursing teams without requiring a nursing license. One example is a certified nursing assistant (CNA). CNAs can earn a certificate in a few months. In their role, CNAs assist nurses with basic care tasks, such as bathing, feeding and turning patients. They also assist the nursing staff in other ways, such as preparing rooms for new patients.
