Understanding the Nurse Hierarchy

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The hands of several nurses are clasped one on top of the other.There are more than 4 million nurses across the nation, representing the largest segment of the health care workforce. While all nurses contribute to ensuring the best patient outcomes, the nurse hierarchy is made up of several levels, with nurses at each level contributing in important ways.

A nurse’s ability to rise through this hierarchy is dependent on factors such as education, experience, specialized training, and credentials. Reaching the upper echelons of the nurse hierarchy and taking on roles with greater responsibility (and higher pay) generally requires not only a significant amount of experience but also an advanced degree.

Basic-Level Nursing Positions

The nurse hierarchy starts with the certified nurse assistant (CNA) and licensed practical nurse (LPN) roles.

Certified Nurse Assistants

Certified nurse assistants provide basic care, including monitoring and recording patients’ vital signs, such as their blood pressure, temperature, and heart rate. They also help patients perform daily functions, which include basic activities such as bathing, eating, standing, and sitting. Most CNAs work in hospitals, long-term care facilities, and hospice facilities.

Becoming a CNA requires a high school diploma or GED, plus the completion of an accredited CNA training program. These programs typically take no more than 12 weeks to complete.

Licensed Practical Nurses

Licensed practical nurses perform many of the same tasks as CNAs, helping patients eat, bathe, and dress, but they may also handle clinical functions like caring for wounds and changing bandages. LPNs, like CNAs, work in hospitals, hospice facilities, and extended care facilities.

Becoming an LPN does not require an undergraduate nursing degree, but it does require completing practical nursing courses, then passing the NCLEX-PN exam.

Standard-Level Nursing Positions

Nurses who earn either an associate degree or a bachelor’s degree in nursing, pass the NCLEX-RN, and become licensed as registered nurses (RNs) by the state where they will practice can begin their nursing career at a higher level than CNAs and LPNs.

Since registered nurses have obtained additional training, they can play a more direct and autonomous role in administering patient care and in supporting physicians.

An RN’s duties typically include:

  • Recording patients’ medical histories
  • Assessing patients’ conditions and symptoms
  • Administering medication
  • Collaborating with other providers on treatment plans
  • Running diagnostic tests
  • Providing basic education to patients and their family members

RNs work in hospitals, private practices, long-term care facilities, hospice facilities, and community clinics.

Advanced-Level Nursing Positions

By earning a graduate degree or gaining additional experience, RNs can rise higher in the nurse hierarchy. Two advanced-level roles for nurses are charge nurse and advanced practice registered nurse (APRN). These roles typically come with more autonomy and higher salaries than other RN roles.

Charge Nurses

Charge nurses are RNs who gain enough experience to assume a managerial role over an entire nursing team or department. These nurses oversee other nurses in the division, delegating responsibilities and ensuring that all nurses adhere to a high standard of quality and safety. Charge nurses may also devote some of their practice to direct patient care.

A charge nurse’s duties typically include:

  • Supervising nursing staff
  • Managing patient admissions and discharges
  • Coordinating with physicians and administrators
  • Ensuring health and safety compliance
  • Mentoring and training staff


Advanced practice registered nurses are RNs who have earned an advanced degree in order to work more autonomously, in some cases providing primary care to patients. Nurses interested in becoming APRNs can earn either a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP). Each of these degrees has its own requirements, focus, and timeline, and aspiring APRNs should consider these factors when comparing MSN vs. DNP degrees.

Specific APRN roles include:

  • Nurse practitioners. Nurse practitioners play a more direct and autonomous role in patient care than RNs. Some nurse practitioners work in family practice, essentially filling the role of a primary care provider, while others specialize in fields such as women’s health, pediatric care, or mental health care.
  • Certified nurse midwives. Certified nurse midwives provide gynecological care to women throughout their lives, as well as assistance in navigating pregnancy, childbirth, and menopause.
  • Clinical nurse specialists. The role of the clinical nurse specialist consists of both specialized direct patient care, including diagnosis and treatment, and influence over health policies and procedures. The clinical nurse specialist may help their organization or nursing department design and implement evidence-based practices.
  • Certified registered nurse anesthetists. Certified registered nurse anesthetists are registered nurses who promote patient safety and comfort before, during, and after the administration of anesthesia.

Leadership-Level Nursing Positions

The upper end of the nurse hierarchy includes many types of leadership positions. To fill these roles, employers seek nurses who possess a high level of skill and extensive experience as well as an advanced degree.

Nurse Managers

Nurse managers typically work in hospitals or large practices, where they directly supervise a team or shift of nurses. Most nurse manager positions require a master’s-level degree and several years of experience, preferably in a variety of nursing fields or departments.

While nurse managers sometimes perform direct patient care, their role mostly involves administrative and managerial functions.

Duties of a nurse manager typically include:

  • Managing nursing department operations
  • Budgeting
  • Establishing specialty staff teams
  • Evaluating nurse performance
  • Resolving escalating patient care situations
  • Enforcing safety regulations and facility policy

Directors of Nursing

Directors of nursing typically serve as leaders for the entire nursing department of a hospital or large practice. Most directors have several years of experience and either an MSN or a DNP.

Duties of a nursing director typically include:

  • Recruiting and hiring nurses
  • Overseeing nursing staff’s professional development
  • Budgeting
  • Scheduling nursing shifts
  • Overseeing compliance

Chief Nursing Officers

Chief nursing officers (CNOs) have an executive-level role that is also the highest level nurse leadership position. CNOs usually have responsibility for all nursing functions within a hospital or an entire health system, encompassing multiple hospitals or facilities.

A CNO may manage or oversee multiple directors. CNOs typically have many years of nursing experience and also hold either an MSN or a DNP.

Typical duties of a CNO include:

  • Developing strategies to improve staff performance
  • Hiring and overseeing the onboarding of new staff
  • Collaborating with doctors and administrators
  • Analyzing costs and recommending budget changes
  • Representing the medical facility to the public

Ascend the Nurse Hierarchy with a DNP

Nurses and nurse leaders at every level of the nurse hierarchy play a significant role in promoting positive patient experiences.

For those who desire to cultivate the skills to advance their nursing career and ascend the hierarchy, an advanced degree is essential. The online MSN to Doctor of Nursing Practice program at Regis College offers an accelerated path for aspiring nurse leaders who wish to make a significant impact on health care processes and patient outcomes.

Explore the program and learn how Regis can set you on a path to advanced practice nursing today.

Recommended Readings

How DEI Training in Health Care Can Improve Patient Outcomes

Telehealth Nursing Tips: How to Effectively Communicate with Patients

How to Become a Health Policy Analyst


American Nurses Association, Advanced Practice Registered Nurse (APRN)

Betterteam, Charge Nurse Job Description

Betterteam, Director of Nursing Job Description

Incredible Health, “6 Levels of Nursing: A Beginner’s Guide to Nursing Ranks”

Indeed, Licensed Practical Nurse (LPN) Job Description: Top Duties and Qualifications

Indeed, “Nurse Manager: What They Do, Skills and Job Requirements”

Indeed, Understanding the Nursing Hierarchy

Indeed, “What Is a Chief Nursing Officer and How Do You Become One?”

Trusted Health, “What Is a Charge Nurse?”U.S. Bureau of Labor Statistics, Licensed Practical and Licensed Vocational Nurses

U.S. Bureau of Labor Statistics, Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners

U.S. Bureau of Labor Statistics, Nursing Assistants and Orderlies

U.S. Bureau of Labor Statistics, Registered Nurses

Zippia, What Is the Hierarchy of Nurses?