Nursing Hierarchy Explained: A Guide to Nursing Ranks & Levels
Whether you are interested in becoming a nurse, or you already have many years under your belt, it is essential to understand the nursing hierarchy so that you know what options you have in your career. Generally speaking, the higher the degree level a nurse has, the more education and experience they have received.
Between starting as a novice nurse and the highest ranks of nursing, there is a wide range of positions. Read on to understand the ranks and levels of nursing.
Chief Nursing Officer (CNO)
At the very top of the nursing hierarchy within a healthcare system is the Chief Nursing Officer (CNO). This position requires overseeing and communicating with nursing departments about business matters, best nursing practices, and nursing issues. This position ensures that a hospital’s nursing operations are efficient.
Education and training required to be a CNO are extensive, as it is the highest administrative role within the nursing profession. To become a CNO, a nurse needs several years of nursing and leadership experience, as well as business expertise by working as a mid-level nurse manager. Becoming a charge nurse and unit director is a helpful way to get this experience.
Education to become a CNO includes a Masters of Science in Nursing (MSN) or higher, with a focus on business administration.
Doctor Of Nursing Practice (DNP)
A Doctorate Of Nursing Practice (DNP) is the highest level of nursing education and expertise within the nursing profession. DNP’s work in nursing administration or direct patient care as an Advanced Practice Registered Nurse (APRN). As thought leaders, DNP’s also implement health policy and influence healthcare outcomes.
In the healthcare setting, DNP’s work in:
- Organizational leadership
- Nurse management
- State and national health policy
- Health informatics
Education to obtain a DNP requires three to six years of study, depending on what level of nursing education you currently have. Most DNP programs require that you have a master’s degree in nursing, although some will start at the BSN level and require more years of study.
Advanced Practice Registered Nurse (APRN)
An APRN is a master’s degree prepared RN with a post-master's certificate, or a DNP in one of the following four roles:
- Nurse Practitioner
- Clinical Nurse Specialist
- Certified Registered Nurse Anesthetist
- Certified Nurse-Midwife
APRN’s are licensed through the state board of nursing in which they practice. In many states, APRNs can prescribe medication and practice independently, while in other states, they do so under the oversight of a Medical Doctor (MD).
Many nurses who are APRNs also have a DNP, but you can have one without the other. An APRN with a DNP is considered a practicing doctorate.
Masters Of Science, Nursing (MSN)
Obtaining an MSN helps nurses increase their earning potential and advance their careers away from the bedside. Nurses with an MSN work in advanced nursing roles with increased responsibility. To obtain an MSN, nurses must first obtain an RN and Bachelor of Nursing (BSN) degree.
Here are a few career choices for those with an MSN degree:
- Director of Nursing
- Nursing Educator
- Professional Practice Director
- Nurse Manager
- Patient Educator
- Healthcare Administrator
- Patient Safety Director
- Quality Improvement (QI) Executive
A nursing director, also known as a unit manager, works directly with patients and staff within the healthcare setting and handles various administration and management duties within respective nursing units.
Nursing Directors are registered nurses with a minimum education of an MSN, with a focus on business administration. They have many years of experience working in nursing and other administrative roles.
Bachelors Of Science In Nursing (BSN)
A BSN is a 4-year nursing degree for students who want to be a registered nurse (RN), or for RNs who currently only have an associates degree in nursing (ADN). Many nurses who start their careers with an ADN eventually advance their careers by achieving a BSN.
Bachelor’s trained nurses work in nursing specialties throughout the hospital setting. For example, cardiac, neuro, pediatrics, labor & delivery, emergency room, and ICU, to name a few.
Nurses are encouraged to become certified within their chosen specialty after they have gained at least one or more years of direct nursing experience. For example, a nurse on an ICU neuro/trauma can study and sit for the Certified Neuroscience Registered Nurses Certification (CNRN). Achieving certification within your chosen specialty shows that you are an expert nurse in a particular nursing field. In addition, many institutions will pay nurses more when they are certified within their specialty.
Both ADN and BSN graduates must pass the NCLEX-RN examination to become licensed to work as an RN.
Associates Degree In Nursing (ADN)
An ADN is a 2-year degree and is the minimum amount of education required to obtain a license to work as an RN, other than an RN diploma (See next section).
Most RN’s begin their careers working at the bedside performing direct patient care. This experience is usually preferred for nurses who wish to advance their careers and eventually earn a BSN, MSN, APRN, or DNP. However, there are also many career paths that an RN can take outside of the hospital setting, including case management, or aesthetic nursing.
An RN diploma is another route to becoming a registered nurse. Like the ADN, these programs typically take around two years to complete and they both prepare students to take the NCLEX-RN. The main difference is that the ADN is a college degree while the diploma is not. Diploma programs are typically offered at hospitals, but may also be available at technical or vocational schools.
Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN)
LVNs and LPNs are interchangeable titles depending on where you work in the US. California and Texas use the title LVN, and the rest of the US uses LPN.
To become an LVN/LPN, you need a high school diploma or GED and to graduate from an accredited LVN/LPN program and pass the National Council Licensure Exam. LPN programs typically include one year of coursework and training at a hospital, community college, or technical school.
LPNs and LVNs work in hospitals, nursing homes, and other medical facilities and are typically responsible for more basic kinds of patient care and comfort measures. Usually, they work under the guidance of an RN or MD.
Opportunities for Career Advancement in Nursing
There will be more opportunities than ever for nursing career advancement in the coming years. Nationwide employment of RNs is projected to grow 12 percent from 2018 to 2028. This is partially due to an increased emphasis on preventative care, higher rates of chronic conditions such as obesity and type 2 diabetes, and an aging baby boomer population.
Advancing your education has never been more attainable, especially with the rise of online learning. A few educational opportunities you may want to consider are RN to BSN, BSN to MSN, and MSN to DNP programs.