Who’s who in the Nursing Hierarchy

Just like with doctors, there exists a hierarchy in the nursing profession. Nurses should not only be knowledgeable when it comes to nursing concepts. It is also important for one to be aware about this hierarchy so that he/she would know who to approach in certain situations.


– Chief nursing officer/ Director of nursing

– Nurse manager or nurse supervisor

– Advanced practice nurse or clinical nurse specialist

– Charge nurse

– Staff or bedside nurse (RN)

– Licensed vocational nurse/licensed practical nurse (LVN or LPN)

– Unlicensed assistive personnel


Chief of Nursing Officer

The highest ranking nurse may be known by a variety of names such as the Chief Nursing Officer (CNO), the Chief Nurse Executive (CNE), or the Director of Nursing (DON). A nurse in this top level position reports directly to the CEO or primary administrator of the facility or agency. CNOs usually have a Master’s degree in nursing, if not a Ph.D., and it’s primarily an administrative role. The CNO is in charge of all nursing services provided throughout the hospital, facility, or agency.

Nurse supervisor

Several nurses may share the House Supervisor role in providing administrative leadership level of nursing services on weekends, holidays, and even off-shifts such as evenings and nights. Nurse supervisors are part of the leadership team and are considered “nursing executives.” There is a nurse manager or nurse supervisor available 24 hours a day who is the direct supervisor of the charge nurses.  He/she must also be available to patients, either in person or via consultation in an on-call capacity.

Responsibilities of a nurse supervisor often include staffing for call-ins, inter-facility transfers, emergencies, and on-call systems. Clinical skills and leadership experience is the primary requirement and not always advanced education. This role usually reports to the CNO.

Advanced Practice Nurses

These are registered nurses who have completed advanced training beyond the basic criteria that all RNs must fulfill. They meet higher educational and clinical requirements than other nursing groups. Two groups fall within this category:

NURSE PRACTITIONERS work closely with physicians and are qualified to diagnose and treat common illnesses and injuries. A NP can actually function as a patient’s main healthcare provider.

A CLINICAL NURSE SPECIALIST functions as an expert whose focus is on a specific area of nursing practice. For example, a CNS may specialize in treating surgical, diabetic, geriatric, cardiovascular, psychiatric or pediatric patients.

Charge Nurses

Also known as Shift Managers, they manage the day-to-day clinical patient care on a specific shift and unit. The Charge Nurse is also responsible for compliance with all policies, procedures, and assignments and for coordinating staffing with House Supervisors to cover call-ins and make float assignments as needed.

The Charge Nurse reports to the Nurse Manager. Charge Nurses are RNs, although in some situations, such as long-term care, Charge Nurses may be LPNs. Several nurses may rotate this responsibility on each shift. Strong leadership and clinical skills are required, and a BSN is highly recommended.



These are registered nurses who provide direct patient care at the bedside. He/she will be up-to-date on the patient’s vital signs, medications, and overall treatment plan. He/she is also the first nurse to consult if the patients have a question or concern.

However, not all members of the nursing staff have RN degrees. Patients are often cared for by licensed vocational nurses (LVNs or LPNs) and by assistive personnel such as nurses’ aides (NAs) and patient care assistants (PCAs). LPNs and nursing aides provide the bedside nursing care as assigned and supervised by the Team Leader or other RN, like the Charge Nurse of Nurse Manager.



He/she completes 1500 hours or approximately one year of training and is licensed by the state in which he or she works. Responsibilities include performing basic patient duties such as taking vital signs, monitoring IV’s and other catheters, administering oral medications and writing notes in the patient’s chart. LVNs also collect patient information but they do not make treatment decisions based on these facts, since this requires the training and skill of a registered nurse.



These are individuals who work in a supportive role under a licensed nurse. Duties include helping patients with their basic needs, answering call lights and taking vital signs. Some assistive personnel, including nurses’ aides (NAs) and nursing assistants may be licensed by their states but other types of workers such as patient care assistants (PCAs) may have brief training courses that do not require passing a state licensing exam.



Liane Clores, RN MAN

Currently an Intensive Care Unit nurse, pursuing a degree in Master of Arts in Nursing Major in Nursing Service Administration. Has been a contributor of Student Nurses Quarterly, Vox Populi, The Hillside Echo and the Voice of Nightingale publications. Other experience include: Medical-Surgical, Pediatric, Obstetric, Emergency and Recovery Room Nursing.

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