Nursing Hierarchy: Understanding Nursing Leadership Levels

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From front-line staff to high-level administrators, nurses play a vital role at every level of the health care industry. That means nurses and nursing students who want to climb the nursing hierarchy have many options.

Some nurses find immense satisfaction providing direct care to patients. For others, the most rewarding career involves advancement into a managerial position, a policymaking job, or a role in nurse education. In order to scale the nursing hierarchy and ascend into more advanced positions, ongoing education is imperative.

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Given the significant role that nurses play in the health care industry, it should come as no surprise that this vocation offers ample opportunity for growth. In fact, according to United States Bureau of Labor Statistics data from 2020, the nursing field comprises more than 4 million clinical nursing jobs, spanning roles from registered nurse to nurse midwife assistant. (Roles in nurse education and nurse leadership were not included in this count.)

Not only that, the nursing vocation is growing at a rate much faster than the average rate of job growth for all professions.

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Nurses who desire to expand their responsibilities and to grow into positions of greater authority should keep in mind the following career trajectory.

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Some nurses begin their careers in either licensed practical nurse (LPN) or licensed vocational nurse (LVN) roles. These roles typically require one year of formal training that certifies nurses can perform basic functions such as checking blood pressure, inserting catheters, collecting vital signs, and performing basic wound care.

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Nurses who gain at least two years of formal education or, more frequently, a Bachelor of Science in Nursing (BSN) can become registered nurses (RNs). These nurses, too, focus on direct patient care, but they have a wider scope of responsibilities than LPNs and LVNs. They typically spend more time talking directly with patients, and they work more closely with physicians to develop treatment plans.

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Nurse practitioners play a unique role in the nursing hierarchy. Essentially, they represent the highest level of nursing care outside of administrative and supervisory roles. Nurse practitioners have additional education, building from their RN licensure by earning a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP) degree. They can collaborate with physicians or even work autonomously to diagnose and develop treatment plans.

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Nurse managers hold supervisory roles, overseeing nurses in certain departments or on particular shifts. Most nurse managers spend minimal time providing direct patient care. Ascending to this role requires a minimum of a BSN, though many nurse manager roles require an MSN or higher.

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Directors of nursing play an even higher role in the nursing hierarchy, supplying leadership for all nurses within an organization or a department and developing policies and protocols related to patient care. Gaining this position requires an MSN or higher.

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The pinnacle of nursing job growth is the chief nursing officer position. This is a “buck stops here” position, meaning the chief nursing officer is ultimately responsible for all nurses and nursing services in a hospital or health care organization. The position requires a master’s degree in nursing.

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Even beyond this basic trajectory, there are some alternative ways for nurses to use their skills to help patients and shape health care organizations.

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Advanced practice registered nurses are registered nurses who have obtained additional education, empowering them to work more closely with physicians to develop diagnoses and treatment plans. This role can be a good intermediate step for nurses who may be on the fence about pursuing nurse practitioner certification.

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Some nurses step away from day-to-day clinical practice to instruct other nurses, creating professional development opportunities for the next generation of caregivers. Joining the faculty of a nursing school requires significant hands-on clinical experience as well as an advanced degree.

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Another way for nurses to step away from day-to-day patient care is as researchers. Nurse researchers work in a laboratory or university setting, striving to develop new ways to improve patient care or to make nursing practice more efficient.

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Nurses who are passionate about the administrative side of health care and wish to combine their clinical experience with business acumen take on management positions. Health care executives play a crucial role in directing hospitals, pharmaceutical companies, and other organizations.

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To ensure efficiency and consistency with patient care and fully comply with state and federal guidelines, every health care organization needs multiple levels of nursing leadership. For nurses who desire to have a supervisory role over other nursing professionals, or who wish to have more of a voice in shaping policies and protocols, it’s important to understand the levels of nursing leadership.

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The general nurse leadership structure typically begins with a nurse manager, whose role is to supervise nurses in a specific department or on a particular shift. Becoming a nurse manager usually requires several years of hands-on nursing experience. Some roles may also require an advanced degree, such as an MSN.

The next level up is director of nursing. The director of nursing has a supervisory role that encompasses all nurses within an organization. Moving from nurse manager to director of nursing requires clinical experience combined with an advanced degree such as an MSN or DNP.

The most advanced level of nurse leadership is chief nursing officer, a management role that includes responsibility over all nursing activities within the organization. The director of nursing usually answers directly to the chief nursing officer. Nurses in this executive-level position will have advanced degrees, often a DNP.

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Some nurses may wish to advance their career without ascending the hierarchy of nurse leadership. An alternative path is to become an advanced practice nurse or nurse practitioner. This involves gaining a more robust formal education, and practicing with greater independence and autonomy. Advanced practice nurses may work with physicians or on their own to diagnose and treat patients, often focusing on specialty care or particular populations. For example, an advanced practice nurse could be a family nurse practitioner, nurse midwife, or nurse anesthetist.

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Leaders at every level play a vital role within the nursing hierarchy. Assuming a nurse leadership position requires a number of skills and qualities, all of which are cultivated through a combination of formal training and hands-on experience. Some examples of core nursing skills include:

• The ability to create safe work environments
• Demonstration of integrity and respect
• Advocacy for patients as well as clinical staff members

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Nurses who wish to gain leadership experience will typically begin with the nurse manager role. The job of the nurse manager is to oversee the nursing staff within a single unit, department, or program.

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While the specific responsibilities of this role can vary from one organization to the next, the most common duties include:

• Mentoring other nurses, providing guidance and space for professional development
• Managing the budget for their unit or department
• Scheduling nurse shifts, ensuring all patient care needs are adequately covered
• Hiring nurses
• Ensuring that nurses are aware of policies and procedures, and that they comply

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Assuming a managerial role typically requires a few years of clinical experience, though this can vary by organization and position. Additionally, most managerial roles require a minimum of a BSN, with an MSN being preferable. Becoming a manager may require gaining a relevant certification, such as the American Nurses Credentialing Center’s nurse executive (NE-BC) certification or nurse executive advanced (NEA-BC) certification.

Through clinical experience as well as formal education, nurses can hone the skills necessary for managerial success. These skills include interpersonal skills, flexibility, competence working with a budget, and the ability to manage multiple priorities.

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Nurses who desire promotion into a managerial role will naturally have some questions about salary. According to data obtained from Payscale in July 2022, the median annual salary for nurse managers is approximately $89,700.

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For those who wish to advance through the nursing hierarchy, the next step up from manager is director of nursing. The overall responsibility of directors of nursing is to oversee the nursing staff across multiple units, departments, or programs.

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Several specific responsibilities are associated with this director-level position, including:

• Supervising nurse managers, and thus providing indirect oversight to all nurses in the organization
• Ensuring that the nursing department achieves all organizational goals, focusing on metrics such as quality, patient safety, and budget
• Creating an environment in which nurses can grow and enjoy professional development opportunities

Note that the director focuses very little on direct patient care, but many directors will spend a few clinical hours each week or month to keep their patient care skills sharp.

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Becoming a director usually requires a number of years of clinical experience, as well as experience in a leadership position. Often, directors begin their careers as managers. Additionally, director of nursing positions require an MSN or higher. Becoming a director may require nurses to pass an examination for a key professional certification, such as the NE-BC or NEA-BC. Completing these steps enables the director to cultivate important competencies, such as quality improvement skills and skills in operations management.

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According to Payscale data from July 2022, the median annual salary for directors of nursing is approximately $93,900.

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For nurses who wish to rise to a top position in leadership, the chief nursing officer role represents the highest position available within the nursing hierarchy. The person in this role is responsible for the entire professional nursing practice of a health care organization.

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This high-level nurse leadership position encompasses all big-picture aspects of nursing practice within an organization. Core duties and responsibilities include:

• Developing the overall strategy and vision for nursing practice in the organization, aligning it with broader business goals and patient care considerations
• Forecasting financial information and using it to shape departmental budgets
• Ensuring safety in the delivery of care, specifically through creating and communicating quality protocols
• Promoting engagement among patients as well as staff members
• Providing oversight for nurse leaders in the organization, such as the director

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Assuming a chief nursing officer position requires an MSN or higher and leadership experience, and may require gaining a relevant certification such as the NEA-BC. Through a combination of formal training and hands-on experience, the nurses in this role will develop important competencies such as communication skills, business skills, and strategic planning skills.

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According to Payscale data from July 2022, the median annual salary for chief nursing officers is around $134,200.

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Nurses who wish to experience professional advancement without necessarily taking on managerial or leadership roles may consider becoming advanced practice registered nurses, or APRNs. Specific types of APRNS include nurse midwives, nurse anesthetists, clinical nurse specialists, and nurse practitioners.

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The role of the nurse midwife is to provide support and holistic health care to women who are giving birth. Qualifying for this position involves gaining an RN license, then pursuing additional training and certification focused on issues specific to women’s health care. Most nurse midwife positions require a BSN or higher, though this can vary by position. Through a combination of formal training and hands-on experience, nurse midwives develop vital skills such as communication, remaining steady under pressure, and managing the anxieties of their patients.

According to data from Payscale obtained in July 2022, nurse midwives have a median annual salary of approximately $100,000.

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The nurse anesthetist helps disseminate sedation and anesthesia services to make certain that patients are as comfortable as possible during medical procedures. They work with anesthesiologists to keep patients safe, to properly screen them for anesthesia eligibility, and to help them as they recover from the effects of their anesthesia.

These nurses usually have more advanced degrees, sometimes MSNs but often DNPs, and complete examinations to become certified registered nurse anesthetists (CRNAs). A year of intensive care unit (ICU) experience is also required. This position calls for a number of vital skills, such as attention to detail and critical thinking skills.

According to data from Payscale obtained in July 2022, nurse anesthetists have a median annual salary of approximately $166,700.

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A clinical nurse specialist is an RN who goes on to complete either an MSN or a DNP, certifying them to play a more direct role in diagnosing patients and developing treatment plans. The clinical nurse specialist focuses on providing high-quality care as efficiently as possible. As such, their role may include clinical work as well as research and health care management.

Clinical nurse specialists may sit for certification examples in a subspecialty field, such as geriatrics, wound care, or oncology. These well-rounded nursing professionals have to cultivate skills pertaining to patient interaction, management, and policy formation.

According to data from Payscale obtained in July 2022, clinical nurse specialists have a median annual salary of around $94,700.

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A final type of advanced practice registered nurse is the nurse practitioner. Nurse practitioners receive a higher level of training than RNs, allowing them to focus on a specialized area of practice. Common examples of nurse practitioner care concentrations are adult-gerontology acute, adult-gerontology primary, family, neonatal, pediatric, psychiatric mental health, and women’s health.

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The role of the adult-gerontology acute care NP is to manage the health care needs of adult or geriatric patients who are critically ill. These NPs often work in settings such as hospital emergency rooms or special care units. These NPs must have master’s-level degrees or higher, then pass examinations to become certified in the adult-gerontology specialty. These clinical care professionals must be able to work well under pressure, and to apply critical thinking skills to potentially complicated diagnoses.

According to Payscale data from July 2022, nurse practitioners who provide adult-gerontology care have a median annual salary of approximately $102,900.

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Adult-gerontology practitioners may work in a primary care setting, where the focus is more on managing chronic conditions or promoting overall wellness, as opposed to dealing with emergency conditions or acute illnesses. These NPs must have master’s-level degrees or higher, then pass examinations to become certified in the adult-gerontology specialty. Success in this role requires a passion for building relationships and communicating well with patients.

According to Payscale data from July 2022, nurse practitioners who provide adult-gerontology care have a median annual salary of around $102,900.

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A nurse practitioner may choose to focus on family care, serving as a primary care provider for patients of all ages. These NPs can diagnose and treat illnesses and injuries, promote wellness, and manage chronic conditions. Qualifying for this role requires a master’s-level nursing degree or higher, licensure as an NP, and additional training and certification in family care. NPs in this role tend to be skilled in communication and relationship-building, good at analytic thinking, and comfortable collaborating with other medical providers.

According to Payscale data from July 2022, family NPs have a median annual salary of approximately $98,400.

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Neonatal NPs typically work in a hospital setting, caring for high-risk infants who experience low birth weights, congenital abnormalities, or complications stemming from premature birth. These NPs have high-level degrees, an MSN or higher, and are trained and certified in neonatal care.

Critical thinking and analytic skills are essential for success in this role, as well as the ability to remain clear-headed under pressure and to collaborate well with other care providers.

According to Payscale data from July 2022, neonatal NPs have a median annual salary of approximately $111,000.

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Pediatric nurse practitioners focus on diagnosing and treating infants, toddlers, children, and teenagers. This role may also include general wellness promotion, with an emphasis on developmental health. These nurse practitioners have master’s-level nursing degrees or higher, and are trained and certified in pediatric care. They tend to be comfortable communicating with children and families, are patient, and have an approachable bedside manner.

According to Payscale data from July 2022, nurse practitioners who provide pediatric care have a median annual salary of approximately $94,000.

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The nurse practitioners in this role focus on diagnosing and treating patients dealing with mental health disorders, which can include depression, anxiety, and substance abuse disorders. Becoming a mental health NP requires RN licensure, an MSN or higher, and specialized training and certification in psychiatric mental health care. These NPs are good critical thinkers and problem-solvers.

According to Payscale data from July 2022, nurse practitioners who focus on mental health and psychiatric issues have a median annual salary of approximately $114,000.

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The women’s health NP role involves attending to women’s health care needs throughout their lifespan, including preventive care, breast examinations, and contraceptive support. These providers have RN licensure, MSNs, and specialized training and certification in women’s health. Success in this role requires strong analytic thinking abilities.

According to Payscale data from July 2022, women’s health NPs have a median annual salary of approximately $97,000.

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The nursing hierarchy contains numerous opportunities to provide direct patient care or high-level nurse leadership. To take advantage of these opportunities for career advancement, education is critical. Hawai‘i Pacific University’s online Bachelor of Science in Nursing to Doctor of Nursing Practice program offers a chance to earn advanced nursing credentials and hone the skills necessary to make a big organizational impact. Take the first step toward a nurse leadership role today.