A Guide To The Nursing Hierarchy

The nursing hierarchy is the leadership structure nurses work within, from certified nursing assistants at the base to the chief nursing officer at the top. Knowing where each role sits, and what it takes to get there, helps you decide whether you want to stay in direct patient care, earn an advanced degree, or lead nursing staff.

Salary figures below are median annual wages from the Bureau of Labor Statistics (May 2024) unless noted otherwise.

Entry-Level Nursing

Every nurse starts here, and this is where you have the most direct contact with patients. Plan on two to three years of entry-level experience before you pursue an advanced degree or a leadership role. Your path in depends on how much time you have for school and how much authority, autonomy, and pay you want afterward.

Certified Nursing Assistant (CNA)

CNAs help patients with activities of daily living such as moving, bathing, eating, and dressing. They check vital signs, watch for changes in patient condition, and report those changes to the LPN or RN they work under.

• Education: High school diploma or GED plus a state-approved CNA training program
• Median Annual Salary: $39,530
• Autonomy: None. CNAs work under an LPN or RN even though they hold their own license.
• Authority: None.

Licensed Practical Nurse (LPN)

LPNs monitor patient health, provide basic care and comfort, and keep patient records. They may insert catheters, care for infants, and change bandages. Their exact responsibilities vary by state and setting.

• Education: State-approved LPN program
• Median Annual Salary: $62,340
• Autonomy: LPNs provide basic care under the direction of an RN or physician.
• Authority: LPNs supervise CNAs and, depending on the state, other LPNs and licensed vocational nurses (LVN).

Registered Nurse or Staff Nurse (RN)

RNs monitor patient health, deliver care, and educate patients. They coordinate care with other providers, take part in care planning, and advocate for patients. Responsibilities shift depending on whether the RN works in a hospital, outpatient setting, or nursing home.

• Education: Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN)
• Median Annual Salary: $93,600
• Autonomy: RNs work with, rather than under, physicians and advanced practice providers to coordinate and deliver care.
• Authority: RNs supervise LPNs and CNAs.

Advanced Practice Nursing Positions

These roles require a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP). The advanced degree gives you the autonomy to build and manage care plans, deliver care, educate patients, and oversee nursing staff, and it lets you specialize in areas like family medicine, midwifery, anesthesia, or nursing education.

Nurse Practitioner (NP)

NPs diagnose, treat, and educate patients. They share many responsibilities with physicians but more often specialize in primary care. Most work in physicians' offices, hospitals, and outpatient care centers. Their scope varies by specialty and state.

• Education: MSN or DNP
• Median Annual Salary: $129,210
• Autonomy: NPs may have full autonomy over patient care in a full-practice authority state.
• Authority: NPs oversee RNs, LPNs, and CNAs.

Clinical Nurse Specialist (CNS)

A CNS provides expertise and consultation to other nurses in a specialty such as family practice, pediatrics, adult-gerontology, or neonatal care. They research and implement best practices and serve as educators, preceptors, researchers, advisors, and policy advocates.

• Education: MSN or DNP
• Median Annual Salary: $98,050 (Payscale, 2023)
• Autonomy: A CNS can practice independently in some states, depending on requirements.
• Authority: A CNS precepts and teaches nurses and student nurses.

Certified Nurse Midwife (CNM)

CNMs provide care and education before, during, and after birth. They oversee deliveries, treat patients for sexually transmitted infections, educate patients on healthy pregnancies, and care for newborns and parents after birth.

• Education: MSN or DNP
• Median Annual Salary: $128,790
• Autonomy: CNMs may have full autonomy over prenatal, delivery, and postnatal care in an independent practice authority state.
• Authority: CNMs oversee labor and delivery nurses, LPNs, and CNAs.

Nurse Educator

Nurse educators teach, mentor, and motivate student nurses at every level. They work in colleges, universities, and healthcare settings, building courses, tracking their effectiveness, and supervising students during clinicals. Many also research evidence-based practice.

• Education: MSN or DNP
• Median Annual Salary: about $84,000 (BLS, nursing instructors and teachers, postsecondary)
• Autonomy: Nurse educators design curriculum, measure its effectiveness, and supervise students in clinical settings.
• Authority: They oversee student nurses across all education levels, including clinical and simulation labs.

Certified Registered Nurse Anesthetist (CRNA)

CRNAs take patient histories, monitor vital signs, administer local and general anesthesia, and collaborate with physicians. Many work in outpatient care as the only anesthesia provider on shift.

• Education: DNP
• Median Annual Salary: $223,210
• Autonomy: CRNAs may have full autonomy depending on state supervision requirements, practice setting, or care model.
• Authority: CRNAs can supervise student registered nurse anesthetists (SRNA), RNs, LPNs, and nursing assistants.

Nursing Leadership Positions

Leadership roles oversee nursing care for a department or organization and lead the nurses on the team. These nurses usually do not work directly with patients. The roles require direct-care experience and typically an advanced degree.

Charge Nurse

Charge nurses plan patient care for the shift, schedule and oversee unit staff, and connect nursing staff with physicians and hospital leadership. They decide what care gets delivered during the shift and make sure staff use their resources well.

• Education: BSN or MSN
• Median Annual Salary: $80,160 (Payscale, 2023)
• Autonomy: Charge nurses make decisions about their own practice, plan care on their unit, and oversee the nurses there.
• Authority: They supervise and schedule RNs, LPNs, and CNAs on their shifts and units.

Nursing Director

Nursing directors, or nursing administrators, use their clinical background to lead nursing staff across an organization. They do not provide direct care. Instead, they represent nursing staff in meetings, hire and recruit nurses, and run performance reviews and professional development.

• Education: MSN or DNP
• Median Annual Salary: $97,050 (Payscale, 2023)
• Autonomy: Nursing directors decide on hiring, firing, training, and evaluation of nursing staff.
• Authority: They oversee hiring, recruiting, training, and performance across a department or organization.

Chief Nursing Officer (CNO)

CNOs manage nursing care for an entire hospital or health system, focused on safety and patient outcomes. They work with hospital leadership on care strategy, emergency procedures, budgets, and professional development. CNOs do not deliver direct care but must hold an active nursing license in case of staffing emergencies.

• Education: MSN or DNP
• Median Annual Salary: $140,330 (Payscale, 2023)
• Autonomy: CNOs lead and make decisions about nursing staff and all nursing care.
• Authority: As the lead nurse in the organization, the CNO has authority over all nursing care, budgeting, staffing, and policy.

Choosing the Right Level for You

Every level of the hierarchy matters, and each one shapes patient care. The choice comes down to whether you want to work directly with patients or lead nurses and make organizational decisions. Weigh the education, pay, autonomy, and authority you want, then aim for the role that fits your career goals, holds your interest, and gives you professional satisfaction.

Frequently Asked Questions

What are the different levels of nurses?

Certified nursing assistant (CNA), licensed practical nurse (LPN), registered nurse (RN), charge nurse (RN), advanced practice registered nurse (APRN), nursing director or administrator, and chief nursing officer (CNO).

What is the highest level of nursing?

The chief nursing officer (CNO). CNOs hold a graduate or doctoral degree and oversee all nursing care in a hospital or healthcare facility.

Why does the nursing hierarchy matter?

It maps the education, authority, autonomy, and salary tied to each role, so you can make informed decisions about your short-term and long-term goals.

How does education relate to the hierarchy?

More education generally leads to higher pay, autonomy, and authority. Some roles break the pattern: CRNAs need a doctoral degree (DNP) for an advanced role, and charge nurses need a bachelor's (BSN) for a leadership role.