Hospital Hierarchy


I am a pre-nursing student finishing up my pre-reqs and trying to lay out a loose career plan for myself.

I was wondering if anyone would be willing to lay out the chain of command in a typical hospital for me in any given unit starting from the bottom and working their way up? What kind of education and experience is needed for each level? I keep hearing that if you want to get into "management" then you should plan on going for you BS over your ADN/ASN but i'm not sure exactly what type of mangement jobs they are talking about.



Specializes in Critical Care, Education. Has 35 years experience.


It's wonderful to hear that you are already thinking in terms of your long-term career aspirations. I can provide some global information - but each facility is different.

In nursing, the heirarchy goes like this (from the top):

Chief Nurse exec - Report to CEO or President of the organization. 100% administrative focus. May be called VP of Nursing Services, CNE, CNO, DON (old fashioned), etc. - they are responsible for nursing services wherever they are delivered in the organization. This includes inpatient, outpatient, clinics, ancillary depts, etc. Minimum qualification is generally a Masters degree - some organizations require a doctorate

Director (or various other titles): Report to Nurse Executive. More "administrative" than clinical focus. Responsible for a clinical service line or other division that includes multiple departments (Cardiac, Women's Health, etc.) Generally requires a Masters degree. Some facilties require a masters in the appropriate clinical area. They have budgetary responsiblity, including development & implementation of capital & operating budgets.

Manager (or various other titles): job focus is 50% admin, 50% clinical (IMO, the HARDEST job in any hospital)

Report to Director. Responsible for one or more departments. In general, they may manage one big department or multiple smaller departments. They are responsible for day-to-day 24X7 patient care, including hiring & firing, ongoing interaction with physicians and ancillary departments, staffing & scheduling, etc. May have day-to-day operating budget responsibility. Most organizations have specific educational requirements - generally a BSN. Specialty areas may require clinical certification in that specialty.

Charge Nurse (various titles): Report to Managers. Responsible for managing patient care for a shift. Responsible for compliance with all policies & procedures, shift assignments, coordination of staffing with the House Supervisor for call-ins, floating, etc. There may be specific educational requirements, but not always. Clinical experience & demonstrated leadership ability is important.

House Supervisor: Hybrid management position - usually reports to CNE and provides "administrative" leadership on off shifts & weekends. These folks usually are responsible for things like overall staffing - covering call-ins, coordinating inter-facility patient transfers, activating on-call services, etc. etc. etc They do not have hire/fire authority. Most important qualification is usually experience (clinical & management). House Sups are frequently not seeking any advancement - they like this position and tend to stay put.

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llg, PhD, RN

13,469 Posts

Specializes in Nursing Professional Development. Has 46 years experience.

There are also leadership positions that are not actually in management. These positions include advanced clinical positions (such as Clinical Nurse Specialists, Researchers, Program Coordinators, Nurse Practitioners, etc.). There are also educational positions (unit educations, Staff Development Specialists, etc.).

There are many, many different job titles in this category. The main difference between these positions and straight management positions is that these people are not the administrators for a department. They perform a clinical or educational function rather than be the boss of the staff and responsible for managing them and the department's budget. A lot of people prefer these types of roles instead of management positions because the pay can be similar, but we don't have to worry about the running of the departments 24/7. The Managers and Administrators are responsible for finding replacement staff when people call in sick on Saturday night -- not us. The Managers and Administrators have to worry about how much money we spend on IV tubing -- not us. (OK, we get a little involved in some of those things, but not as much as the management.)

I've probably just muddied the waters for any newbie reading this thread, but I think it is important to realize that not all leadership jobs are in management. There are lots of other jobs that are options for nurses seeking career advancement. You don't have to go into management to be a nursing leader or "move up the career ladder" in nursing.


274 Posts

Thank you both, that was exactly what I was looking for.

llg - So in the scheme of things where would a NP fit in exactly? Does she report to the director of the unit as well?


264 Posts

Specializes in Pulmonary, MICU. Has 5 years experience.

A NP would report to the Manager of the unit or to the House Supervisor (depending), or may not report to any of the above. Examples of each:

An NP that works in the ER would be hired/staffed by the Manager of the ER.

An Acute Care NP could possibly be controlled by the House Supervisors, and would have responsibilities more like a resource nurse / float nurse / task nurse, with an extended scope of practice. Alternately an Acute Care NP could also be employed by an ER or ICU (most likely places).

An NP could also work for a physician group and round on patients, etc., without actually being employed by the hospital at all, and then would answer to the physicians within the group.


74 Posts

Has 3 years experience.
Thank you both, that was exactly what I was looking for.

llg - So in the scheme of things where would a NP fit in exactly? Does she report to the director of the unit as well?

In my facility, the NP reports to the medical director/MD of the unit, none of the nursing staff. Hope this helps and good luck in your studies.

classicdame, MSN, EdD

2 Articles; 7,255 Posts

Specializes in Hospital Education Coordinator.

THe NP's role may be determined by the state requirements (supervision by MD may/may not be required).

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