Nursing is one of the most diverse and essential professions in healthcare, with roles that span from hands-on patient care to advanced clinical leadership. With such a wide range of responsibilities, education levels, and licenses, it’s natural to wonder how nursing positions relate to one another in terms of training and authority.
Understanding Nursing Roles and Career Pathways
This guide explores the concept of nursing hierarchy—not as a measure of personal value or worth, but as a way to understand the structure of the profession based on education, licensure, and scope of practice. Whether you’re just starting your nursing journey or planning your next career step, this overview will help clarify where different roles fit within the broader nursing landscape.
We’ll walk through:
- The levels of nursing from entry-level to doctoral-prepared professionals
- Key licensure requirements for each role
- How advanced practice and leadership roles differ
- A visual breakdown and comparison of nursing ranks
It’s important to note: Every nurse, at every level, plays a critical role in patient care and healthcare delivery. This guide is intended to inform—not to rank individuals—by outlining the structure of the nursing profession as it exists today.
Tier 1: Entry-Level Nursing Roles
Entry-level nursing roles provide essential support to healthcare teams and serve as a starting point for many individuals entering the nursing profession. These roles typically require less formal education than registered nursing or advanced practice positions, but they play a critical part in patient care and system efficiency.
Certified Nursing Assistant (CNA)
- Education Required: State-approved training program (typically 4–12 weeks)
- Licensure/Certification: Must pass a state competency exam and be listed on the state CNA registry
- Key Responsibilities:
- Assisting patients with daily activities (bathing, dressing, eating)
- Measuring vital signs
- Reporting changes in patient condition to nursing staff
- Supporting nurses with basic care tasks
- Assisting patients with daily activities (bathing, dressing, eating)
CNAs often work in nursing homes, long-term care facilities, and hospitals. Many use this role as a stepping stone toward becoming an LPN or RN.
Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN)
- Education Required: 12–18 month practical nursing program (usually at a technical or community college)
- Licensure/Certification: Must pass the NCLEX-PN
- Key Responsibilities:
- Administering medications and injections
- Assisting with wound care
- Monitoring patient status and reporting to RNs or physicians
- Supporting patient comfort and education
- Administering medications and injections
LPNs/LVNs have a broader scope of practice than CNAs, but still typically work under the supervision of RNs or physicians. Their duties may vary by state regulations. This role is common in long-term care, home health, and some hospital settings.
These foundational roles are essential for delivering hands-on care and ensuring that patients receive attention and assistance throughout their stay. They also provide valuable clinical experience for those planning to advance within the nursing profession.
Tier 2: Registered Nurses (RNs)
Registered nurses (RNs) form the backbone of clinical care across hospitals, outpatient clinics, schools, public health settings, and more. They have a significantly broader scope of practice than entry-level roles and serve as care coordinators, educators, and advocates for patients and families.
There are two primary educational paths to becoming an RN: the Associate Degree in Nursing (ADN) and the Bachelor of Science in Nursing (BSN). While both qualify graduates to take the same licensure exam (NCLEX-RN), BSN-prepared nurses often have access to broader career opportunities.
Associate Degree in Nursing (ADN) – Registered Nurse
- Education Required: 2–3 year ADN program (typically at a community college)
- Licensure: Must pass the NCLEX-RN
- Key Responsibilities:
- Conducting physical assessments and interpreting patient data
- Administering medications and treatments
- Coordinating care plans with interdisciplinary teams
- Educating patients and families about health conditions
- Supervising LPNs and CNAs
- Conducting physical assessments and interpreting patient data
ADN-prepared RNs provide essential direct care and are eligible for most RN positions, though some employers now prefer or require a BSN for advancement.
Bachelor of Science in Nursing (BSN) – Registered Nurse
- Education Required: 4-year BSN program or RN-to-BSN bridge program
- Licensure: Must pass the NCLEX-RN (same exam as ADN graduates)
- Expanded Opportunities:
- Leadership roles (e.g., charge nurse)
- Public health or community nursing
- Better positioning for graduate school (e.g., MSN, DNP)
- Specialized clinical roles or certifications
- Leadership roles (e.g., charge nurse)
Many hospitals now seek “BSN-preferred” or “BSN-required” candidates, especially in settings pursuing or maintaining Magnet® designation.
RNs serve as critical thinkers and care coordinators in nearly every area of healthcare. They often act as a liaison between patients and providers and are instrumental in improving care outcomes.
Tier 3: Advanced Practice Registered Nurses (APRNs)
Advanced Practice Registered Nurses (APRNs) are licensed RNs who have completed graduate-level education and advanced clinical training. They hold either a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP) and are certified to provide specialized care, often with greater autonomy than RNs. In many states, APRNs can diagnose conditions, prescribe medications, and manage patient treatment independently.
APRNs fall into four recognized categories, each with distinct roles and areas of focus:
Nurse Practitioner (NP)
- Education Required: MSN or DNP
- Certification: National board certification in a population focus (e.g., FNP, PMHNP, AGNP)
- Scope of Practice:
- Diagnosing and managing acute and chronic conditions
- Prescribing medications
- Performing physical exams and ordering diagnostic tests
- Specializing in areas such as family, psychiatric, adult-gerontology, pediatrics, or women’s health
- Diagnosing and managing acute and chronic conditions
Many NPs work in primary care, mental health, and specialty clinics. Scope of practice varies by state—some allow full independent practice, while others require physician collaboration.
Clinical Nurse Specialist (CNS)
- Education Required: MSN or DNP
- Certification: Population or specialty-specific certification (e.g., adult health, oncology)
- Scope of Practice:
- Providing expert consultation to nursing staff
- Improving clinical practices and patient outcomes
- Leading evidence-based practice initiatives
- Educating patients and staff
- Providing expert consultation to nursing staff
CNSs often work in hospitals or academic medical centers, focusing on quality improvement and staff development.
Certified Nurse Midwife (CNM)
- Education Required: MSN or DNP in Nurse-Midwifery
- Certification: AMCB certification
- Scope of Practice:
- Providing prenatal, labor, birth, and postpartum care
- Offering well-woman and reproductive health services
- Prescribing medications and managing routine gynecologic care
- Providing prenatal, labor, birth, and postpartum care
CNMs work in hospitals, birth centers, and clinics and are known for their holistic, patient-centered approach to women’s health.
Certified Registered Nurse Anesthetist (CRNA)
- Education Required: DNP (transitioned from MSN as of 2022 for new entrants)
- Certification: NBCRNA certification
- Scope of Practice:
- Administering anesthesia for surgery, labor and delivery, and procedures
- Monitoring patients during and after anesthesia
- Working independently or alongside anesthesiologists, depending on state law
- Administering anesthesia for surgery, labor and delivery, and procedures
CRNAs are among the highest-paid nursing professionals and are vital in both hospital and outpatient surgical settings.
APRNs represent the most clinically autonomous tier of the nursing profession. Their advanced training allows them to fill critical gaps in care, particularly in underserved areas and high-demand specialties.
Tier 4: Doctorally Prepared and Leadership Nurses
At the highest tier of the nursing hierarchy are doctorally prepared nurses who contribute to healthcare through advanced clinical practice, leadership, education, or research. These individuals often serve as decision-makers, policy influencers, or innovators in the field. While they may or may not provide direct patient care, their expertise shapes nursing practice at the organizational, academic, or national level.
Doctor of Nursing Practice (DNP)
- Education Required: Post-MSN or BSN-to-DNP program (3–6 years depending on entry point)
- Focus: Advanced clinical practice, leadership, healthcare systems, and quality improvement
- Common Roles:
- Nurse practitioner (for those who pursue an NP specialization)
- Clinical nurse leader or director
- Faculty for NP and clinical programs
- Executive roles (e.g., Chief Nursing Officer, VP of Clinical Services)
- Nurse practitioner (for those who pursue an NP specialization)
The DNP is a practice-focused doctorate designed to prepare nurses for leadership at the highest level of clinical care. It is increasingly the standard for APRNs, particularly CRNAs and NPs in leadership roles.
Ph.D. in Nursing
- Education Required: Doctoral program focused on nursing science and research (4–6 years)
- Focus: Generating new knowledge through research, influencing policy, and advancing the academic discipline
- Common Roles:
- Nurse scientist or researcher
- University professor or academic dean
- Policy advisor or consultant
- Nurse scientist or researcher
The Ph.D. is a research-focused doctorate ideal for nurses who want to shape the evidence base for practice, lead health studies, or teach the next generation of nurses.
Nurse Executives and Administrative Leaders
- Education Required: Often MSN or DNP; some hold MBAs or MHA degrees as well
- Common Titles:
- Chief Nursing Officer (CNO)
- Director of Nursing
- Clinical Operations Manager
- Chief Nursing Officer (CNO)
These leaders oversee nursing staff, manage budgets, implement policies, and ensure care quality across entire organizations or systems.
Note: Some nurses may fall into multiple categories (e.g., a DNP-prepared NP who also serves as a department director). This tier reflects the top of the formal educational and leadership structure—not a value judgment, but a recognition of expanded scope and system-level impact.
Nursing Roles at a Glance
The table below summarizes key nursing roles by tier, highlighting education, licensure, and core responsibilities. This format offers a quick reference for understanding how nursing positions relate to one another in terms of preparation and scope of practice.
| Tier | Title | Education Required | License/Certification | Typical Responsibilities |
| 1 | Certified Nursing Assistant (CNA) | State-approved training (4–12 weeks) | State registry | Assist with daily care (bathing, feeding, vitals), report patient changes |
| 1 | Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN) | 1-year LPN program | NCLEX-PN | Administer meds, wound care, assist RNs, monitor patients |
| 2 | Registered Nurse (ADN) | Associate Degree in Nursing (2–3 years) | NCLEX-RN | Direct patient care, care coordination, patient education |
| 2 | Registered Nurse (BSN) | Bachelor of Science in Nursing (4 years) | NCLEX-RN | Broader clinical roles, leadership, community/public health |
| 3 | Nurse Practitioner (NP) | MSN or DNP | National NP certification + state APRN license | Diagnose, prescribe, manage care, often independently |
| 3 | Clinical Nurse Specialist (CNS) | MSN or DNP | National CNS certification | Clinical expertise, staff support, system-level improvements |
| 3 | Certified Nurse Midwife (CNM) | MSN or DNP | AMCB certification | Prenatal care, childbirth, well-woman care |
| 3 | Certified Registered Nurse Anesthetist (CRNA) | DNP (required for new entrants) | NBCRNA certification | Anesthesia care, surgical support, patient monitoring |
| 4 | Doctor of Nursing Practice (DNP) | Post-MSN or BSN-to-DNP | Varies by role | Advanced practice, clinical leadership, quality improvement |
| 4 | Ph.D. in Nursing | Research doctorate (4–6 years) | Not license-based | Nursing research, academia, policy development |
| 4 | Nurse Executive / CNO | MSN, DNP, or dual degrees (e.g., MSN-MBA) | Varies by role | Strategic leadership, operations, staff oversight |
This table reflects general trends and qualifications. Licensure requirements, titles, and scopes of practice may vary by state or employer. Many nurses also hold additional certifications or specialize further within their role.
Exploring Advanced NP Roles and Education Options
If you’re considering a move into advanced practice nursing, it’s important to understand how nurse practitioner roles are structured—and how to choose the right educational path for your goals.
Nurse practitioners (NPs) fall under the broader category of Advanced Practice Registered Nurses (APRNs), which also includes clinical nurse specialists, nurse midwives, and nurse anesthetists. To understand the relationship between these roles, explore this guide on NP vs APRN.
Among NPs, the Family Nurse Practitioner (FNP) is one of the most common and versatile specializations, offering broad primary care across the lifespan. For a breakdown of how this role compares with other NP tracks, see NP vs FNP.
If you’re still exploring your options, reviewing the many types of nurse practitioners can help clarify which population or specialty focus might be the best fit for your interests.
Educationally, most nurse practitioners earn a Master of Science in Nursing (MSN) with a chosen NP specialization. Programs like this top MSN to FNP program can be a good place to start if you’re aiming for family practice. For those pursuing leadership or the highest level of clinical training, an affordable online DNP program may offer the best long-term value—especially as more roles move toward requiring or preferring a doctoral degree.
Advancing Within the Nursing Hierarchy
No matter where you begin your nursing journey, there are clear and achievable pathways for advancement. Many nurses start as CNAs or LPNs and progress to RN or APRN roles through bridge programs, work experience, and continued education. Others enter with a BSN and pursue graduate study to move into advanced practice or leadership.
Key Steps for Moving Up
- Pursue Further Education: Bridge programs (e.g., LPN-to-RN, RN-to-BSN, BSN-to-MSN) and flexible online options make it easier than ever to earn higher credentials while working.
- Gain Experience in Diverse Settings: Clinical experience builds both confidence and qualification for specialty roles and leadership positions.
- Seek Certifications: Specialty certifications (e.g., critical care, pediatrics, oncology) enhance your skills and career options.
- Consider Graduate or Doctoral Study: A master’s or doctoral degree opens doors to advanced clinical practice, education, research, and executive leadership.
Final Thoughts
The nursing hierarchy is not about status—it’s about scope of practice, responsibility, and opportunity. Every role contributes to patient care and system performance. Whether you’re starting out or planning your next step, understanding the structure of nursing careers can help you chart a clear, fulfilling path forward.
