Understanding the Organizational Structure in Nursing

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Nurses need to understand the power structure within their healthcare organization.

In the business world, “organizational structure” refers to how tasks are allocated, coordinated, supervised and directed to meet organizational goals. The structure helps maintain a productive workflow and sets rules and procedures. In nursing, organizational structure also applies to the hierarchy of nurses and how important processes are carried out.

Working as a registered nurse (RN) means understanding the power structure within a healthcare organization. RNs who work in hospitals must understand the chain of command so they can follow the correct policies and procedures.

RNs make up the largest segment of healthcare professionals in the United States. Some RNs start their careers after earning an associate degree in nursing (ADN). However, a Bachelor of Science in Nursing (BSN) is increasingly becoming the minimum degree for entry into nursing practice.

For RNs who hope to pursue careers with a BSN degree, understanding the power structure is all the more important because new responsibilities may mean more interactions with managers, supervisors and administrators.

Nursing Team Members

Most often, healthcare facilities including hospitals, medical centers and large clinics utilize a vertical structure of leadership with various levels of administration, which is necessary due to the broad scope of services. At the same time, large medical facilities follow a strict leadership structure for effective communication.

Here is a typical hierarchy for nursing staffs at hospitals or large medical organizations:

Staff or bedside nurse

Staff or bedside nurses provide direct patient care by monitoring, observing and evaluating patients. They are responsible for being current on patient care plans, vital signs and medications and are the first point of contact for patient and family questions regarding care.

Charge nurse

Charge nurses supervise staff nurses. They direct nursing care over an entire unit during a specific period (usually a shift). Charge nurses coordinate staffing and make nursing assignments as needed. They are responsible for ensuring all staff or bedside nurses follow proper protocols and procedures. They answer complaints from patients regarding staff or bedside nursing. They are sometimes called shift managers.

Nurse manager

As the person in charge of whole nursing units, nurse managers work as direct supervisors over charge nurses. Nurse managers are responsible for budgeting, staffing, investigating complaints and coordinating educational programs, among other duties. Nurse managers coordinate with doctors and other healthcare personnel to provide safe and healthy environments for positive patient outcomes. Nurse managers are sometimes called nursing supervisors, unit managers or head nurses.

Director of Nursing

Directors of nursing are also called directors of patient care services (DOPCS) or directors of nursing services (DONS). They primarily work in administrative roles but sometimes play a part in clinical care. They are primarily responsible for all nursing services in a facility and collaborate with other medical professionals, departments and organizations (such as nonprofits, government agencies and advocacy groups) to support patient care and nursing functions. They oversee budgets, staffing, policies and procedures as they relate to nursing services.

Chief Nursing Officer (CNO)

As the head administrator over nursing staffs in healthcare organizations, CNOs oversee an organization’s nursing department. They work as the nurse representative within the administration of healthcare organizations and help the organizations run smoothly. Most CNOs report directly to hospital administrators or presidents. In some healthcare organizations, the role of CNO and director of nursing may be the same.

Other Important RN Roles

In addition to having positions that squarely fit into an organizational chart, the nursing profession has many roles that fit horizontally, including:

  • Family nurse practitioner (FNP)

FNPs work as primary care providers to evaluate patients, make diagnoses and initiate treatment plans. To determine an accurate diagnosis, FNPs interview patients, perform physical exams, run diagnostic tests and use clinical reasoning. FNPs are legally permitted to practice independently or under the supervision of physicians, depending on individual state laws. FNPs are often employed in hospitals, medical centers and clinics, working alongside or in place of physicians. All FNPs are advanced practice registered nurses (APRNs) who have passed certification and licensure testing.

  • Forensic nurse

Forensic nurses assist by treating crime and violence victims, documenting injuries to assist in the legal process and providing outreach services. Some forensic nurses also work as sexual assault nurse examiners (SANEs). Forensic nurses also lead educational programs in the community. They often work in hospital emergency departments. 

RN to BSN Nurses Working Within the Nursing Organizational Structure

Decades ago, the ADN was considered the optimal degree for most RNs, but RNs today are handling more complicated medical cases with more advanced technology than ever before.

Studies show BSN-prepared nurses are better equipped to handle fast-moving situations thanks to their sharpened critical-thinking and decision-making skills. BSN nurses are trained to manage modern technology and the needs of patients with complex medical problems simultaneously.

RNs who are seeking BSN degrees are turning to RN to BSN online programs to take the next step in their careers.

About Duquesne University’s Online RN-BSN Program

Duquesne University’s online RN-BSN program provides a pathway for RNs to earn their BSN degree while continuing their career and personal responsibilities. The 100 percent online program is flexible so students can complete their coursework from anywhere at any time. The program can also be customized for specific learning outcomes.

Duquesne University provides one-on-one faculty mentorship and the opportunity for student assignment collaboration. Our expert RN faculty members understand the challenges nurses face every day and strive to see their students succeed. For more information, contact Duquesne University now.


What is an Organizational Structure: Investopedia

Hospital Guide For Patients and Families: Empowered Patient

Nurse Manager Competencies: AONE

Debate Continues on Nursing Degrees: Inside Higher Ed