Where do nurses rank in the hospital hierarchy?

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Do they usually have more authority than residents and med students? What about PAs?
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It depends if your talking about those "large and incharge" stereotypical nurses (and by large i literally mean large) who have been a nurse forever and know every doctor in the state and call everyone "hun" or "honey"

or the brand new nurses that are virtually the same age or younger than most med students.....i've seen both and the former definitely exude some dominance in their area of the hospital....and therefore should never be crossed, whether you're a med student, resident, doctor, PA, whatever

either way though, you are bottom rung until you get some sort of license or certification to actually work at a hospital and treat people....
 
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i'd say nurses rank just below MD students/physicians but just above DO students/physicians.







p.s. i am joking.
 
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ryserr21 said:
i'd say nurses rank just below MD students/physicians but just above DO students/physicians.







p.s. i am joking.
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HILARIOUS!

Volunteer (Premed) < House Keeping < Technician < Med Student < RN < PA/NP < Resident MD/DO < Chief Resident < Attending MD/DO < Cheif of ______
 
Remember that it's far better to treat everyone with respect that is due. Even if you assume that someone is beneath you in terms of perceived or actual hierarchy, you don't know their actual influence and/or whose ear they may have, especially if they've been there for a good while. Attendings have been known to ask the opinions of their staff, which include nurses, for evaluation purposes. Also, you might learn a lot from seasoned staff members, regardless of their position.

That being said, I think medical students are perhaps the lowest rung at an academic hospital. Almost everyone will know more and have more say than medical students.
 
spicedmanna said:
Remember that it's far better to treat everyone with respect that is due. Even if you assume that someone is beneath you in terms of perceived or actual hierarchy, you don't know their actual influence and/or whose ear they may have, especially if they've been there for a good while. Attendings have been known to ask the opinions of their staff, which include nurses, for evaluation purposes. Also, you might learn a lot from seasoned staff, regardless of their position.

That being said, I think medical students are perhaps the lowest rung at an academic hospital. Almost everyone will know more and have more say than medical students.
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hey now, give the med students some credit!

theyre right above (but not by much) the premed volunteers
 
What exactly are the duties of a chief resident? Do they make any more money?
 
I think you're talking different hierarchies here, OP. The have different authority and responsibilities than med students, residents, and PA's. They're part of the health care web, but not part of the same ladder.
 
You better get your mind out of the gutter soon, otherwise you'll have problems for the rest of your career, be it as a medical student or an attending.

There is no hierarchy; they have their job to do and we have ours. In the end, we all work together as a team to help the patients.
 
Janitor >= Bob Kelso > Perry >= Carla > Turk = JD = Elliot > Ted
 
ejay286 said:
What exactly are the duties of a chief resident? Do they make any more money?
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It's pretty much just as it sounds. They are usually in charge of all of the residents and medical students in their service, or residency program, and report to the attendings. And, yes, they usually make more money. Your salary generally increases as you ascend through the residency program. For a specialty like IM, which is usually a 3 year residency, if you opt for and are elected to be chief resident, you can stay for a 4th year and be in charge.
 
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ejay286 said:
What exactly are the duties of a chief resident? Do they make any more money?
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good question


and I thinkt the OP realizes that there are no "real" hierarchies here...it is obviously in the best interest of patients and med staff alike to work as a cohesive team....however, every team has a captain...someone has to make the final decision or else chaos would ensue
 
ejay286 said:
What exactly are the duties of a chief resident? Do they make any more money?
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I'm far away from having experience with that, but here's my understanding.
Chief Residents are in their final year of residency and have additional supervisory responsibilities. They are often responsible for making schedules, coordinating and directing those in earlier years of training, and setting up conferences, Grand Rounds, and such. I don't know if they are paid more for the duties that go with the title, but many places have a sliding scale for residents' pay, depending on which year they are.

(I type too slowly. Question already answered.)
 
Equivalent to housekeeping staff
 
HumidBeing said:
I'm far away from having experience with that, but here's my understanding.
Chief Residents are in their final year of residency and have additional supervisory responsibilities. They are often responsible for making schedules, coordinating and directing those in earlier years of training, and setting up conferences, Grand Rounds, and such. I don't know if they are paid more for the duties that go with the title, but many places have a sliding scale for residents' pay, depending on which year they are.

(I type too slowly. Question already answered.)
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Specialty dependent:

IM/Peds: chiefs are PGY-4s who have opted to stay for an extra year for prestige/interest/resume buffing.

EM/probably others: chiefs do not stay an extra year but get a slight break on clinical hours to do more administrative work.

Surgery: often no official chief residents, rather refers to the senior resident on a particular service i.e. "the trauma chief" or "the vascular chief."
 
rockydoc said:
good question


and I thinkt the OP realizes that there are no "real" hierarchies here...it is obviously in the best interest of patients and med staff alike to work as a cohesive team....however, every team has a captain...someone has to make the final decision or else chaos would ensue
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Sure there are. Physicians write orders for nurses to follow, if the nurses refuse to follow the orders it is a big deal.

Your chief resident is one of your bosses. Your attendings are their bosses. Your chair is their boss.

It might be a very collegial and team-like atmosphere but there is certainly a hierarchy.
 
Charles English said:
wait, you don't like Ted? but he can sing boy!! his band rocks.
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I never said I don't like him. My personal feelings have no bearing on his place in the hierarchy. Have you seen how many times he has been pimped by essentially everyone in that hospital? Its like an episode of "Pimp my Ride." Except Ted is the broke down car and everyone else is X-zibit and the shop crew.
 
WinterLights said:
Janitor >= Bob Kelso > Perry >= Carla > Turk = JD = Elliot > Ted
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Speaking of scrubs, wikipedia says that Turk JD and Elliot are attendings, I always thought they were residents. I know I know its wikipedia, but still.

EDIT: Nvm, I pretty much only watch the older episodes which is why I haven't caught up.
 
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The chief of staff at one of the hospitals I used to work at liked to paraphrase a quote from Omar Bradley (a general during WWII for those of you who do not compulsively watch the History Channel). He said "I have good nurses, good RTs, good techs, and good housekeeping staff. All of those mean more to the smooth operation of a hospital than the nature of my abilities as a chief of staff or as a doctor."* Anyone who thinks doctors really make the hospital function has their head crammed pretty far up their butt in my opinion.


 *-In the event anyone cares, the original quote was along the lines of "I have good sergeants, good lieutenants and good captains and that means far more than my being a good general ever could."
 
Just a note: If you f$#! with nurses no matter what "rank" you are, they will ignore you in rather petty ways.
 
The Neuro-Oncologist I shadowed said nurses run the show and that they should be treated like royalty or nothing will get done...

but in heiarchy my thoughts are below the residents but for sure above the medical students
 
In patient care, the doctor will have the final say on everything, but in terms of everything else, the charge nurse runs the show.
 
ejay286 said:
Speaking of scrubs, wikipedia says that Turk JD and Elliot are attendings, I always thought they were residents. I know I know its wikipedia, but still.

EDIT: Nvm, I pretty much only watch the older episodes which is why I haven't caught up.
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It must not have been an SDN-addicted, crazed pre-med who entered that entry into Wiki...


Nurses own med students. I volunteered at the ER of an academic medical center for awhile...and man, those nurses ate med students alive. They were about on the same level as residents from what I observed. But as many have already said, it's a team effort and frankly, the jobs of each are different enough that there isn't a true hierarchy...although the overall goals are the same of course.
 
bawer234 said:
HILARIOUS!

Volunteer (Premed) < House Keeping < Technician < Med Student < RN < PA/NP < Resident MD/DO < Chief Resident < Attending MD/DO < Cheif of ______
Click to expand...

that sounds about right.
 
TexasTriathlete said:
In patient care, the doctor will have the final say on everything, but in terms of everything else, the charge nurse runs the show.
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There's some truth there. When I was literally a fly on the wall and knee-deep shadowing an ER attending, I got chewed up and down by a charge nurse. Apparently JAACO was coming through and she was extra wound-up and my tag had flipped around so she decided to lay it on thick as she zoned in for the kill. Anyway, the attending I was shadowing finally came over and got her off my ass and told her I was with the docs. They (attendings) had a good laugh about it...
 
AmoryBlaine said:
Sure there are. Physicians write orders for nurses to follow, if the nurses refuse to follow the orders it is a big deal.

Your chief resident is one of your bosses. Your attendings are their bosses. Your chair is their boss.

It might be a very collegial and team-like atmosphere but there is certainly a hierarchy.
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The chief residents are not my boss. They have no disciplinary or other authority over me. At my program, the chiefs are exceptional residents who selflessly (usually) undertake many of the administrative tasks of the program. They do not work any fewer hours but instead probably work many extra.

You cold not realistically pay me enough to be chief resident. In my specialty, it has very little effect on starting salary as an attending or finding a job unless you are interested in an academic position or a job in a highly competitive city (like Indianapolis or San Diego) where your salary will probably be lower anyway.

Chief residents are in charge of the junior residents on some rotations so in that sense they are "the boss."
 
gasapple said:
There's some truth there. When I was literally a fly on the wall and knee-deep shadowing an ER attending, I got chewed up and down by a charge nurse. Apparently JAACO was coming through and she was extra wound-up and my tag had flipped around so she decided to lay it on thick as she zoned in for the kill. Anyway, the attending I was shadowing finally came over and got her off my ass and told her I was with the docs. They (attendings) had a good laugh about it...
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Man. I'm spoiled because I work almost exclusively with emergency Department and ICU nurses who are some of the best in the business. But you know, even the Charge Nurse, in the realm of medical decision making, is going to do what I tell her to do. On the other hand, when it comes to her area of authority I do everything in my power to make her job easier (dispositioning patients in a timely manner, not being too needy) and she is most definitely in charge of the things of which she is in charge and you cross her at your peril. Nurses, and I know this is obvious, are 85 percent of the time more important to patient care than doctors.

I have never had a nurse or anybody question any decision I made except the few times when I was obviously about to **** something up.
 
AmoryBlaine said:
Sure there are. Physicians write orders for nurses to follow, if the nurses refuse to follow the orders it is a big deal.

Your chief resident is one of your bosses. Your attendings are their bosses. Your chair is their boss.

It might be a very collegial and team-like atmosphere but there is certainly a hierarchy.
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I'd say that medicine is actually one of the MOST hierarchical of professions. And med students are at the extreme bottom of the pile. Nurses (particularly scrub nurses) will give you a hard time now and then because they can -- you are the only person on the team they don't really have to listen to. The intern answers to the residents, the most senior resident leads the team, s/he answers to the fellows if any, above that you have attendings. The attendings answer to department heads, chairmen, and at the top at a teaching hospital tends to be the Dean. Nurses, PAs, etc are ancillary professionals and not actually in this hierarchy, but their job is to execute orders from physicians (which is why med students can still get their wrath). But if a nurse is mistreated, they can even the score through scores of silly pages for things they ought to be trouble-shooting on their own. So it pays as a physician to be nice to the nurses -- otherwise you might not get any sleep on call and might have to see patients for silly things.
 
I work in a pharmacy. We're a team, my boss is great, I actually might be in love with her (shes 40 and married tho : - ( ) But anyway, I'm a pharmacy technician. The pharmacists all run the show in the pharmacy. I cant sell medicine without them supervising me at every step of the way. On the same token, though, if it weren't for technicians like me, theres not a snowballs chance in hell that the pharmacy would function at anywhere near the current stability level. So, on the one hand, I have to follow the law and understand that the pharmacist has 4 more years of schooling, is an expert in pharmacology, etc. and respect their authority when it comes to procedure, do what they ask me to do, etc. But, on the same hand, I make nine bucks an hour and deal with a lot of a-holes so if any of my supervisors started treating me badly, I could tell them to go stick it and walk away (and they would be the losers in that situation, not me) or I could simply be petty and make their job a living nightmare. But there is definitely a hierarchy - all that goodie goodie teamwork rhetoric doesn't change the power structure but that structure is checked by intrinsic motivation and political forces, so it usually works out to everyones benefit.
 
Hot nurses are wayyyyyyy above the old decrepit ones.
 
Panda Bear said:
Man. I'm spoiled because I work almost exclusively with emergency Department and ICU nurses who are some of the best in the business. But you know, even the Charge Nurse, in the realm of medical decision making, is going to do what I tell her to do. On the other hand, when it comes to her area of authority I do everything in my power to make her job easier (dispositioning patients in a timely manner, not being too needy) and she is most definitely in charge of the things of which she is in charge and you cross her at your peril. Nurses, and I know this is obvious, are 85 percent of the time more important to patient care than doctors.

I have never had a nurse or anybody question any decision I made except the few times when I was obviously about to **** something up.
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That's good to know.

I really was only wallpaper so I was surprised she came after me like a pitbull; it's possible I was just an unfamiliar face who became an outlet for the stress of the day. Caught me a tad bit offguard but at least the Attendings came to the rescue after they'd met their hourly amusement quota - and at my expense. :D
 
Would you all consider a nurse or a PA more "powerful" or whatever you want to call it? If a decision needed to be made and they both collided and no attneding was around, who would have the power?
 
Paulz said:
Would you all consider a nurse or a PA more "powerful" or whatever you want to call it? If a decision needed to be made and they both collided and no attneding was around, who would have the power?
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The PA would have the say over nurses in matters pertaining to patient management, of course. PA's and NP's, etc., are considered mid-level practitioners and have more training in patient management. PA's work under the license of a physician and function about the level of a more experience resident. In general, they stand higher in the chain of patient management than your typical nurse.
 
don't mess with nurses, I heard stories of nurses slipping laxatives in a MD's coffee that he left at desk, because he did not speak to her in a polite manner
 
The Big Nurse laying down the pwn inside the ****oo nest?

Tired said:
The relationship between residents and nurses (and med students and PAs) is quite a bit more nuanced than the simplistic "hierarchy" model being discussed here. Like so many others, I was run over by nursing as an MSIII, and like Panda, I have never had a nurse refuse one of my orders on "medical decision-making grounds" (though they have refused on many occassions due to "floor policy" which is maddening and usually spawns a host of obscenities from my mouth).

That being said though, medicine no longer functions as a true hierarchy outside of inter-physician relationships. Nurses are not "subordinate" to any physician, simply because we have zero oversight over them. I have harped on this before, but there is very little oversight in the nursing community. If they make an error, even one of gross incompetence, the most you can do as a physician is file an incident report or talk to their (nursing) supervisor. Since most hospitals now function on a "systems analysis" model of errors, the individual is rarely held accountable for their actions. Most nursing errors result in the implementation of new policies, which basically means additional layers of bureaucracy and paperwork.

And in instances where a nurse is grossly and obviously incompetent, you are much more likely to see multiple episodes of "rehabilitation" and "remedial training" rather than actual termination.

You also need to consider which nurse and which resident/medical student you are talking about when you discuss position in a supposed-hierarchy. When I rotated through Orthopaedic services as an intern, I carried far more authority than on other services that were outside my home department. On some services, like Cardiothoracic Surgery, certain nurses were "specialty nurses" meaning that the attending staff knew them and trusted them. In instances where resident assessments of a patient's status conflicted with that of the nurses, the RN would phone the attending directly, and more often than not he would accept her assessment and plan over that of the resident.

What I am trying to say to all you future physicians is this: From day 1 of your clinical training, get a handle on the players in the game, and let go of your overly-simplistic assumptions about the "hierarchy" in the hospital. Some nurses are experienced and trusted, and going up against them will get you slapped down by your attendings. Some nurses are incompetent and dangerous, and their opinion will never be respected by anyone, including their nursing colleagues. You will also have residents who are idiots, and even as a medical student it is important to identify them and discount everything they tell you.

Medicine is game of individual players, not broad categories. Figure out the specific power structure of your institution, and try to take what you can from those who have something worthwhile to offer. Trust no one except yourself, and always remember that it's just a game and you don't need to take any of it personally.
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Tired is right about the more nuanced version of things in the hospital. For brevity I usually leave those things out.

For instance, ICU nurses generally carry more weight than floor nurses. Experienced and trusted ICU nurses carry even more weight.

Same with the floor, especially specialty floors. If there's an experienced pulmonary nurse who's been on that floor for 10 years, best not to screw with her.

Charge nurses rotate, so it's not always the same person who's in charge. They really don't make "medical decisions". They may dictate certain things on the floor but they definitely are not making medical decisions...i think that was overstated a bit previously.

The short white coat is essentially a neutering technique that leaves you with no balls. You are viewed as a newbie in the hospital by pretty much everyone, and for good reason.

That being said, no matter how powerful the nurse or NP or PA, ultimately you hold final power as a physician. I would be careful with the exceptional cardiothoracic PA who's been there 15 yrs or something like that however. Best to use your superiors in situations like that.
 
gasapple said:
There's some truth there. When I was literally a fly on the wall and knee-deep shadowing an ER attending, I got chewed up and down by a charge nurse. Apparently JAACO was coming through and she was extra wound-up and my tag had flipped around so she decided to lay it on thick as she zoned in for the kill. Anyway, the attending I was shadowing finally came over and got her off my ass and told her I was with the docs. They (attendings) had a good laugh about it...
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Just shows how unprofessional many, many RNs are. Imagine if some mid-level person at a regular office had started screaming at one of the lower employees in the middle of the office for a minor infraction. It would be a big deal. But since this lady was a nurse, and a charge nurse at that, she is a sacred cow who cannot but crossed under any circumstances.
 
Tired said:
The relationship between residents and nurses (and med students and PAs) is quite a bit more nuanced than the simplistic "hierarchy" model being discussed here. Like so many others, I was run over by nursing as an MSIII, and like Panda, I have never had a nurse refuse one of my orders on "medical decision-making grounds" (though they have refused on many occassions due to "floor policy" which is maddening and usually spawns a host of obscenities from my mouth).

That being said though, medicine no longer functions as a true hierarchy outside of inter-physician relationships. Nurses are not "subordinate" to any physician, simply because we have zero oversight over them. I have harped on this before, but there is very little oversight in the nursing community. If they make an error, even one of gross incompetence, the most you can do as a physician is file an incident report or talk to their (nursing) supervisor. Since most hospitals now function on a "systems analysis" model of errors, the individual is rarely held accountable for their actions. Most nursing errors result in the implementation of new policies, which basically means additional layers of bureaucracy and paperwork.

And in instances where a nurse is grossly and obviously incompetent, you are much more likely to see multiple episodes of "rehabilitation" and "remedial training" rather than actual termination.

You also need to consider which nurse and which resident/medical student you are talking about when you discuss position in a supposed-hierarchy. When I rotated through Orthopaedic services as an intern, I carried far more authority than on other services that were outside my home department. On some services, like Cardiothoracic Surgery, certain nurses were "specialty nurses" meaning that the attending staff knew them and trusted them. In instances where resident assessments of a patient's status conflicted with that of the nurses, the RN would phone the attending directly, and more often than not he would accept her assessment and plan over that of the resident.

What I am trying to say to all you future physicians is this: From day 1 of your clinical training, get a handle on the players in the game, and let go of your overly-simplistic assumptions about the "hierarchy" in the hospital. Some nurses are experienced and trusted, and going up against them will get you slapped down by your attendings. Some nurses are incompetent and dangerous, and their opinion will never be respected by anyone, including their nursing colleagues. You will also have residents who are idiots, and even as a medical student it is important to identify them and discount everything they tell you.

Medicine is game of individual players, not broad categories. Figure out the specific power structure of your institution, and try to take what you can from those who have something worthwhile to offer. Trust no one except yourself, and always remember that it's just a game and you don't need to take any of it personally.
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Its true. At least in CA, the people who are in charge of (and who hire) the doctors are completely different from the people who are in charge of (and hire) all the ancillary staff. The chief of medicine couldn't do a damn thing to the lowliest nurse in the hospital, much less the janitor. (Well, a complaint to the hospital administrator would probably do it, but nothing directly).

At the hospital where my mother works (as a physician), theres only two things that could *ever* get a nurse fired. The first is straight out fraud. Any nurse that forges papers, or issues orders in the name of a doctor without his permission is pretty much fired on the spot. The second, is outright refusal to follow a physicians orders. If a doctor writes it down and signs it, the nurses must follow the order (if possible). Hell, its considered pretty bad form to even try and make an end run around an order by having a different physician take a look at it. If its something blatantly wrong, they can always ask the ordering physician to take another look at it (they often do), but if they are given the go ahead, thats that. Shows their place in the hierarchy. Of course, med students cant write orders, and are at the bottom of the heap anyway.
 
Tired said:
INo one ever tells medical students that they don't have to take rude and abusive behavior. But they should. Ultimately you'll decide if a good grade is worth risking to keep your dignity. I made my choice; so will everyone coming after me.
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i think that's pretty much the question. I was unwilling to stand up to many people...up until about now. I wanted to get comfortable with my clinical decision making and get to a position where I felt competent enough to do so. This is difficult to do. It's also difficult as an intern. By your second year and beyond you should be gaining more confidence to stand up to people. If you can get away with it before then, kudos to you.
 
You all have some type of learning disability.

Nurses run the show. They will cut your balls off if you cross them. Watch a physician-nurse interaction some time and see for yourself. Scary. Be nice to them and buy them candy.

PS I want to be an MD so don't think I'm plugging nursing- but they will cut off your balls
 
I think there are some inherent flaws to thinking there is a specific, standardized hierarchy in the medical field.

There are many determining factors as to whether or not someone has pull. Of course there's position, but there's also seniority, and even personality (don't mess with charge nurse Big Bertha). If you are a brand new attending, and you try to mix it up with a charge nurse who's been on that floor for 10+ years, you'll get nowhere fast. Likewise, if you have been there 10+ years, and some new person tries to mix you up, its not going to fly.

We're all on the same team, but in an emergency situation the hierarchy becomes more linear to facilitate patient care. Its kind of like baseball. The center fielder has say over any fly balls in question with the left or right fielder. But in the locker room, that command will disappear, and usually the person with the most seniority/talent will lead.

But to anyone who has the desire to be trail boss, I suggest going in to practice for yourself, cause any other way you will be someone's subordinate at some point.
 
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