The Nursing Pecking Order

A colleague friend and I were talking the other day about the unspoken but clearly defined hierarchy in nursing, which is arranged according to specialty. This is quite funny as theoretically we nurses are all equal, but in reality the opposite is true. My friend believes status depends on some equation related on the knowledge we need in order to competently fulfill our positions plus actual autonomy plus perceived crustiness.* My own, simpler theory is that status is intimately linked to the number of tubes and wires we can fiddle with at once: the more IVs running and monitors beeping, the higher we are. In short, we’re talking patient acuity.

Here’s my take on it. Your mileage may vary, though I think everyone might agree that the poor nursing home nurses, regardless of individual merit, are near the bottom.

1. At the top of the food chain, the hyper-specialized, like NICU nurses, or neuro ICU. And the NPs and clinical nurse specialists.

2. Then the generalist ICU nurses and the Emergency nurses.

3. Then the PACU and OR nurses and the paeds nurses. Home Care case managers would be somewhere near here, mostly because they get to wear street clothes and keep banker’s hours.

4. L & D nurses, nursery nurses, dialysis nurses.

5. Then the day surgery nurses and the medical outpatient nurses.

7. Then the surgery ward nurses.

8. The medical ward nurses.

9. The psych nurses.

10. The home care nurses.

11. And at the bottom of the food chain, the nursing home nurses and “private duty” nurses.


*Emerg nurses score pretty high on the perceived crustiness scale, when actually we are all gentle, misunderstood souls yearning to be loved.

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  1. #1 by bennymay on Sunday 10 January 2010 - 0932

    Vaccinations: a personal story

  2. #2 by JennJilks on Sunday 10 January 2010 - 1030

    Pecking order, an interesting concept!
    I have a question for you…
    normally, can you peck at each other? Is there a place where you meet?
    How does the pecking order manifest itself?
    I know, as a teacher, the staff meeting is the place where it is obvious, despite the principal potentially (just say!) being younger that a teacher, less experienced, with less education! The staff room is the place where there is a bit more equality.

    My feeling is that ‘there are no small parts, only small actors’, if you know what I mean. That sweet, young nurse who visited the day before mom died was a sweetie. She knew little of my mom’s case, and mom died the next day, but she was as important as the intake nurse at the hospital at 2 a.m.!

    • #3 by torontoemerg on Sunday 10 January 2010 - 1932

      The staff lounge is the usual place for pecking. Where else to completely slag your colleagues? :)

  3. #4 by Rural on Sunday 10 January 2010 - 1154

    Just stumbled (no medical attention rqd!) across your blog, interesting seeing the “other” point of view as it were. In my view you all deserve much more respect (as compared with most doctors) than you generaly get. So here is a Tip o the Hat to all of you.
    I wonder where those medivac nurses fit in the pecking order? Judging from the number of flights going over my house on the way from a small city hospital (where it seems they cannot / do not handle much more than routine cases) to the “regional” hospital they must be in high demand!

    • #5 by torontoemerg on Sunday 10 January 2010 - 1922

      I think medivac nurses are fairly high, from my point of view.

  4. #6 by Gert on Sunday 10 January 2010 - 1747

    I know that these feelings of pecking order (superiority, in other words) exist. It’s too bad. There are different kinds of nursing and different kinds of nurses. I worked in acute care in oncology and BMT, put people in conscious sedation for some truly incredible procedures on the floor. I did it for several years and I did it well. But it was not my chosen area.

    I refuse to feel diminished by anyone who thinks that home care nursing (actually hospice in my case, which I realize will be deemed by some as even ‘less’ than home care) is somehow ‘less’ than ICU nursing. It’s definitely different. ER nurses, ICU nurses, acute care nurses, home care/hospice nurses and the bottom-rung (on your list) SNF nurses all perform needed services. It doesn’t have to be ‘you’re a (insert SNF/hospice/home care) nurse because you’re not (smart enough? good enough?) to be on the unit’.

    I am a better hospice nurse than I was acute care nurse. But I can tell you that even the best ICU nurse will be completely out of place in hospice if he/she doesn’t have the true desire to do that sort of nursing. It takes a particular skill set to do hospice well…..not just anybody will have the skills. And we do continue to draw labs and manage IV’s/PICC’s although to a much lesser extent. We’re also out in the field with very litte backup support. You’ve got to know your stuff.

    And, there are just plain sub-par nurses in EVERY area of nursing, although they probably do tend to trickle down (as per your list) over time.

    I don’t think you were TRYING to be insulting with your list, by the way.

    • #7 by Gert on Sunday 10 January 2010 - 1753

      At least I hope you weren’t!

    • #8 by torontoemerg on Sunday 10 January 2010 - 1921

      No…. just idle (if clumsy) reflections on how we perceive ourselves. And I should add I have a huge amount of respect for home care nurses and palliative care nurses. But I also think it isn’t much use pretending we have equivalent skill sets in our respective practice areas (apart from things like temperament, career goals, etc). I mean, I think an emergency nurse could relatively easily work on a med-surg unit without much further training, but I am not certain the reverse is true.

      • #9 by Gert on Sunday 10 January 2010 - 2047

        There’s no doubt, if I did desire to return to acute care, that I would need to be reoriented to regain skills. Hospice nursing is just very different. I didn’t choose it because it’s not as difficult as hospital nursing, I chose it because I really wanted to do it. I saw too many people suffering too much up until their deaths because they or their doctor were reluctant to ‘give up’ (and yes, sometimes it’s the doctor’s reluctance to let go that keeps people going for treatment after treatment, as well as a patient population trained to listen and do what the doctor says).

        In hospice, it’s pretty much one-on-one. No call bells going off right and left. It’s patient centered care first and foremost. It’s the reason I wanted to be a nurse.

        But I love to read all the ER stories! Keep up the good work!

  5. #10 by torontoemerg on Sunday 10 January 2010 - 2059

    Hey Gert, I really appreciate your engagement — and I have seriously at times considered doing palliative for the exact reasons you mention. Nothing beats the one on one stuff.

  6. #11 by jparadisirn on Sunday 10 January 2010 - 2111

    I used to work pediatric intensive care and neonatal units. During that time, nurses in our unit were frequently called upon to assist in other areas of the hospital (like ER) where our specialty skills came in handy. Now that I work outpatient ocnology, I do notice a difference when talking to the ER when admitting a patient. I can tell my assessment is under suspicion, until I bring the patient over and the ER nurse can see for himself, as my assesments are still strong. Nurses who take care of high acuity patients are a little suspicious of nurses from lesser acuity areas. The reality is, nursing is so specialized now that I feel the old days when any old nurse with a stethescope could float to any unit in a hospital are over as most units require unique skill sets.

  7. #12 by JennJilks on Sunday 10 January 2010 - 2130

    If I may say, hospice work, if in a client’s home, is a place where we, as family members, need the strongest advocates. So many myths about palliative pain management abound.

  8. #13 by Art Doctor on Sunday 10 January 2010 - 2133

    Geriatric nurses are always short staffed, and put up with tons of crap from Social Work, Physio, Occupational staff, plus Doctors doing half-butt jobs on patient visits. Still, I think they would require a lot of training to match er nurses. You have to be on your toes in the ER, esp at major inner city hospitals where there are a lot of trauma, and in and out cases. Tons of respect from me to ER nurses.

    PRNs I think are up there with ER nurses though. Smaller universities and colleges often have a PRN plus a Doc in-house, and the PRN often prescribes, or refers, or even treats like a GP.

    Interesting post—keep writing!

    • #14 by Gert on Monday 11 January 2010 - 0052

      It’s comparing apples and oranges. There aren’t better nursing specialties or worse ones, just different ones. ER and ICU nurses aren’t the only good nurses. A great ER nurse may be a terrible home health nurse. Each specialty has it’s strengths and smart, good nurses know where their particular skills will be most useful. These nurses will also be more likely to enjoy what they do, and this makes for better nurses all around.

      There are rock star nurses in every specialty!

  9. #15 by Wanderer on Monday 11 January 2010 - 0423

    You forgot to add tele/progressive care nurses to #4. We have specialized knowledge, but need to know everything a medical floor and a surgical floor does (’cause the one true rule of who gets admitted to tele: they have a heart…). And after dealing with the endless succession of CHFers/Chest painer(eurs)/CABG/Valves/Angios/EPS/Pacemakers, psych, geriatrics and the assorted drug seekers etc. that just get chunked to tele, we get a wee bit crusty too.

    Just my opinion though. Besides, an “order” is misdirecting, like folks have said above, we all have a certain set of skills. I could never do peds/NICU/L&D, but wouldn’t expect one of them to handle a load on my floor. We play to our talents.

  10. #16 by KitchRN on Tuesday 12 January 2010 - 1656

    Funny observation about the pecking order. When I was a NICU RN, my fellow nurses in the unit and I did have a bit of a sense of superiority. Lots of tubes, bells and whistles and decimal points involved in calculating itty-biity dosages of medication. I will confess to feeling an utter sense of panic, however, when I had to float to a general pediatric floor. The patients weren’t in their beds! There were so many of them! Running around all over! Complete chaos! Such a relief to go back home to the NICU. A true port in the storm for all of us control freaks! : )

    I have also worked in home care and psych, and they were both just as hard as the NICU, just in different ways.

  11. #17 by Harry @ physiotherapy jobs on Sunday 07 February 2010 - 2155

    Reminds me of a form of school hierarchy where all the cool kids hang out together and shun the not so cool kids. All that immaturity is covered by a professional mask in this case, am I right?

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