All about Hospital Hierarchy

Why is this topic important?

Every health service, regardless of the size or location, will have a system where staff members have a ranking based on their relative authority, and be badged accordingly.

Knowing what the hierarchy is within your place of work will enable you to understand how all the policies (formal and informal), and ways of doing things, are formed. You will also be able to look outside your inner circle of influence and better understand the bigger picture - by doing this, the importance of your work will be even more obvious.

This Guide will describe what a typical health service hierarchy may look like and where a graduate nurse and/or midwife may fit in.

What does typical Hospital Hierarchy look like?

Every health service must meet very strict accreditation and other standards in order to exist. To ensure this can occur, health services must be managed, or governed, transparently.

Effective governance is the framework that health services use to provide accountability to continuous improvement in many areas including financial performance, patient/consumer care quality and safety, and staff credentialing, training and safety.

Governance is often seen as both clinical and corporate. Clinical governance focuses on patient/consumer quality and safety, whereas corporate governance focuses more on the performance of a health service as a business and compliance with multiple laws and regulations.

Now, governance is indeed the responsibility of everyone, but health services have managers or leaders in various roles to ensure that continuous improvement occurs. Inversely, despite the fact that certain roles are badged as leadership or management roles, it is important to consider the patient/consumer as the central role around which every other discipline works together.

In other words, all disciplines and services that collaborate in providing patient/consumer care are equally important, including non-clinical roles.

The formal org chart

Take a look at the Organisational Chart of the health service you are working in - this will give you an idea of what the formal hierarchy looks like.

A typical health service will have a Board of Directors that oversee governance and meet regularly with the Executive Team to review performance. The Executive Team typically includes Executive Directors, or Chiefs, of Nursing and Midwifery, Mental Health, People and Culture, Finance, Medicine, Allied Health and Quality/Safety. Each of these Executive Directorates then stream into discipline specific structures/hierarchies.

The hierarchy specific to Nursing and Midwifery will depend on the size of the health service and what services are provided. Typically, there will be a Director, or Directors, of Nursing and/or Midwifery. The function of this role is to role model nursing and/or midwifery professional leadership and to collaborate with other disciplines to provide safe and quality patient care.

Directors of Nursing will usually oversee a number of different wards or clinical areas, providing leadership for Nurse/Midwifery Unit Managers (NUMS/MUMS). The NUM/MUM role is critical and they are supported by Associate Nurse Unit Managers (ANUMS) to ensure leadership and management across a full 24 hours a day/7 days a week service.

Other roles you will see at this clinical level will include Clinical Nurse Specialists, who are typically nurses with significant clinical experience in that particular specialty. In addition, there will be nurses and/or midwives working in the clinical areas with a range of experience and skills, including Enrolled Nurses. Other paid roles included the Registered Undergraduate Student of Nursing (or Midwifery) role, although other names may be used such as Health Assistant in Nursing.

It is also likely that part of the hierarchy are Educators and/or Clinical Support Nurses - these roles are integral to your support and you will learn so much from them.

At any given time, you will also come across formal learners such as University or TAFE Students, at both undergraduate and postgraduate levels. These students do not appear on any Organisational Charts but they are an important part of the workplace.

As a graduate nurse and/or midwife, you will be surrounded by people with more experience and skills than you, so this is a great time to absorb as much as you can from others.

The informal org chart

You will start to appreciate that, despite the presence of a formal Organisational Chart, there are also informal hierarchies that exist. For example, you may find that despite many years of experience, some colleagues are not approachable - likewise those who may not be badged highly in terms of formal hierarchy may be the most approachable.

You will navigate your way through both the formal and informal frameworks that exist - in the future you will find yourself in a different place in the hierarchy. The Organisational Chart describes what roles exist within the hierarchy but cannot capture how these roles are performed, how engaged those people are, etc.

Conclusion

The presence of hierarchy in any health service is a necessary way of providing governance over all the systems and processes that need to work together to provide a culture of safety.

Initially, you will focus on the smaller picture hierarchy in your immediate clinical area but, as you gain confidence, you will start to look outside of this.

What is important is that everyone is human and that we are all working together across all roles and professional disciplines for the sake of safe and quality patient care.

Who wrote this Guide?

Tony McGillion | RMIT

Tony McGillion is a Registered Nurse with over three decades of experience across various roles. He began his career in the UK, also working in Saudi Arabia, before transitioning to leadership and educational roles in Australia, including positions at Epworth Hospital, Cabrini Health, Austin Health, and as a policy advisor to the Victorian Government. Currently, he holds the positions of Adjunct Professor (RMIT University) and Clinical Associate Professor (The University of Melbourne). Tony spent 5 years at La Trobe University as an Associate Professor and held multiple directorships. Tony holds a Bachelor of Education and a Master of Health Administration and he currently focuses on leadership development in nursing, served as Chair for the Australian College of Nursing in Victoria and Melbourne, and mentors early and mid-career nurse leaders. He also volunteers as a Scholarships/Grants Assessor for the Australian College of Nursing and, in his spare time, is an Athletics Australia Recreational Running Coach.