Nursing Chain Of Command

The daily routine of a nurse can be quite complex, to say the least. Sometimes the nurse may have a smooth sailing day, while other times, the nurse may be faced with many challenges. So, when the nurse faces these challenges who does she turn to? Is she expected to figure it all out for herself or is there an authority in nursing that needs to be notified of difficult circumstances? 

This is where the chain of command comes into play and can be a huge lifesaver for the nurse. Read on and we’ll discuss what exactly a chain of command is and how it relates to nursing, as well as, the importance of chain of command and the benefits it has for each individual nurse and healthcare team.

Nursing Chain Of Command

Define Chain of Command

So, what is the definition for chain of command? According to the Merriam-Webster dictionary, a chain of command is a series of executive positions in order of authority. The chain of command in nursing is an organizational structure and system that is used to show exactly how authority is passed down from the most superior individuals in the organization to the least superior individuals. Other chain of command synonyms includes the line of responsibility or hierarchy of authority in healthcare.

Purpose of the Chain of Command 

The purpose of having a chain of command policy present within a healthcare organization is to immediately establish a formal process to use when needing to get answers, create a satisfactory resolution to a problem, or to use if needing to report potentially bad or questionable patient conditions and care.  Therefore, it also provides a safety net for patients because it ensures everyone is being held accountable for their individual actions.

Importance of a Chain of Command

There are a ton of benefits to having a formal chain of command! First of all, everyone is accounted for and I literally mean everyone! When a chain of command in healthcare is made, it considers every individual that works within the organization and it clearly defines the hierarchy of all these individuals and positions. This should get you excited as a nurse because it means that whether you are the CEO or just starting out as a staff RN you have a place in the hierarchy and your role is clearly defined. 

A chain of command also helps to improve communication within the department and the overall organization, as well as, improve teamwork and collaboration. This is because (as mentioned earlier) everyone has a role and each is well defined. It also helps to distribute power and responsibilities and shows each member of the team who is in charge for which activities and clearly communicates to the team who is the appropriate person to speak to if a questionable situation arises. 

The chain of command also holds people accountable. In healthcare it doesn’t matter where you fall on the totem pole every person has a responsibility to the team and the chain of command helps to ensure this responsibility and accountability to your fellow team members. 

It also helps to make work go more smoothly and efficiently and provides clarity to all individuals on the team and what each should be doing. Finally, it can also be used as a way to make sure all teams members are kept up-to-date on any news within their organization and specific department.

Nursing Chain of Command Progression

All team members should be aware of the appropriate chain of command within their department and organization. Depending on the organization size there may be some variation in the titles used but for the most part the list below is a fairly good indicator of the appropriate nurse chain of command from the bottom to the top:

  • Patient Care Tech/Nursing Assistant (CNA)
  • Licensed Practical Nurse (LPN)
  • Registered Nurse (RN)
  • Charge Nurse
  • Nursing Supervisor
  • Nurse Manager
  • Department Manager
  • Hospital Supervisor 
  • Chief Nursing Officer (CNO)
  • Hospital CEO/President

Chain of Command Example

So, let’s look at an example.  Say there is a post-operative patient, in contact isolation, that has not urinated in well over 10 hours, despite receiving continuous IV fluids. The nurse decides to perform a bladder scan to assess the amount of urine the patient is potentially retaining. She finds out the patient is currently retaining 800mL of urine. She immediately calls and speaks with the MD and receives an order for a Foley catheter. The nurse knows this is a sterile nursing procedure so she grabs all of her supplies and heads into her contact isolation room. She also takes an additional nurse with her to assist with positioning the patient appropriately for the insertion of the catheter. In setting up her supplies, the catheter accidentally touches the floor. The assisting nurse comments about the need to get a new catheter however, the primary nurse says no it’s fine to continue to use this catheter because it “barely touched the floor.”  A few days later the patient develops a fever along with discolored and odorous urine. A sample is sent to the lab and comes back positive for infection. Ultimately, the patient is started on IV antibiotics and his hospital stay is lengthened because of the bladder infection.  

In this situation what is the appropriate nursing action and how could the assisting RN have utilized the chain of command to prevent this from occurring? The assisting nurse started out doing the right thing by addressing the issues directly with the primary nurse and pointing out the need for a new catheter. Given that the primary nurse was not receptive to this idea the next step for the assisting nurse would be to go to her direct superior on that shift, either the charge nurse or lead RN. Following this the charge nurse/lead RN would take over responsibility of the situation and address the issue firsthand with the primary nurse and if warranted escalate it further to her direct nursing supervisor or manager depending on the department structure.

Final Thoughts

The chain of command is a vital part of healthcare and is present no matter what setting you are working in. For instance, there is a hospital chain of command, a nursing home chain of command, and even a chain of command in the outpatient clinic environments. This hierarchy in healthcare is there to provide clarity to team members and most importantly there to protect our patients keeping each one safe while under our nursing care. Don’t be afraid to use the chain of command if you see something that should be reported. It’s your duty as the nurse to advocate for your patient. Besides, utilizing the chain of command also allows a great opportunity to make teachable moments and supports team members learning and growth! So, do you know what the chain of command is in your department and organization? I urge you to find out today and begin using it when appropriately needed.

Written by
Tabitha Cumpian