The roles above a registered nurse fall into two main tracks: clinical advancement and leadership. On the clinical side, Advanced Practice Registered Nurses (APRNs) hold graduate degrees and can diagnose patients, prescribe medications, and manage treatment plans independently. On the leadership side, positions like nurse manager, director of nursing, and chief nursing officer carry increasing authority over hospital operations and staff. Many nurses also move into specialized non-clinical careers in education, informatics, or consulting. Here’s how each path works and what it takes to get there.
Advanced Practice Registered Nurses
The most direct step above an RN is becoming an APRN, which requires at minimum a master’s degree in nursing (MSN). APRNs have a fundamentally different scope of practice than staff nurses. They evaluate patients, diagnose conditions, order and interpret tests, and prescribe medications, including controlled substances. In many states, they do this under their own licensure authority without physician oversight.
There are four distinct APRN roles:
- Nurse practitioner (NP): Provides primary or specialty care, managing everything from routine checkups to chronic disease. The median salary is about $109,820 per year.
- Certified registered nurse anesthetist (CRNA): Delivers anesthesia care and performs many of the same functions as physician anesthesiologists. CRNAs are the highest-paid nursing professionals, with a median salary around $174,790.
- Certified nurse midwife (CNM): Manages pregnancy, labor, and postpartum care, and often serves as a primary care provider for women’s health.
- Clinical nurse specialist (CNS): Works in specialty or hospital-based settings, focusing on improving care quality within a specific patient population or unit.
A notable shift is underway in education requirements. The National Organization of Nurse Practitioner Faculties has been pushing to make the Doctor of Nursing Practice (DNP) the standard entry-level degree for APRNs. Nurse anesthetist programs have already made this transition. As of 2022, all new CRNA students must enroll in a doctoral program. No state licensing boards have yet required a DNP for nurse practitioner licensure, but the trend is moving in that direction.
Nursing Leadership Roles
The administrative ladder offers a separate path upward. These roles focus less on direct patient care and more on managing staff, budgets, and the systems that shape how care gets delivered.
The typical progression looks like this: a charge nurse leads a single shift on a unit, handling patient assignments and immediate problem-solving. Above that, a nurse manager oversees an entire unit or department around the clock, handling staffing, budgets, and performance. A director of nursing (DON) manages day-to-day operations across multiple units or departments within a facility. At the top sits the chief nursing officer (CNO), a high-ranking executive responsible for the strategic direction of all nursing services across the organization, shaping policies, standards, and institutional priorities.
Nurse manager roles typically require a BSN and several years of bedside experience, though many employers prefer or require a master’s degree. Director and CNO positions almost always call for graduate education, often an MSN in nursing leadership or a healthcare administration degree, along with significant management experience.
Doctoral Degrees in Nursing
Nursing has two terminal degrees, and they serve very different purposes. The DNP is a practice doctorate designed to create clinical leaders. DNP programs focus on translating research into bedside improvements, transforming health care systems, and developing leadership skills. Students complete a minimum of 400 clinical hours and a scholarly project.
The PhD in Nursing is a research doctorate. PhD-prepared nurses design and conduct original studies, develop new knowledge for the science of nursing, and lead interdisciplinary research teams. Their training centers on advanced research methods, statistics, and data analysis, and they complete a traditional dissertation. PhD graduates typically work in universities or research institutions rather than in direct patient care.
Both degrees position nurses at the top of the profession, but in different arenas. A DNP prepares you to lead clinical practice. A PhD prepares you to generate the evidence that clinical practice relies on.
Specialty Certifications Without a New Degree
Not every step up requires going back to school for a graduate degree. Specialty certifications let RNs validate advanced knowledge in a focused area, such as critical care, emergency nursing, or oncology, without enrolling in a degree program. While RN licensure measures entry-level competence, certification signals expertise in a specific clinical domain.
The practical benefits are real. Certified nurses in acute and critical care can receive a 10% discount on malpractice insurance premiums. Certification also positions nurses for recognition, promotions, and higher pay within their current workplace. Studies on nursing workforce retention consistently identify support for certification as a key driver of job satisfaction.
Non-Clinical Career Paths
Some of the roles above an RN leave the bedside entirely. Nursing informatics specialists work at the intersection of healthcare and technology, designing and managing the electronic systems that hospitals rely on. Most informatics positions require an MSN with a focus on informatics, though entry-level roles may accept a BSN with certification through the American Nurses Credentialing Center.
Nurse educators teach in colleges, hospitals, or simulation labs. Positions at universities generally require a master’s degree at minimum, with doctoral preparation preferred for tenure-track faculty roles. Legal nurse consultants use their clinical expertise to review medical records and advise attorneys on malpractice and personal injury cases. These roles draw on the same clinical knowledge an RN builds at the bedside but apply it in entirely different settings, often with more flexibility and higher earning potential than staff nursing.