American nursing is organized in four tiers: the unlicensed assistant, the licensed practical or vocational nurse, the registered nurse, and the advanced practice registered nurse. The tiers are not a difficulty ladder. What separates them is legal authority — specifically, who may assess a patient, who may form a nursing judgment, and who bears accountability when a task is handed to someone else.
Nursing assistants
Nursing assistants hold no nursing licence. Depending on the state and setting they are certified, registered, or simply trained, and federal law imposes a training and competency requirement for those working in nursing homes. They are the second-largest group in the field by headcount, after registered nurses: roughly 1.56 million jobs in 2025, with a median wage of about $42,300 a year.
The defining legal fact about this tier is that its members have no independent scope. An assistant performs tasks that a licensed nurse has delegated, and the nurse who delegated retains accountability for the outcome. This is why the phrase "the aide didn't tell me" is not a defence in a disciplinary proceeding: the duty to supervise the delegation is the nurse's own. See scope of practice and, in full, nursing assistants.
Licensed practical and vocational nurses
Practical nurses — called vocational nurses in California and Texas — hold a licence issued by a board of nursing after completing a state-approved programme, typically about a year, and passing the practical nurse licensing examination. There were roughly 667,000 such jobs in 2025, with a median wage near $64,400.
The boundary between practical and registered nursing is where the most confusion lives, because it is usually described in terms of tasks and is actually about assessment. In most states the registered nurse conducts the nursing assessment, arrives at the nursing diagnosis, and constructs the plan of care. The practical nurse gathers data, contributes to the plan, and carries out care within it. Several practice acts express this by describing practical nursing as directed by a registered nurse or physician.
Which concrete procedures follow from that principle varies enormously between states — intravenous push medications, blood product administration, central line care, and independent wound assessment are all permitted in some states and prohibited in others. A practical nurse who relocates and assumes the old rules apply is one of the more common ways a competent nurse ends up practising outside scope.
The tier's position has shifted over time. Hospitals employed practical nurses heavily in the mid-twentieth century, moved toward all-registered-nurse staffing in acute care from the 1980s, and the role is now concentrated in long-term care, post-acute settings, home health, and clinics. Projected growth is modest. See licensed practical and vocational nurses.
Registered nurses
The registered nurse is the profession's core licence and its largest professional group: about 3.47 million jobs in 2025, median wage roughly $97,600, with employment projected to grow 6 percent through 2035.
Three educational routes still lead to the same licence and the same examination — a hospital diploma programme, a two-year associate degree, and a four-year bachelor's degree. This has been contested inside the profession since 1965, when the American Nurses Association proposed the bachelor's degree as the minimum for professional practice. The proposal was never enacted anywhere as a licensure requirement, but it has been substantially achieved through the labour market: federal occupational data now lists the bachelor's degree as the typical entry-level education, and Magnet-recognized hospitals and many large systems hire almost exclusively at that level or require completion within a set period. Research is part of the reason. A 2014 study across nine European countries found that a larger proportion of bachelor's-prepared nurses was associated with lower surgical mortality, alongside the effect of staffing levels. See nurse staffing and patient outcomes.
The registered nurse's authority is what the rest of the structure hangs on: the licence to assess, to diagnose within nursing's domain, to plan, and to delegate. See the nursing process and, in full, registered nurses.
Advanced practice registered nurses
Four roles sit in this tier: the nurse practitioner, the certified registered nurse anesthetist, the certified nurse-midwife, and the clinical nurse specialist. Together they account for around 399,000 jobs, though the distribution is lopsided — about 336,300 nurse practitioners, 54,500 nurse anesthetists, and 8,200 nurse-midwives, with clinical nurse specialists counted separately in federal data. Median pay for the group is roughly $134,900, with nurse anesthetists substantially higher at about $236,600. Projected growth for the group is 36 percent through 2035, the fastest in nursing by a wide margin.
Since 2008 the tier has been organized by the Consensus Model for advanced practice registered nurse regulation, developed jointly by the boards of nursing and the professional and accrediting bodies. It defines the four roles above and six population foci — family and individual across the lifespan, adult-gerontology, pediatrics, neonatal, women's health and gender-related, and psychiatric-mental health — and requires that a nurse's education, certification, and licence all match on both role and population. The model's four pillars, licensure, accreditation, certification, and education, are commonly referred to together by their initials.
State adoption of the Consensus Model is incomplete, and advanced practice authority remains the most variable area in American nursing law: some states permit practice and prescribing without any physician relationship, others require a written collaborative agreement or direct supervision.
The tiers in detail
- Nursing assistants
- Licensed practical and vocational nurses
- Registered nurses
- Nurse practitioners
- Certified registered nurse anesthetists
- Clinical nurse specialists
- Nurse midwifery
Related
- Scope of practice
- Nurse practice acts and boards of nursing
- Nursing specialties
- Nurse staffing and patient outcomes
Sources
- Occupational Outlook Handbook: Registered Nurses — U.S. Bureau of Labor Statistics, 2025 data. Accessed September 8, 2026.
- Occupational Outlook Handbook: Licensed Practical and Licensed Vocational Nurses — U.S. Bureau of Labor Statistics, 2025 data. Accessed September 8, 2026.
- Occupational Outlook Handbook: Nursing Assistants and Orderlies — U.S. Bureau of Labor Statistics, 2025 data. Accessed September 8, 2026.
- Occupational Outlook Handbook: Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners — U.S. Bureau of Labor Statistics, May 2025 data. Accessed September 8, 2026.
- Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education — APRN Consensus Work Group and NCSBN APRN Advisory Committee, July 7, 2008. Accessed September 8, 2026.
- National Guidelines for Nursing Delegation — National Council of State Boards of Nursing and American Nurses Association, 2019. Accessed September 8, 2026.
- Nurse staffing and education and hospital mortality in nine European countries — Aiken LH, Sloane DM, Bruyneel L, et al., The Lancet 2014;383(9931):1824–1830. Accessed September 8, 2026.