Oregon Oregon Health Authority, Public Health Division

Rule Rule 333-510-0040
Nurse Executive


The nurse executive position shall be full-time (40 hours per week). Time spent in professional association workshops, seminars and continuing education may be counted as duties in considering whether or not the nurse executive is full-time. If the nurse executive has responsibility for direct patient care activities, sufficient time must be available to devote to administrative duties. For hospitals with attached long-term care facilities, the nurse executive may function as the nurse executive for both the hospital and the long-term care facility.


The nurse executive shall have had progressive responsibility in managing in a health care setting. The nurse executive shall be a registered nurse licensed in Oregon. In addition, the nurse executive must have a baccalaureate degree, other advanced degree, or appropriate equivalent experience, with emphasis in management preferred.


The nurse executive shall have written administrative authority, responsibility, and accountability for assuring functions and activities of the nursing services department and shall participate in the development of any policies that affect the nursing services department. This includes budget formation, implementation and evaluation. The nurse executive shall ensure the:


Development and maintenance of a nursing service philosophy, objective, standards of practice, policy and procedure manuals, and job descriptions for each level of nursing service personnel;


Development and maintenance of personnel policies of recruitment, orientation, in-service education, supervision, evaluation, and termination of nursing service staff or ensure it is done by another department;


Development and maintenance of policies and procedures for determination of nursing staff’s capacity for providing nursing care for any patient seeking admission to the facility;


Development and maintenance of a quality assessment and performance improvement program for nursing service;


Coordination of nursing service departmental function and activities with the function and activities of other departments; and


Ensure participation with the administrator and other department directors in development and maintenance of practices and procedures that promote infection control, fire safety, and hazard reduction.


Whenever the nurse executive is not available in person or by phone, the nurse executive shall designate in writing a specific registered nurse or nurses, licensed to practice in Oregon, to be available in person or by phone to direct the functions and activities of the nursing services department.

Last accessed
Jun. 8, 2021