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Medical unions are especially prone to organizational problems due to the nature of medical profession licensing and the work itself. The reality is that a CNA, an LPN, an RN, and a APN are on vastly different skill levels. Add in other professionals like physical therapists, psychologists, social works, and of course, doctors themselves, and you have a byzantine command structure that spiders out floor by floor. Even amongst those specific licensees theres a hierarchy of command, with individuals in charge of specific wards and then a layer of supervisors who are essentially executives who are in charge of everyone in a specific class.