Level 3...not good enough?

babyNP., APRN · Apr 4, 2017

Yeah, that is true. Most of the babies that come to my unit aren't really sick, which is a good thing. We ship all the babies who require surgical/more intense intervention to the Level IV NICUs. I am just wondering, if I can't get level IV experience and I decide to go through NNP school, will I be stuck managing Level III, II and Special Care Nurseries as an NNP?

No, I wouldn't say so. Level IV academic NNPs are actually fewer than you might think and they are generally always short. You'll probably get an extensive orientation, but it shouldn't be too difficult to get a job, particularly if you work out as a NNP for a year or two elsewhere. I've worked with (as a RN, NNP student, or NNP) with 4 academic centers now, 2 on the east coast, 1 in the southwest, and 1 in the northwest and all 4 were perpetually short of NNPs. Most NNPs don't want to do the Level IV academic stuff for various reasons.

Shayjam86 · Apr 5, 2017

If at all possible you should try to find a job in a level IV. If that is not a possibility for you then just ask your education coordinator or whoever is responsible for your development. You should have been given a full orientation upon hire. It isn't fair to you to be held back . How else are you supposed to develop your skills? With that said different level NICUs will give yoi different experiences and different skillsets. You should be fine getting your NNP while working in a level 3. I work at a level 2 and a couple of my coworkers are getting their NNP. Don't be discouraged just speak up. We are responsible for our own experiences as nurses. Actively seek out the ones that will make you a better nurse. Good luck.

megatronRN · Apr 5, 2017

Push for the sicker babies and continue on your path. When I want a particular assignment, I try to get to the unit earlier than normal and speak to the Charge Nurse. I'm not sure how your unit functions or does assignments, but this usually works for me. Also, do nurses on your unit take primary patients? Why not take a small and/or sicker baby as a primary patient? Finally, speak to the nurses that usually do assignments and explain your situation.

Sometimes you really need to push for what you want and be vocal about it. Nurses (especially NICU nurses) can be protective of patients and place the sicker kids with experienced nurses without giving it much thought. Speak up about your desire for more experience. There is a ton to learn in a level III unit.

TeenyTiny, ADN, BSN · Apr 6, 2017

I keep getting confused, because here in Canada (or Ontario at least), level III is our highest level with the sickest babies. I work in a level III right now with IMC and level II pods mixed in...new staff always start in these pods before being trained in the critical care pods. Many people have been waiting over a year to be trained in the critical care pods....

It varies state to state here. My unit would be a level IV (and the only on in our state) if our state recognized it.

OP, some level III's may be acceptable to get you the experience based on this fact. What's important to ask about the unit and what types of things they do.

Some one may have already said this (I could have missed it) but if you are able to request assignments, request an assignment that has the type of experience you are looking for.

ThePrincessBride, MSN, RN, NP · Apr 7, 2017

No, I wouldn't say so. Level IV academic NNPs are actually fewer than you might think and they are generally always short. You'll probably get an extensive orientation, but it shouldn't be too difficult to get a job, particularly if you work out as a NNP for a year or two elsewhere. I've worked with (as a RN, NNP student, or NNP) with 4 academic centers now, 2 on the east coast, 1 in the southwest, and 1 in the northwest and all 4 were perpetually short of NNPs. Most NNPs don't want to do the Level IV academic stuff for various reasons.

Why is that? Wouldn't level IV academic jobs be considered the cream of the crop?

So you have worked in more than one NICU? What level did you start off in? Have they all been level IV?

babyNP., APRN · Apr 7, 2017

Why is that? Wouldn't level IV academic jobs be considered the cream of the crop?
So you have worked in more than one NICU? What level did you start off in? Have they all been level IV?

I started out on the east coast as a new grad at a large Level IV NICU (children's hospital). After I had some experience, I did some per diem through a local company to work at some community hospitals, Level II through Level III.

Went to school (continued to work as a RN at my home Level IV unit) and did a rotation in two Level IV units (neither were my home unit) and a community Level III. Then I moved to the southwest for my first job as a NNP at a large Level IV. Today I work in the PNW for a community Level III hospital that is part of a network of the local children's hospital.

It's interesting to hear your thoughts about Level IV academic jobs being the cream of the crop. That has not been my experience at all. Now that I've worked in both settings as a NNP, here is my perspective based on my own anecdotal experience that seems to follow with other folks with whom I've had this type of discussion:

Academic pros:

Sick kids. Odd kids. Kids that you'll see once in your career and never again. Access to lots of good education in the form of grand rounds, morning reports, and every specialty imaginable and being able to pick their brains. Being at the forefront of the latest and greatest in evidence based practice. If we're being honest, somewhat of an ego to say that yes you work at a certain facility. Salary is hit or miss, depending on the institution.

Academic cons:

Generally in big cities and so has all the inconveniences of living in a city including high cost of living, terrible parking (NPs don't generally rank high enough to park on campus except for night shift unlike at many community hospitals), less "perks." Generally 12 hour shifts, no 24s (depends on your outlook whether or not this is a pro or a con).

Much less opportunity for procedures and if you are- having 23935498 people in the wings waiting just in case (competing for who gets to do the procedure is a thing, largely due to lack of availability). Generally no deliveries (this isn't always the case, but overall majority). Chronic babies that are 6 months upwards of a year old with a million problems that most NNPs don't want to really manage (as this isn't our skill set and not what we learn in grad school) that also come along with parents who are sick and tired of the NICU and resist the medical inevitability (not all of course, but the number of times we've spent months and months trying to convince a parent that yes a trach really is the way to go, eep).

And...sick kids. All the time. Not much room for a break. It's different kind of stress being the provider in charge as a provider versus the nurse. Managing a baby on ECMO even despite everyone (surgery, heme, fellows, attendings, etc etc) right there helping you is a completely different experience than when I was the bedside ECMO nurse. Then you have the kids dying on a fairly regular basis. And giving "the talk" to parents and being the one to tell them that yes, their child is dying and no there is nothing I can do about it.

Many NNPs don't want any part of the above...

Eep. That was long. Don't get me wrong. I loved my Level IV job. But it was stressful. Not all the time. But I felt like I made a good difference and that's what made it all worth it. I poured my heart into the families for months at a time while their baby was ill and I learned so, so much from attending grand rounds and talking with consulting services.

Community sites are generally the opposite. For example, I've done more procedures in 1 month than I would do in 6 months at my previous job. I only work 6-7 days a month. True, my babies are not very sick, but I like to call them my "rainbows and sunshine" babies. They're pretty nice. And I am still learning- learning how to manage "regular" acute babies that don't go to Level IVs but still need specialized care that I didn't treat in my other role.

I've also had to stand more on my own; my attending leaves by the mid-afternoon and while they are always just a phone call away, I'm otherwise it for the NICU and any delivery in the hospital. There is something to be said for being more autonomous and becoming a stronger provider because of it. One of my favorite parts of my new role is doing prenatal consults with families that expect to delivery prematurely.

Overall, I am glad I have the experience I do and wouldn't change a single thing. Perhaps I'll change my mind in a few years and go back to Level IV, but it's nice to be a more rounded NP for now with a better lifestyle.

Semper_Gumby · Apr 8, 2017

I started out on the east coast as a new grad at a large Level IV NICU (children's hospital). After I had some experience, I did some per diem through a local company to work at some community hospitals, Level II through Level III.
Went to school (continued to work as a RN at my home Level IV unit) and did a rotation in two Level IV units (neither were my home unit) and a community Level III. Then I moved to the southwest for my first job as a NNP at a large Level IV. Today I work in the PNW for a community Level III hospital that is part of a network of the local children's hospital.
It's interesting to hear your thoughts about Level IV academic jobs being the cream of the crop. That has not been my experience at all. Now that I've worked in both settings as a NNP, here is my perspective based on my own anecdotal experience that seems to follow with other folks with whom I've had this type of discussion:
Academic pros:
Sick kids. Odd kids. Kids that you'll see once in your career and never again. Access to lots of good education in the form of grand rounds, morning reports, and every specialty imaginable and being able to pick their brains. Being at the forefront of the latest and greatest in evidence based practice. If we're being honest, somewhat of an ego to say that yes you work at a certain facility. Salary is hit or miss, depending on the institution.
Academic cons:
Generally in big cities and so has all the inconveniences of living in a city including high cost of living, terrible parking (NPs don't generally rank high enough to park on campus except for night shift unlike at many community hospitals), less "perks." Generally 12 hour shifts, no 24s (depends on your outlook whether or not this is a pro or a con).
Much less opportunity for procedures and if you are- having 23935498 people in the wings waiting just in case (competing for who gets to do the procedure is a thing, largely due to lack of availability). Generally no deliveries (this isn't always the case, but overall majority). Chronic babies that are 6 months upwards of a year old with a million problems that most NNPs don't want to really manage (as this isn't our skill set and not what we learn in grad school) that also come along with parents who are sick and tired of the NICU and resist the medical inevitability (not all of course, but the number of times we've spent months and months trying to convince a parent that yes a trach really is the way to go, eep).
And...sick kids. All the time. Not much room for a break. It's different kind of stress being the provider in charge as a provider versus the nurse. Managing a baby on ECMO even despite everyone (surgery, heme, fellows, attendings, etc etc) right there helping you is a completely different experience than when I was the bedside ECMO nurse. Then you have the kids dying on a fairly regular basis. And giving "the talk" to parents and being the one to tell them that yes, their child is dying and no there is nothing I can do about it.
Many NNPs don't want any part of the above...
Eep. That was long. Don't get me wrong. I loved my Level IV job. But it was stressful. Not all the time. But I felt like I made a good difference and that's what made it all worth it. I poured my heart into the families for months at a time while their baby was ill and I learned so, so much from attending grand rounds and talking with consulting services.
Community sites are generally the opposite. For example, I've done more procedures in 1 month than I would do in 6 months at my previous job. I only work 6-7 days a month. True, my babies are not very sick, but I like to call them my "rainbows and sunshine" babies. They're pretty nice. And I am still learning- learning how to manage "regular" acute babies that don't go to Level IVs but still need specialized care that I didn't treat in my other role.
I've also had to stand more on my own; my attending leaves by the mid-afternoon and while they are always just a phone call away, I'm otherwise it for the NICU and any delivery in the hospital. There is something to be said for being more autonomous and becoming a stronger provider because of it. One of my favorite parts of my new role is doing prenatal consults with families that expect to delivery prematurely.
Overall, I am glad I have the experience I do and wouldn't change a single thing. Perhaps I'll change my mind in a few years and go back to Level IV, but it's nice to be a more rounded NP for now with a better lifestyle.

What an awesome summary! Thanks, babyNP. I've been interested in NNP myself and really appreciate this comparison.

I was a nursery nurse in my first nursing job at a small community hospital with little backup; I think it strengthened my skills overall to have that kind of autonomy. I just had a brief stint at a teaching hospital in postpartum and it was a vastly different feel compared to the community hospital.

Skippingtowork · Apr 10, 2017

What's in a name? What's in a level? There are many institutions calling themselves level this or that, that do not actually meet the criteria for that designation. Level IV is really about cardiac service. Everything else can be done in level III. Also, it is more efficient to send cardiac babies to one institution which has a lot of experience, regardless of your own insitution level. An nurse or NP in one state can get experience that another nurse or NP would not get in another, even when both hospitals have the same level designation. All the level IIs that I have been in have ventilators, drips, and keep micro-preemies that do not need surgical intervention. I have worked in a level III that did not have ECMO and transferred babies down the street to another "level 3" with ECMO. There are level IIs that do not keep anything under 32 weeks gestation, while others think nothing of the 23-weeker. It all depends on the state and hospital.

I have seen young nurses graduate from college, start working, and go straight into NP school. They worked and trained at the same hospital and completed their programs in about 2-1/2 years. After completion, they did very well. One NP came from a level II which did not keep anything remotely complicated.

There are NICUs that are like a club, excluding those who want to move ahead, while others are eager for you to progress. Even if you feel shut out, nothing stops you from reading, going to conferences, picking the brains of the seasoned nurses, etc. And sometimes, you really do get to do more in a scaled-down setting. Your knowledge needs to be top-notch and you get to develop skills that you might not have the opportunity for if there are a million residents, fellows and interns running around in an academic setting.

ThePrincessBride, MSN, RN, NP · Apr 16, 2017

It's interesting to hear your thoughts about Level IV academic jobs being the cream of the crop. That has not been my experience at all. Now that I've worked in both settings as a NNP, here is my perspective based on my own anecdotal experience that seems to follow with other folks with whom I've had this type of discussion:
Academic pros:
Sick kids. Odd kids. Kids that you'll see once in your career and never again. Access to lots of good education in the form of grand rounds, morning reports, and every specialty imaginable and being able to pick their brains. Being at the forefront of the latest and greatest in evidence based practice. If we're being honest, somewhat of an ego to say that yes you work at a certain facility. Salary is hit or miss, depending on the institution.
Academic cons:
Generally in big cities and so has all the inconveniences of living in a city including high cost of living, terrible parking (NPs don't generally rank high enough to park on campus except for night shift unlike at many community hospitals), less "perks." Generally 12 hour shifts, no 24s (depends on your outlook whether or not this is a pro or a con).
Much less opportunity for procedures and if you are- having 23935498 people in the wings waiting just in case (competing for who gets to do the procedure is a thing, largely due to lack of availability). Generally no deliveries (this isn't always the case, but overall majority). Chronic babies that are 6 months upwards of a year old with a million problems that most NNPs don't want to really manage (as this isn't our skill set and not what we learn in grad school) that also come along with parents who are sick and tired of the NICU and resist the medical inevitability (not all of course, but the number of times we've spent months and months trying to convince a parent that yes a trach really is the way to go, eep).
And...sick kids. All the time. Not much room for a break. It's different kind of stress being the provider in charge as a provider versus the nurse. Managing a baby on ECMO even despite everyone (surgery, heme, fellows, attendings, etc etc) right there helping you is a completely different experience than when I was the bedside ECMO nurse. Then you have the kids dying on a fairly regular basis. And giving "the talk" to parents and being the one to tell them that yes, their child is dying and no there is nothing I can do about it.
Many NNPs don't want any part of the above...

Thanks for the reply.

I was always under the impression that academic jobs were held in such high regard because there are usually more resources, better staffing and more educational opportunities than a non-teaching hospital.

But it is interesting (and sad) to hear that NPs aren't treated with much respect in an academic facility, but I find that this is a case in many areas, unfortunately, especially when dealing with Neos, residents, etc. However, I do think working three 12s is much more preferable to a couple of 24-hour shifts (that sounds brutal). Also, aren't benefits usually better?

My concern is that as a (wannabe) NNP, I want to be able to handle any and everything that comes through the door (within my scope of practice, of course). I don't want to be stuck in lower acuity NICUs and not feel confident in my ability to manage a very sick baby's care. For now, I am stuck with more stable babies and Level IVs are so few in my area.

Oh, and I have absolutely NO experience working with ECMO patients whatsoever.

Community sites are generally the opposite. For example, I've done more procedures in 1 month than I would do in 6 months at my previous job. I only work 6-7 days a month. True, my babies are not very sick, but I like to call them my "rainbows and sunshine" babies. They're pretty nice. And I am still learning- learning how to manage "regular" acute babies that don't go to Level IVs but still need specialized care that I didn't treat in my other role.
I've also had to stand more on my own; my attending leaves by the mid-afternoon and while they are always just a phone call away, I'm otherwise it for the NICU and any delivery in the hospital. There is something to be said for being more autonomous and becoming a stronger provider because of it. One of my favorite parts of my new role is doing prenatal consults with families that expect to delivery prematurely.
Overall, I am glad I have the experience I do and wouldn't change a single thing. Perhaps I'll change my mind in a few years and go back to Level IV, but it's nice to be a more rounded NP for now with a better lifestyle.

Do you think you would have fared well with just level III experience?

ThePrincessBride, MSN, RN, NP · Apr 16, 2017

What's in a name? What's in a level? There are many institutions calling themselves level this or that, that do not actually meet the criteria for that designation. Level IV is really about cardiac service. Everything else can be done in level III. Also, it is more efficient to send cardiac babies to one institution which has a lot of experience, regardless of your own insitution level. An nurse or NP in one state can get experience that another nurse or NP would not get in another, even when both hospitals have the same level designation. All the level IIs that I have been in have ventilators, drips, and keep micro-preemies that do not need surgical intervention. I have worked in a level III that did not have ECMO and transferred babies down the street to another "level 3" with ECMO. There are level IIs that do not keep anything under 32 weeks gestation, while others think nothing of the 23-weeker. It all depends on the state and hospital.
I have seen young nurses graduate from college, start working, and go straight into NP school. They worked and trained at the same hospital and completed their programs in about 2-1/2 years. After completion, they did very well. One NP came from a level II which did not keep anything remotely complicated.
There are NICUs that are like a club, excluding those who want to move ahead, while others are eager for you to progress. Even if you feel shut out, nothing stops you from reading, going to conferences, picking the brains of the seasoned nurses, etc. And sometimes, you really do get to do more in a scaled-down setting. Your knowledge needs to be top-notch and you get to develop skills that you might not have the opportunity for if there are a million residents, fellows and interns running around in an academic setting.

To me, Level IV not only includes cardiac care, but anything surgical/more intensive. My unit takes baies under 23 weeks (and I was fortunate to have received that experience), but the minute the perf/nec/show signs of needing a specialist surgeon, they are shipped, and I feel like I am missing a huge part of the NICU by not having that hands-on surgical experience.

Or do NNPs not deal with anything surgical?

Club is definitely an apt description to describe NICUs, and it really isn't safe, in my opinion.

Skippingtowork · Apr 18, 2017

To me, Level IV not only includes cardiac care, but anything surgical/more intensive. My unit takes baies under 23 weeks (and I was fortunate to have received that experience), but the minute the perf/nec/show signs of needing a specialist surgeon, they are shipped, and I feel like I am missing a huge part of the NICU by not having that hands-on surgical experience.
Or do NNPs not deal with anything surgical?
Club is definitely an apt description to describe NICUs, and it really isn't safe, in my opinion.

I have worked in both, as RN and specialist NP. Level IIIs handle 23 weekers routinely and every level II I have worked in also handled 23 weekers. Surgical issues are identified by the neonatologist and handled by surgeons, with neonatologist staff handling the medical side. A lot of critical issues will be outside your scope of practice to handle by yourself. The majority of critical babies in this country do not require surgery. Medical management has changed so much, that the terrible things we used to see is decreasing. At the level 4, you will have the chance to see issues that are beyond a particular hospital's ability to handle, but I've seen diagnoses handled in a level 3 that were very interesting and rare. When you work in a specialty, you know where those babies are coming from and they're coming from everywhere.

One other thing to remember, "good care is not excessive care." Sometimes in larger centers, because of all the training, the approaches may not always be evidenced-based and often for practice. When there are a lot of levels of training going on, consistency and careful watch is not always occurring. There are very good results coming out of lesser known units.

You may want to compare the work experience of NPs in level IVs to that of the NPs in level III and II. Sometimes after the training is over, they are relegated to the less sick babies anyways, due to residents and hospital rules. If you went to a NICU conference, you might be able to speak to a variety of NPs in person. Nothing is better than face-to-face conversation. BabyNP shared some important insites.