NICU Nurse Career Guide | Four Levels of Neonatal Intensive Care (NICU)

Hey there! Maybe you are reading this article because you’re interested in NICU nursing and want to learn everything about it so that you have the best shot at landing a job? Or, maybe you have taken a break from nursing and are searching for a new specialty where you can really make a difference.

If either of these sounds like you, then you are in the right place.

If you haven’t seen my other article – The Ultimate Guide to NICU Nursing – then you might want to start there. Just click here.

Let’s start at the beginning with some definitions:

  1. NICU stands for Neonatal Intensive Care Unit.The NICU is a special department in hospitals where sick and premature newborn babies (and babies up to 28 days of life) who need extra medical attention are cared for. Babies in the NICU have a very large medical care team. They are cared for by NICU nurses, Neonatologists, Neonatal Nurse Practitioners, and Pediatric Subspecialists (like Infectious Disease doctors, Cardiologists, and Neurologists just to name a few). Also, babies in the NICU rely on many other specially trained professionals, like NICU Respiratory Therapists, Occupational/Physical Therapists, Social Workers, Pharmacists, Dieticians, Child Life Specialists, and more to help restore their physical health and support their parent’s mental and emotional health too!
  2. Levels in the NICU.Just like there are different levels of Trauma Centers, there are different levels of care in the NICU too. Not all babies that are admitted to the NICU are extremely sick and in need of all the services that can be offered in the NICU (like surgery or cardiac specialists).Having different levels of NICU care available allows for babies who are most critically ill to go to a specialty hospital (or to be transferred there before they are born). Whenever possible, babies should be cared for in the same hospital where they were born. This is not always possible and some babies must be transferred by NICU nurses, doctors, and respiratory therapists who are trained in neonatal transport within in minutes or hours after birth.Whenever possible, babies should be cared for in their delivery hospital (which might be a smaller, local community hospital) so that they can stay closer to their families. Staying in the same hospital as their mom has several benefits to the baby and mother (like the ability to practice breastfeeding daily or being held skin to skin) but this may not be possible if the newborn baby has special needs that are only available at a higher level of care hospital.
  3. Regionalization of Neonatal intensive care unit (NICU) care

In the 1990’s there was a trend toward offering “Regionalization” of Neonatal Care. As more medical interventions were available for premature and sick newborns, more NICUs were developed in the US, and there was a shortage of trained NICU nurses and physicians.

Regionalization of care in the NICU has evolved over the years to address the unique needs of premature and critically ill newborns with a variety of needs. This strategy has led to improved outcomes, cost-effective care, and the development of highly skilled healthcare providers, with a focus on delivering family-centered care. This practice involves centralizing specialized neonatal care in a limited number of high-level NICUs within a given region, allowing for more effective management of resources, expertise, and equipment. To move babies from their birth hospital to a higher level of care (when needed) the specialty of Neonatal transport was also created during this time.

  1. Neonatal TransportNeonatal transport is an exciting specialty for NICU nurses who want to learn new skills, who thrive on excitement (like flying in helicopters), and who may want to pursue advanced practice roles (like Neonatal Nurse Practitioner, NNP or DNP) in the future. I think we’ll have to plan to do a future article about this role. What do you think?

The history of regionalization reflects a growing understanding of the benefits of centralized, specialized neonatal care. The regionalization of care in the Neonatal Intensive Care Unit (NICU) was a crucial development in the field of neonatology that emerged from the need to improve the outcomes of premature and critically ill infants.

If this is your first time reading our blog, you might also want to check our detailed blog on “How to Become a NICU Nurse” — add link to SYN blog

What are the different levels of NICU care?

The NICU environment is categorized into different levels, corresponding to the complexity and intensity of care provided.

These levels are designed to meet the diverse and specific needs of newborns (up to 28 days of life), ranging from basic neonatal care (like antibiotics, low blood sugars, and feeding difficulties) to highly advanced interventions for the most critically ill infants (like cardiac surgery, ECMO, neurosurgery, and continuous neurological monitoring).

Understanding the different levels of NICU is crucial for nurses, or any professional, looking to start a career in the field of neonatal care. Depending on your personal preferences for work environment, where you live (or want to live), and the time you want to spend gaining specialized knowledge and training you may want to pursue a job in a specific level of NICU.

Different hospitals and different levels of NICU care will ultimately guide your training, skill development, and career opportunities so that NICU patients receive the best possible care tailored to their specific medical and nursing needs.

To help define the “Levels of Care” in the NICU – The American Academy of Pediatrics (AAP) has created four distinct levels and published them as guidelines. A table and summary of these levels are outlined below.


What is a Level I NICU and what kind of care do they provide?

A Level 1 NICU is called – Basic Neonatal Care

These units can care for “late” preterm infants approximately 35 to 37 weeks gestation who are physiologically stable, with normal vital signs, like heart rate, respiratory rate, oxygen saturation, and blood pressure, and without the need for significant respiratory support. They can also stabilize newborn infants who are less than 35 weeks of gestation or who are ill until they can be transferred to a facility at which specialty neonatal care is provided.

What is a Level II NICU and what kind of care do they provide?

A Level 2/II NICU is called a Specialty Neonatal Care Unit

Care in a specialty-level facility (level II) NICU should be reserved for stable or moderately ill newborn infants who are born at ≥32 weeks’ gestation or who weigh ≥1500 g at birth with problems that are expected to resolve rapidly and who would not be anticipated to need subspecialty-level services on an urgent basis. Babies in a Level 2 NICU can be on oxygen and non-invasive respiratory support (called CPAP – Continuous Positive Airway Pressure), and IV fluids and antibiotics. Depending on the resources in a Level II NICU infants can even need more respiratory support like mechanical ventilation through an ETT tube. Infants in a Level II / Level 2 NICU may require long-term IV nutrition (called TPN) and if premature (less than 35 weeks) they may need to be feed breastmilk or formula through a feeding tube until they are ready to breast or bottle feed. Many infants in a Level II / Level 2 NICU are stable but just need to grow and mature until they can maintain their temperature, breathe and feed on their own.

What is a Level III/Level 3 NICU and what kind of care do they provide?

A Level 3/III NICU offers Subspecialty Neonatal Care

They deal with the most critical cases and provide intensive care to premature babies or those with serious medical conditions. They are highly skilled and knowledgeable in areas such as ventilator support, managing complex medical equipment, and performing life-saving procedures if necessary. They work tirelessly to stabilize and improve the health of these fragile little ones.

What is a Level 4/IV NICU and what kind of care do they provide?

A Level IV/ Level 4 of NICU is often called a Regional Neonatal Intensive-Care Unit.

Level 4 NICU provide the highest level of neonatal care. This level is typically found in specialized children’s hospitals or regional medical centers equipped with advanced technology and resources. Level 4 NICU nurses handle extremely complex cases, such as babies born with severe respiratory failure, needing ECMO, cooling for HIE, perinatal stroke, cyanotic cardiac disease, seizures, and babies with birth defects or those requiring surgical interventions. Babies who need specialists to consult on their care, like cardiologists, endocrinologists, and neurologists will likely need to be transported to a Level 4 NICU if they were not born at one.

Advancing Your Career in NICU Nursing

Advancing a career in NICU (Neonatal Intensive Care Unit) nursing and transitioning to higher levels of care within the NICU involves a combination of further education, gaining experience, obtaining certifications, and developing specific skills. Here’s a roadmap for NICU nurses looking to advance their careers:

1. Gain Experience in Neonatal Nursing

  • Start in a Level I or II NICU: Begin your career in a lower-level NICU to build foundational skills in neonatal care.
  • Seek Diverse Experiences: Within your work environment, look for opportunities to care for a variety of patients, dealing with different conditions and levels of acuity.

2. Pursue Further Education

  • Bachelor of Science in Nursing (BSN): If you started your career with an Associate Degree in Nursing (ADN), obtaining a BSN can open more opportunities and is often required for advancement.
  • Advanced Degrees: Consider pursuing a Master’s of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP) with a focus on neonatal care. These degrees are essential for becoming a Neonatal Nurse Practitioner (NNP) or a Clinical Nurse Specialist (CNS).

3. Obtain Specialized Certifications

4. Develop Advanced Skills

  • Clinical Skills: Focus on developing skills specific to the needs of higher-acuity neonates, such as ventilator management, administering medication, and understanding complex neonatal conditions.
  • Soft Skills: Enhance communication, leadership, and critical thinking skills, which are crucial for managing more complex cases and leading teams.

5. Seek Leadership or Specialized Roles

  • Charge Nurse: Take on roles like charge nurse or team leader to gain leadership experience.
  • Specialized Areas: Look for opportunities in areas like neonatal surgery, extracorporeal membrane oxygenation (ECMO) therapy, or transport nursing, which require additional expertise.

6. Networking and Professional Development

7. Research and Teaching

  • If you’re inclined towards academics, engaging in research or becoming a nurse educator can be a fulfilling way to advance your career and contribute to the field.

8. Consider Lateral Moves for Broader Experience

  • Different NICU Levels: Working in various NICU levels can provide a broader range of experiences, making you more versatile and knowledgeable.

9. Mentorship

  • Find a Mentor: Connect with experienced NICU nurses or nurse leaders who can provide guidance, support, and insight into career development.

Key Competencies of NICU Nurses

The competencies required of NICU nurses span across a wide range of skills and knowledge bases, some of which include:

  • Technical Proficiency: Mastery of the technology and equipment crucial for neonatal care.
  • Critical Thinking: The ability to make sound decisions swiftly in high-stress situations.
  • Communication Skills: Being adept at communicating empathetically with anxious families.
  • Continual Learning: With the evolving field of neonatal care, a commitment to ongoing learning and professional development is essential.

What are the benefits of being a NICU nurse?

Being a NICU nurse can be rewarding and fulfilling for many reasons, such as:

  • You can make a positive difference in the lives of newborn babies and their families by providing them with compassionate and quality care.
  • You can work in a dynamic and challenging environment that offers opportunities for learning and growth.
  • You can collaborate with other healthcare professionals who share your passion and dedication for neonatal nursing.
  • You can enjoy competitive compensation and benefits that reflect your skills and expertise.

What are the challenges of being a NICU nurse?

Being a NICU nurse can also be stressful and demanding for several reasons:

  • You may face emotional and ethical dilemmas when dealing with critically ill or dying infants and their parents.
  • You may work long and irregular hours that affect your physical and mental health.
  • You may encounter risks of exposure to infections or injuries from handling fragile infants or operating complex equipment.
  • You may experience burnout or compassion fatigue from coping with high levels of stress and responsibility.

The levels of NICU nursing embody a structured approach to providing tailored care to neonates based on their unique needs. From Level I to Level IV, the escalating levels of expertise and dedication of NICU nurses are the cornerstone of ensuring the best possible outcomes for these fragile lives. Through their skilled and compassionate care, NICU nurses not only contribute to the well-being of the infants but also provide invaluable support to their families during such critical times.

What are the 7 best things about being a NICU nurse?

1. Making a Difference: NICU nurses have a profound impact on the lives of the tiniest and most vulnerable patients.

2. Witnessing Miracles: NICU nurses often witness remarkable recoveries and the resilience of premature infants, which is incredibly inspiring

3. Specialized Expertise: Working in the NICU allows nurses to develop highly specialized skills and knowledge in neonatal care, which can be professionally rewarding.

4. Collaborative Teamwork: NICU nurses work closely with a multidisciplinary team of healthcare professionals, including neonatologists, respiratory therapists, and social workers, fostering a sense of collaboration and shared expertise.

5. Variety of Cases: NICU nurses encounter a wide range of medical conditions and situations, providing a diverse and intellectually stimulating work environment.

6. Growth Opportunities: There are often opportunities for advancement, such as becoming a Neonatal Nurse Practitioner (NNP) or pursuing advanced degrees to take on leadership roles.

7. Job Security: The demand for skilled NICU nurses remains consistently high, ensuring a stable and secure career path.

A career as a NICU nurse offers many ups and down but the opportunity to provide direct care to premature and critically ill newborns, contribute to positive outcomes, and experience a deep sense of fulfillment through meaningful patient relationships and professional growth.

FAQ: Common Questions About NICU Nurse Levels

What are the qualifications and certifications required for each level of NICU nursing?


Level I NICU nurses must have an associate or bachelor’s degree in nursing and a registered nurse (RN) license. They may also have a neonatal resuscitation certification (NRP).

Level II NICU nurses must have a bachelor’s degree in nursing and an RN license, as well as a certification in neonatal intensive care nursing (RNC-NIC) or neonatal pediatric transport (C-NPT).

Level III NICU nurses must have a master’s degree in nursing and an RN license, as well as a certification in neonatal critical care nursing (CCRN) or neonatal nurse practitioner (NNP).

Level IV NICU nurses must have a master’s degree in nursing and an RN license, gain some experience working with neonatal patients who are acutely or critically ill, either as an RN or an APRN. You also need to pass the RNC-NIC certification exam, which covers topics like maternal-fetal complications and pulmonary conditions. You also need to be certified in basic life support and neonatal resuscitation program (NRP), which teach you how to handle emergencies.

How do the salaries and benefits vary across the different levels of NICU nurses?

So, you might be wondering, how much money do NICU nurses make at different levels? Well, it actually depends on their experience and education. The more experience and education they have, the higher their salary and benefits can be.

The benefits in all levels may include health insurance, retirement plan, paid time off and tuition reimbursement.


American Academy of Pediatrics (AAP) – Levels of Neonatal Care | Pediatrics | American Academy of Pediatrics (

National Certification Corporation (NCC) – Exam Detail – National Certification Corporation (

American Association of Critical-Care Nurses (AACCN) – CCRN Neonatal Certification – AACN – How to Become a Nurse Educator | Salary & Programs

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