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National certification (CRNFA) for the RNFA is voluntary. According to the CBPN, eligibility requirements for CRNFAs include the following:

• 95 Must be currently licensed as an RN without provision or condition in the country where currently practicing
• 95 Must be a CNOR at time of application
• 95 Must have a BSN, and a copy of the diploma must accompany application; if your bachelor’s degree is in another field, but you have an MSN, you are eligible for the CRNFA exam
• 95 Must have completed at least 2,000 documented hours of practice as an RNFA — the first 120 hours of assisting is done under a preceptor surgeon

Today, there are nearly 1,700 CRNFAs, but as many as 8,000 RNFAs may be practicing across the country, Denholm says.

Where the work is

Practice settings for RNFAs include hospitals, ambulatory care centers, physician practices, and with independent contractors. With the recent federal legislation that limits residents’ hours to 80 per week, more opportunities are emerging for the RNFA in the hospital setting, Stanfield says. The duties that each RNFA performs depend on the nurse’s practice setting, experience, and respective state laws. AORN’s “Competency Statements for the RN First Assistant” articulate these duties.

In general, nurses function at a variety of levels depending on their experience and work environment. RNFAs who are employed by a surgeon may have more responsibilities than those who work for a hospital.

Other RNFAs, such as Harris, help lead educational training programs. Harris helped organize a program based on AORN’s Core Curriculum for the RN First Assistant at the Toledo Hospital. RNFAs must master six areas of competency as defined by AORN; in certain states, this requires RNFAs to assist with and/or perform wound closures.

Harris uses pigs’ feet to teach nurses how to tie knots and close wounds. “If you are going to be a first assistant you not only need to be book smart, but possess manual dexterity to gain the credibility of the surgeons,” she says.

Irene Cadarette, RN, BA, a nurse manager at Bronson Methodist Hospital in Kalamazoo, Mich., says RNFAs must be self-guided, as well. Cadarette supervises 10 RNFAs.

“They need to facilitate a team, so it’s important that they are able to guide themselves and others,” she says.

At Bronson Methodist, RNFAs rotate throughout the hospital. “Some are more proficient in one area,” says Cadarette, “but we’ve found that having the RNFAs rotate maintains their skills in all services.”

RNFAs at Bronson Methodist assist before, during, and after surgery. However, it was just one year ago that the hospital expanded the RNFA’s role to include preoperative visits. “We found that many times when patients were called to surgery, they weren’t ready, and so this was causing a delay,” Cadarette says. “It was a problem not only for patients, but for the surgeons. We implemented preop visits to reduce this dissatisfaction, and it has helped immensely.”

Dollars and sense

One of the biggest challenges facing RNFAs is reimbursement — Medicare does not reimburse for RNFAs. According to Stanfield, some surgeons hire RNFAs to work with them independently, whereas other hospitals pay a group of RNFAs to take “assistant call.”

“It’s a win-win situation,” Stanfield says. “The surgeons get good help, the hospital has happy on-call surgeons, and the RNFAs get paid for their work.”

Some states, such as Minnesota, have passed legislation mandating RNFA reimbursement. Mary Weis, RN, MSN, CNS, CNOR, CRNFA, has worked as an RNFA for 21 years and is employed by CentraCare Clinic in St. Cloud, Minn. In 1996, Weis and a group of RNFAs, with the assistance of the Minnesota Nurses Association, passed state legislation to require third-party payers to reimburse for an RNFA assisting in surgery.

“One of the reasons for obtaining my advanced practice degree was because the surgeons I work for could not get Medicare reimbursement for my services,” Weis says.

Independent contractors such as Stanfield are eligible for reimbursement from third-party payers other than Medicare, but they are reimbursed at lower levels than other providers. The future for RNFAs ultimately rides upon whether they will one day receive Medicare reimbursement for the services they provide as independent contractors.

“I think we are going to be very valuable when the government starts looking for ways to cut costs,” Harris says. “By being versatile and knowing how to multitask, I help to reduce costs.”

“I bring the whole nursing perspective to the table with me, which includes 30 years of operating room expertise and 10 years of assisting,” Stanfield says. “This all adds up to a huge knowledge-based practice that cannot be provided in the same way by any other practitioner.”

Wendy Martinkus is a freelance writer.