A Cut Above
RN first assistants seek stimulation of the OR
while still providing bedside care

By Wendy Martinkus
November 1, 2004

Gisele Harris, RNFA, MSN, CNOR, a registered nurse first assistant at The Toledo(Ohio) Hospital, remembers one hair-raising, on-the-job experience. She was assisting a surgeon who was preparing for a craniotomy when, suddenly, the surgeon pulled off what appeared to be the patient’s head.

“The surgeon was preparing to shave the woman’s head, and didn’t realize that the woman was wearing a wig,” Harris says. “I will never forget that experience!”

Other RNFAs say such experiences are what make working as an RFNA unforgettable and attractive. “The OR is where all the action is,” Harris says.

The RNFA waltz

Inside the OR, RNFAs assist on a variety of surgical procedures, but Harris’ favorite is open-heart surgery. “It’s so neat to see the surgeon stop the heart, cut it open, and put a valve into it, and start it back up,” she says.

Surgery is a precise practice that requires perfect teamwork. Because she works side by side with surgeons, Harris likens her role to that of a dancer. “There is a certain way to hold your arms and your hands while assisting, which is a lot like learning to position yourself during a dance,” she says.

Like Harris, many RNs are finding they are well-suited to mastering the RNFA dance.

“It’s a very attractive career path,” says Bonnie Denholm, RN, MS, CNOR, specialty assembly coordinator for the Association of periOperative Registered Nurses. “Many nurses find that this is an area in which to specialize while still staying in the clinical setting and without necessarily going into education or management.”

Jill Stanfield, RN, CRNFA, chair of consumer awareness for the AORN specialty assembly, adds that for nurses who want to stay in the OR and be at the bedside doing patient care, being an RNFA is the “only pathway.” Other alternatives are management and education, but both are “at least one step removed from the patient,” she says.

Stanfield says she was looking for a new way to stimulate her career after spending more than 30 years in the OR. She says her decision to become an RNFA “rejuvenated a flagging interest and kept me in the operating room.”

Although circulating and scrub nurses perform work that is similar to what RNFAs do, Stanfield says RNFAs who work independently have more autonomy than RNs. For example, OR nurses who are employed by a hospital must follow a set schedule, but independent contractors set their own.

“This gives us a level of autonomy that is difficult to find in nursing,” Stanfield says. However, this doesn’t mean RNFAs are qualified to do surgery. “The RNFA always works collaboratively with the surgeon,” Stanfield says. “The RNFA never does surgery independently.”

Stanfield is credentialed as an independent contractor for four hospitals in California. As such, her duties include assisting before and during surgery. Before surgery, she checks instruments, sutures, and supplies. During surgery, she assists with patient preparation and helps the OR staff with the surgeon’s requests and preferences.

“The roles of preoperative, intraoperative, and postoperative are all wonderfully intertwined,” Stanfield says. “We can make postoperative rounds, review standing orders, pull drains, help facilitate, and spend time with the patient postoperatively if the surgeon is busy.” Office-based RNFAs also can do histories and physicals.

Stanfield has been assisting Philip Bernstein, MD, an orthopedic surgeon at Mid-Peninsula Orthopedic Medical Group Inc. of San Mateo, Calif., for the past 10 years and has been involved with more than 500 cases. “Jill is very good technically and she is also readily available when I need an assistant,” he says. “She has been a wonderful help to me.”

A burgeoning field

RNs have been first-assisting in the OR for many years, but it was only in 1984 that AORN published its first official statement on the RNFA. By 1985, structured educational programs for RNFAs were established and legislative efforts began to seek third-party reimbursement. In 1990, AORN published its Core Curriculum for the RN First Assistant (revised in 1994), and the National Certification Board: Perioperative Nursing Inc. (now called Certification Board Perioperative Nursing) administered the first national certification exam in 1993.

According to the newly revised “AORN Official Statement on RN First Assistants,” the minimal requirements for an RN to practice as an RNFA include certification in perioperative nursing (CNOR); successful completion of an RNFA program that meets the “AORN recommended education standards for RN first assistant programs” and is accepted by the Certification Board Perioperative Nursing (CBPN); and compliance with statutes, regulations, and institutional policies relevant to RNFAs.

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.