An RN first assistant's guide to private practice - registered nurse

AORN Journal, April, 2003 by Sheila Hughes

Although RN first assistant (RNFA) practice began more than a century ago, current practice began to evolve in the 1970s when members asked AORN to determine whether first assisting by nurses was part of perioperative nursing practice. (1) In the early 1980s, the American College of Surgeons began issuing documents that supported the practice of RNs acting as first assistants. In 1984, AORN published its first official statement on RNFAs. (2) By 1985, structured educational programs were established, and legislative efforts for third-party and Medicare reimbursement had begun. (3)

WHAT IS AN RNFA?

Nurses who function as RNFAs practice in an expanded role, not an advanced practice role (Table 1). Registered nurse first assisting encompasses perioperative nursing care, but primary emphasis is placed on the intraoperative phase during which RNFAs assist surgeons. According to AORN, first assisting is a refinement of perioperative practice and includes observable behaviors based on scientific knowledge, including handling tissue, providing exposure, using instruments, suturing, and providing hemostasis. Registered nurse first assistant job duties can differ depending on various factors, including patient population, practice environment, services provided, accessibility of human and fiscal resources, institutional policy, and state nurse practice acts. (4) Individual state nurse practice acts define and govern the scope of practice, and RNFAs must function within these respective guidelines. (5)

Registered nurse first assistants use the nursing process to plan and implement personalized patient care and education. (6) They may function as liaisons within health care organizations, coordinating patient care and providing ongoing assessment. In addition to intraoperative skills, RNFAs also may demonstrate preoperative skills, including

* preoperative planning and management,

* communication and evaluation,

* consultation with and education of patients and their family members,

* reviewing surgical consent with a patient,

* reviewing a patient's chart,

* obtaining histories,

* performing physical examinations, and

* other nursing behaviors unique to the surgical specialty of the proposed procedure.

Postoperative skills may include writing and implementing postoperative orders (ie, according to facility policy) and immediate and ongoing physiological and psychological assessment and documentation. Additionally, RNFAs may implement continuity of care by evaluating patient outcomes during nursing rounds and providing follow-up care via postoperative appointments in the surgeon's office. Typically, RNFAs who are employed by a health care facility or physician use preoperative and postoperative skills; these skills are not used as frequently by self-employed RNFAs.

Registered nurse first assistants can be self-employed, be employed in a partnership or corporation with other nurses and surgeons, or work for a health care organization. This article focuses on how RNFAs can achieve professional autonomy through self-employment and entrepreneurship.

EDUCATIONAL PREPAREDNESS

Entry-level educational preparedness as an RN and meeting the requirements listed in Table 2 qualify RNs to matriculate in an accredited RNFA program. In an approved Certification Board Perioperative Nursing (CBPN) RNFA program, (7) preparation includes didactic instruction, surgeon-supervised clinical internship, and learning activities based on the Core Curriculum for the RN First Assistant. (8) Upon completion of didactic instruction and the clinical internship, RNs are awarded a certificate of completion and college or university credit. Registered nurse first assistants are eligible for certification after attaining a minimum of 2,000 documented hours of assisting and meeting the certification requirements identified in Table 3. Certification demonstrates an individual's commitment to excellence in practice and validates professional development and achievement.

The education RNFAs receive makes them unique among other health care providers. Beginning in nursing school, RNFAs learn the basics of nursing care. From there, RNFAs gain clinical experience as perioperative practitioners. Further clinical and didactic education, such as that gained in an RNFA program, rounds out the educational experiences of this health care worker, leaving RNFAs with a unique perspective of patients and health care. (9) Registered nurse first assistants can use these qualifications in many ways, including to achieve patient satisfaction through implementation of a personalized plan of care. They also are efficient in time management and turnover, which can reduce health care costs to patients and health care organizations.

REGISTERED NURSE FIRST ASSISTANTS AS CHANGE AGENTS

It is important for RNFAs to act as change agents in the health care system to ensure favorable patient outcomes and improved patient care. Many health care organizations need RNFAs in surgery because of a lack of surgical interns and residents. An RNFA can use this fact as an opportunity to introduce himself or herself to the nurse manager at a facility and suggest using an RNFA in place of an intern or a resident.