Providers of first assisting services

AORN Journal, June, 2004 by Frederick P. Franko

On July 1,2003, the Accreditation Council for Graduate Medical Education (ACGME) common program requirements for all core and subspecialty programs went into effect. The ACGME is the private professional organization responsible for accrediting medical residency education programs. Of particular interest to many AORN members and to hospitals were new requirements regarding resident duty hours. The requirements specify that

* duty hours must be limited to 80 hours per week, averaged during four weeks;

* residents must be provided with one day in seven free from all educational and clinical responsibilities; and

* adequate time for rest and personal activities must be provided. (1)

As with any other area where residents practice, the OR has had to adjust to duty-hour limits for surgical residents. On their web site, the American College of Surgeons (ACS) provides a residency assist page to help administrators and teachers address challenges that come with administering residency programs. A number of articles on this web site offer advice on the use of the nonphysician workforce to meet patient care delivery requirements. (2) It is anticipated that with the reduction in the duty-hour limits for residents, there will be a corresponding rise in the need for nonphysician providers of first assisting services.

ASC STATEMENTS ON PRINCIPLES

The ACS and its members have significant influence on the role of the first assistant as practiced in the United States because nonphysician first assistants are acting under the delegated authority of a licensed physician during the intraoperative phase. There are two areas in the ACS "Statements on principles" relevant to the practice of first assisting. In the principles of patient care section on the training of assistants, the statement says

   Surgeons may participate in the
   training of allied health personnel to
   act as technical assistants. Such
   individuals must perform
   their duties under
   the direct supervision of
   the surgeon, who has
   the responsibility for all
   their actions. (3 (sec IE))

In section B, "Qualifications of the first assistant in the OR under principles of qualifications for surgical privileges," it states in part that

   The first assistant to the
   surgeon during a surgical
   operation should be a
   trained individual who is
   capable of participating
   in the operation and
   actively assisting the
   surgeon as part of a good
   working, team. The first
   assistant provides aid in exposure,
   hemostasis, and other technical functions,
   thereby helping the surgeon
   carry out a safe operation with optimal
   results for the patient. This role
   will vary considerably with the surgical
   operation, specialist area, and type
   of hospital. (3 (sec IIB))

The ACS believes that, ideally, the first assistant should be a surgeon or a resident in a surgical program. The ACS's "Statements on principals," however, acknowledges that this is not always possible and may necessitate the use of a nonphysician in the role of first assistant. Surgeon assistants and physician assistants with additional surgical training may act as first assistants if they meet national standards. Registered nurses who have additional specialized training also may serve as first assistants. Finally, the ACS says that "surgical technologists may function as first assistants in the absence of more qualified individuals." (3)

AORN's OFFICIAL STATEMENT ON RN FIRST ASSISTANTS

Perioperative RNs fill a number of roles to ensure quality patient care in the OR. These include scrub person, circulating nurse, patient educator, OR director, and RN first assistant (RNFA). During Congress in March 2004, the AORN House of Delegates approved a new RNFA position statement (see page 1163 in this issue)

Following is the definition of RNFA in AORN's official statement.

   The RNFA is a perioperative
   registered nurse who
   works in collaboration with
   the surgeon and health care
   team members to achieve
   optimal patient outcomes.
   The RNFA must have
   acquired the necessary
   knowledge, judgment, and
   skills specific to the
   expanded role of RNFA
   clinical practice. Intraoperatively,
   the RNFA
   practices at the direction of
   the surgeon and does not
   concurrently function as a
   scrub nurse. (4)

The position statement also outlines the RNFA scope of practice, saying

   All state boards of nursing
   recognize the role of
   the RNFA as being within
   the scope of nursing practice.
   Perioperative nursing
   is a specialized area of
   practice. Registered nurses
   practicing as first assistants
   in surgery are functioning
   in an expanded
   perioperative nursing role.
   Activities included in first
   assisting are further
   refinements of perioperative
   nursing practice and
   are executed within the
   context of the nursing
   process. First assisting
   behaviors are based on an
   extensive body of scientific
   knowledge. Certain of
   these behaviors include
   delegated medical functions
   that are unique to
   the perioperative RN
   qualified to practice as an
   RNFA. (4)