Assisting a surgeon was once a job reserved primarily for surgical residents or physicians. Now this spot in the operating room (OR) is open to nurses eager to use surgical instruments themselves instead of just handing them over.

With two semesters of additional education, licensed registered professional nurses with OR experience can work with surgeons as RN first assistants (RNFAs). No longer restricted to the traditional perioperative nursing role, an RNFA can do everything from suturing the patient's wound to stopping the bleeding.

Surgical Involvement

Marlene Craden, RN, BSN, CNOR, CRNFA, was a perioperative nurse at Kaleida Health in Buffalo, when a surgeon asked her to assist, because the resident was unavailable. Due to her hospital's shortage of surgical residents, she was asked to assist more often, even though she had no formal training.

Thriving on the challenge and responsibility of assisting, Craden started exploring programs that prepare nurses to become first assistants. To qualify for RNFA programs, nurses need at least two years of OR experience and certification in OR nursing. More than 20 programs in the US offer RNFA education.

Craden finished two semesters of training -- one semester of academic work and one of clinical work. Now she assists surgeons at Kaleida Health with a range of procedures, such as open-heart surgery, retinal-detachment procedures and hip replacements.

"I enjoy it, because the surgeon talks to me like a resident, so I get more information about what will happen in the surgery," says Craden, a member of the Association of periOperative Registered Nurses' (AORN) Coordinating Council of the RNFA Specialty Assembly. "I find it challenging and very rewarding to have a detailed understanding of what is happening to the patient. This enhances my ability to provide comprehensive care and education to the patient and family."

RNFA Skills

As an RNFA, Craden has the skills to perform functions that she could not as a traditional perioperative RN. According to the "Revised AORN Official Statement on RN First Assistants," these functions include:

• Using instruments/medical devices.
• Providing exposure (using instruments such as retractors and forceps to hold organs and tissue in place).
• Handling and/or cutting tissue.
• Providing hemostasis (stopping bleeding).
• Suturing.

Career Advancement

The RNFA role is ideal for OR nurses who want to advance but are not interested in developing their careers along management or academic tracks.

Craden earns somewhat more than she did as a perioperative nurse, though she says financial gain was not a significant factor in her decision to become an RNFA. RNFAs at small facilities (three ORs) reported average base compensation of $64,600, whereas those at large facilities (15 ORs) reported average base compensation of $70,800, according to the "2006 AORN Salary Survey." Compensation can be affected by a host of factors, including overtime, shift differentials, and the size and location of the facility.

Opportunity to Educate

The AORN officially recognized the RNFA role in 1984, but the idea of allowing RNs to first-assist is still new in some hospitals. Most RNFAs looking for jobs seek out surgeons they have worked with and then help develop hospital policies that give them assisting privileges. Winning over surgeons and a hospital to gain RNFA privileges requires a certain degree of assertiveness and provides an opportunity to educate others, Craden says.

Because it is more costly for physicians to first-assist than RNFAs, demand for RNFAs will increase as hospitals and surgeons face the financial constraints of managed care, says Sheila Allen, RN, BSN, CNOR, CRNFA, chair of the RNFA Specialty Assembly.

RNFAs can work for a hospital, a physician or be self-employed. Milha Skelton, RN, CNOR, CRNFA, who has her own practice in Tyler, Texas, regularly assists four orthopedic surgeons. As a self-employed RNFA, she's become an expert in networking and dealing with insurance companies. Learning to navigate the business challenges has increased her confidence.

"I learned a lot of business skills, not just clinical," Skelton says. "I like the independence the role offers. It's broadened my knowledge base and given me an opportunity to learn a lot more skills."