RN First Assistant Survey: Descriptive and Demographic Study 2007
RN First Assistant
Descriptive and Demographic Study
Rita L Griffith RN MS CRNFA
This survey was conducted to assist the RNFA, Hospital Administration and Managers, Surgeons, and
Legislators, who are interested in and require information about the RN First Assistants employment
opportunities and practice settings. The survey was sent to 2500 Registered Nurse First Assistants who
have identified themselves as nurses that work in this role. This survey contains statistics in graph
format that support the information pertaining to the RNFAs employment status, reimbursement and
credentials in the workplace.
The National Association of RN First Assistants (NARNFA) iconducted a survey to help delineate
and provide pertinent information concerning the RN First Assistant’s (RNFA) universe and
employment opportunities. The RN First Assistant practice areas include, Self-
employed/Independent Contractor, Physician employed, or Hospital or facility employed.
The survey was sent to 2500 RN First Assistants. Approximately 25% were returned as
undeliverable. The results tabulated from the 472 RN First Assistants who answered the survey
gave us a response rate of almost 25%. The participants were given three weeks to complete
the survey online, at which time the survey link was deleted. Since the RNFA practice contains
so many variables, including practice settings, education levels, and clinical job descriptions,
several questions provided an opportunity for comments to allow clarity, input, and
explanations. This input was reviewed to identify any consistencies and links in those variables.
To become an RN First Assistant, you must hold a license as a Registered Nurse, be certified in
peri-operative nursing (CNOR), which entails working two years in the operating room, and
received a certificate from a RNFA education program that meets the Association of Operating
Room Standards for RN First Assistant Education Programsii (AORN)iii. RNFA education
programs require both a didactic and clinical component, usually taking 12-15 months to
complete, and supervised by a RNFA mentor and MD preceptor during the student’s first
assisting clinicals. After completing 2000 documented assisting hours and possessing a
Bachelor Degree in Nursing, the RNFA may sit for the Board Certification exam in RN First
Assisting. This is a voluntary exam and not required for practice. Nurse Practitioners (NP) who
are working as RNFAs are not required to have a certification in operating room nursing but
should take a RNFA education program that meets their State Board of Nursing requirements.
RN First Assisting is within the RN scope of practice in all fifty states. However, assisting might
be considered outside their scope of practice if the RN is not educated in the specialty area
which they are practicing such as the operating room.
DEMOGRAPHICS of the RN FIRST ASSISTANT
It takes a minimum of 5-7 years of experience to become a RNFA and recognizing the average
age of the operating room nurse is 47 years old, a little more than 75% of the RNFAs who
answered the survey have been working under 15 years as an RNFA.
1. How long have you been practicing as an RNFA?
1-5 years 133 (29.04%)
6-10 years 130 (28.38%)
11-15 years 113 (24.67%)
more than 15 years 83 (18.12%)
When asked about the RNFA practice areas, more than one answer was given because it is
possible for a RNFA to practice in more than one area simultaneously. For example, someone
who is hospital based could also work as an independent contractor on their days off or
weekends. In the following graph, 506 answers are tabulated from the 472 responders. The
responses compiled show that 35% of RNFAs practice as self-employed/independent
contractors and another 23% are practicing within a MD surgical practice. This survey shows
that 52% of RNFAs are supported by their hospital employers and practice in a hospital setting.
2. Is your RNFA practice
Independent 161 (35.15%)
Hospital Based 239 (52.18%)
Physician Employed 106 (23.14%)
Questions 3-5 provide more specific descriptions of the RN First Assistants employment
environment in all three of their practice settings. 30% of the survey participants identified
they are in a solo practice. Further research would help identify cultural, geographic, and
individual decisions that support their choice of practice settings.
3. If independently employed, are you
a single employee 142 (78.89%)
a group of 2-5 26 (14.44%)
a group over 5 12 (6.67%)
Hospitals employ over 50% of the responding RNFAs and over 50% reported being in a group of four or
4. If you are Hospital based, how many RNFAs are employed at your
1-3 119 (48.97%)
4-6 62 (25.51%)
over 6 63 (25.93%)
RNFAs in a MD based practice are mostly employed by a single surgeon. But, almost 17% are employed
in a group of 5 or more.
5. If you are physician based, how many surgeons in the group do you assist?
1 57 (47.90%)
2 19 (15.97%)
3 13 (10.92%)
4 10 (8.40%)
more than 5 20 (16.81%)
There is some question in the RNFA community whether certification as an RNFA (CRNFA)
impacts the quality of care the RNFA delivers to the surgical patient. Certification in a specialty
is a voluntary test in most nursing practice areas. The RN has the opportunity to practice in
many areas of patient care; surgery, med-surg, obstetrics, pediatrics, school nursing, etc. Most
nurses take a certification exam for personal reasons or satisfaction, to demonstrate a level of
achievement, and sometimes for financial reward. The RNFA certification does not test the
surgical ability of a RNFA. It tests knowledge and competency on a wide variety of nursing tasks
required to function within the operating room arena. The RNFA certification exam tests
operating room proficiency, including pre-operative, intra-operative, and post-operative care.
The Nurse Practitioner does not need the CNOR certification to practice as a RNFA because they
are required to be certified as a Nurse Practitioner. The RNFA must have a BSN and document
2000 assisting hours before becoming eligible for their certification exam. A strong concern for
the RNFA wanting to sit for the RNFA certification exam is the requirement of the 2000
documented assisting hours. These hours are equal to one year full time employment and are
difficult to attain. Most certifications require 500 hours to take a certification exam in their
specialty, give credit for their school hour or training hours, and are eligible to sit for their exam
after completing those requirements. With only 50% of RNFAs sitting for their certification, the
survey results support the belief of the RNFA community that the RNFA certification exam does
not test RNFA proficiency, add to the RNFA’s skills, provides a feeling of accomplishment
beyond the required CNOR certification, or is reasonably attainable with the 2000 hour
6. Are you certified as an RNFA?
YES 229 (50.22%)
NO 227 (49.78%)
REIMBURSEMENT FOR ASSISTING SERVICES
There are currently thirteen states that have laws regarding reimbursement for the RNFA but
those laws do not impact Medicare reimbursement at the federal level. State legislation does
not guarantee payment for services provided by the RNFA. Some Insurance carriers have
developed loopholes which do not accept the RNFA as a provider and list them as an out-of-
network provider. This determines the patient as the responsible party and places the RNFA,
the surgeon, and the patient in an uncomfortable position and asks the question, who is
responsible for the service fee?
Reimbursement for assisting services is a concern and affects the surgeon’s choice for those
procedures needing assisting services. There are published lists of surgeries suggesting which
ones require an assistant, but facilities decide to enforce the recommendations or not. Most
facilities choose to allow the surgeon to make that determination.
Unfortunately, the RNFA may not be an option if the patient has Medicare insurance.
Medicare does not directly reimburse the RNFA. Graph 7 shows that a RNFA will not be chosen
54% of the time because of the lack of Medicare reimbursement. Information from other
studies indicates the non-physician surgical assistant has and will continue to save Medicare
dollars. Medicare refuses to add the RNFA to the list of providers for assisting services despite
their training, availability, and documentation that they meet the same education requirements
of other allowable assistants. Medicare does not restrict the numbers of other non-physician
providers who are eligible yearly and are available to the surgeon, but refuses to allow the
RNFA to receive payment access for their specialty. The RNFA is the only non-physician
provider who is actually trained in the role in which they are asking to be paid.
7. Have you lost an opportunity to first assist due to lack of Medicare
reimbursement for the RNFA?
NO 203 (45.93%)
YES 240 (54.30%)
Question 8 supports the fact when a patient has Medicare, a Physician Assistant or Nurse
Practitioner will generally be their choice. This decision is not based on clinical expertise,
training or skills, but is merely a financial decision based on who Medicare reimburses for
assisting. Some self-employed or physician based RNFAs have agreements or contracts with
surgeons or hospitals to be paid for their services when Medicare or an insurance company will
not recognize the RNFA services. Surgeons recognize the level of skill and operating room
experience the RNFA brings to the field. Studies have determined the RNFA is the best trained
to assist in all specialties when compared to the PA or NP coming out of training, but 63% of the
time they will not be the surgeons’ first choice due to the financial impact. Unfortunately, the
RNFA is not as marketable to the surgeon because of the lack of Medicare reimbursement. It
must be recognized that 50% of the RNFAs who responded are hospital employed and would
receive no Medicare or independent funding as a hospital employee because the hospital is
reimbursed for those services. The 63% who did respond are most likely self-employed,
physician based, or hospital employed RNFAs working on their days off independently.
8. Have you lost an opportunity to first assist to an NP or PA because they
were reimbursable by Medicare?
NO 164 (37.10%)
YES 278 (62.90%)
During one the RNFA’s several legislative attempts to educate the people who impact Medicare
spending decisions, one of the interviewers asked the question, is the RNFA utilized instead of
Residents or Interns in teaching facilities? Our answer was no, and is supported with Question
9 below. The surgeon decides if a surgical assistant is necessary to safely and expediently
provide care to their patient and who that assistant will be. There is an eighty hour restriction
that residents or interns may work in a weekiv. A hospital based RNFA may be chosen or if the
may be chosen to assist, dependent on the patient’s insurance.
9. Have you lost an opportunity to first assist because the facility has
Residents or Interns?
NO 271 (61.31%)
YES 171 (38.69%)
The self-employed RNFA has been forced to be extremely creative and tenacious in finding
ways to be reimbursed for Medicare covered patients. Most RNFAs have created options when
provide assisting services to the surgeon for the patient. The “other” category was answered
primarily by NP/RNFA who can be reimbursed by Medicare. Some of the other comments
were, that contracts are created between RNFAs and Hospitals, or RNFA and Surgeons for
independent contracting services, and sometimes a permit and/or contract is signed by the
patient preoperatively that requires payment by the patient for the assisting service. The
survey’s Questions 10 & 11 breaks down some of the payment options available to the RNFA
for reimbursement. With almost 57% of the RNFAs receiving no compensation, they report
that the surgeon will choose a reimbursable assistant 54% of the time and that choice is a NP or
PA 62% of the time, who can be reimbursed (questions 7 & 8). Medicare dollars are being
spent but not on the RNFA.
10. If self-employed, are you compensated for Medicare insured patients by?
(check all that apply)
NO COMPENSATION 105 (56.76%)
SURGEON PAYS 59 (31.89%)
HOSPITAL PAYS 40 (21.62%)
PATIENT PAYS 14 (7.57%)
OTHER, please specify 30 (16.22%)
Less that 23% of self employed RNFAs receive some reimbursement for their services if the
patient has Medicare insurance.
11. If self-employed and you are compensated for first assisting for a
Medicare patient is it (check all that apply)
an hourly fee from MD 36 (32.43%)
contracted procedure fee
Advance Beneficiary Notice
an hourly fee from facility 30 (27.03%)
contract service fee from
Question 12 outlines several options for RNFA services physician employed nurses negotiate for
their services. “Other” comments included, fees based on production, no additional
reimbursement for assisting, and mixture of several of the options listed.
12. If physician based, is your reimbursement for assisting
hourly based 31 (27.19%)
a contracted procedure fee 16 (14.04%)
salary 54 (47.37%)
bonus 19 (16.67%)
other, please specify 15 (13.16%)
In conclusion, the results of the NARNFA survey provided a detailed sample of where the RN
First Assistant practices, how the RNFA is reimbursed, and supports our concern that the RNFA
is not as marketable as other surgical assistants, i.e., NPs or PAs, due to lack of Medicare
reimbursement. RN First Assistants are experienced, well trained in their specialty, and are
creative in sustaining their field of practice despite the competitive environment in which they
work. NARNFA continues to pursue Medicare Legislation to allow the RN First Assistant to be
directly reimbursed by Medicare.
www.NARNFA.com, National Association of RN First Assistants
AORN Journal, September 2005, VOL 82, NO 3 pg 457-460
http://www.AORN.org, Association of Operating Room Nurses
http://www.acgme.org/acWebsite/dutyHours/dh_Lang703.pdf, accessed on October 30, 2007