APPs In The O.R. | The Ripple Becomes a Current

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The role of Advanced Practice Practitioners (specifically ACNPs and ARNPs) has long been limited to acute care units. The Operating Room is the most prominent acute care unit and yet there seems to be a break in the continuity of care. It is time to bridge the gap that separates the bed from the table. RFK once talked about the power of a 'ripple'. It's time for the current to follow.

Should you become an NP or PA?

APPs In The O.R. | The Ripple Becomes a Current

The term Advanced Practice Provider ("APP") has usually been limited to advanced practice registered nurses in a medical context. I believe recent trends and the efficacy of care is starting to really contemplate what that term can mean in surgical care. Nurses that go on to pursue advanced degrees such as an Acute Care Nurse Practitioner ("ACNP") bring years of high-stakes critical care knowledge and a level of independence that can only be accretive to the performance of a surgical team. As they progress in their abilities to manage the critically ill, why should that stop at the O.R. doors?

I firmly believe that in the next 5 - 10 years we are going to see something that already has momentum start to really take effect, and that is the use of APRNs, ACNPs, and other advanced-level nurses take a larger role in the Operating Room as first assists. I think it is very exciting that UAB is offering an ACNP program with an RNFA certification. I work with some wonderful surgical PA's, but there is a gap between the model in which they've been taught and the nursing model + nursing experience.

There are tremendous synergies that can be obtained by having someone like an ACNP be involved in the full lifecycle of acute care surgery - from consult to pre-op to first-assist to recovery. I think a lot of institutions are starting to see that...and patients want it. Continuity of care is often discussed as important for patients to follow. Well, I think it's equally important that healthcare professionals reciprocate that continuity.

Historically, NPs haven't really pursued intraoperative roles, and I think many want to [I acknowledge some do not]. So, I think it's time that they receive the appropriate training to become valuable members of the intraoperative surgical team. I think they bring a wealth of knowledge to very complex cases and can take what they see on the table and help calibrate the recovery off of what they see...not off of an operative dictation or chart.

There's an amazing article about an ACNP / RNFA named Trisha Hutton who is living this new reality as a Cardiothoracic Surgery First Assist and I think her interview provides an invaluable backdrop as to why this is not about 'personal interest', rather, 'in the best interest of the patient.' It has truly inspired me to reach further, explore more possibilities, and take pride in the experience of nursing that cannot be taught. We are the lucky few who have been in the trenches working as partners with residents, fellows and attendings before and after surgery, so why should we be left out of the middle part - "during surgery". As a teenage cardiac surgery patient, I got to know my advanced practitioner nurse very well - she was the glue of my care. When I asked if she would be able to help me in the Operating Room, she said, "no, there are plenty of amazing hands in there to heal you." And she was right, but is that right? Being a patient and now working on a cardiac surgery team, I understand the value of these amazing nurses who can do everything, but aren't often given the opportunity to prove just that.

The debate between going to nursing school and eventually becoming an NP versus going to PA school is often debated. But, they shouldn't be. Nursing is a very special and unique experience, and we need to show others why that experience is valuable in ALL aspects of care...including in the Operating Room. PAs may be able to assist in surgery, but can they care for post surgery acute care patients after? Would it be beneficial if there was a practitioner that had the aperture to bridge the two? I think undoubtedly the answer is, 'yes it would be.'

Advancing a profession is not about crossing lines of proficiency. Advancing a profession is educating others about the value of proficiency that inherently exists.

I am a cardiothoracic scrub nurse, a CHD warrior, a yogi, a friend, and an advocate. I believe in dreams whether you're 25 or 85 - a dream is what made my nursing story a thought; a belief in that story is what made my dream a reality.

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7 Comment(s)



61 Posts

This is why I decided to pursue a career in nursing! Most nurse faculty that I mentioned this to are confused to say the least, or try to point me in another more familiar AP practice direction. Most APP I see in this role are in cardiac surgery interestingly enough! I'm paving my own way at them moment, not only for myself but for other nurses to follow later in hopes that its easier for them. Nice article !



90 Posts

Wow, this article is spot on! I want to be a nurse practitioner and at the same time I realllly wanna work in the OR:( I really hope this could actually become a possibility or more normal by the time I get to that point.



90 Posts

I have thought about being a CRNA just to be in the OR, but that's not my passion. Becoming an NP that can work in the OR would be a dream come true.

futureprovider said:
This is why I decided to pursue a career in nursing! Most nurse faculty that I mentioned this to are confused to say the least, or try to point me in another more familiar AP practice direction. Most APP I see in this role are in cardiac surgery interestingly enough! I'm paving my own way at them moment, not only for myself but for other nurses to follow later in hopes that its easier for them. Nice article !

In the olden days, many nurses, including some of my own Instructors, believed that the OR wasn't really nursing. One told me that her 90 year old aunt could circulate and a monkey could scrub. That is probably still a common viewpoint. The OR teaches us about sterility and preventing infection, also about advocating for a truly defenseless patient - avoiding Bovie burns and avoiding improper placement of limbs, for example. I never much cared for just holding a retractor while not being able to see into the wound, but an RNFA is able to tie knots, cauterize, and cut excess suture material, and probably writes orders that the MD would then sign. And maybe more. It's been a long time since I've worked OR. Best wishes to all who wish to work in Surgery.



Has 5 years experience. 13 Posts


I stumbled on your article while searching for more information about RNFA. I have just completed my nursing program this month and am in love with the operating room. During my preceptorship in the OR, I have mentioned to many nurses and techs about my passion to become a RNFA in the future. I have had more negative responses than positive ones. I wanted to let you know that you are definitely an inspiration to me! I’m glad to know that there are RNFAs practicing and that we don’t have to go the PA route to get into the sterile field! love nursing and I love surgery and I want to be able to have both coexist in my career. So thank you again for sharing!


J.rizzled, RN

11 Posts

Is there anyway to get a link to the article by Trisha Hutton? I will be starting Peri-op 101 as a new grad next month and I'm really interested in learning more about the different possibilities for RN's to advance in the OR setting .


Specializes in Vents, Telemetry, Home Care, Home infusion. Has 45 years experience. 11 Articles; 17,290 Posts

Trisha Hutton ACNP, RNFA article:

In my area, Delaware County Community College, outside Philadelphia, PA has been educating RNFA's since 1985. The program is now available as a hybrid online with 5 day hand-on campus session. 2yrs OR scrubing and circulating.. BSN degree now required in 2020.

RN First Assistant in Surgery Program - Delaware County:


A special section designed for ARNP includes fundamentals of perioperative practice, such as scrubbing, gowning, gloving and instrument review.