First Assist question! David C. I need help!

BrandiannRN · Dec 11, 2008

You know whats funny is I can actually hear his theme music playing also! I spoke with everyone I know today including the OR manager and my current DON. They had no idea what the rules were. I hate the Oklahoma board of nursing because they are so hard to get a straight answer out of. I'm going to try calling them tomorrow but last time I was put on hold indefinitely :chuckle

core0 · Dec 11, 2008

BrandiannRN said:

Okay, maybe you guys will know this. David you seem to know everything so I figured you might be able to help.
I'm currently in FNP school and have 3 semesters left. I work at an orthopedic hospital and was offered a position with a surgeon recently. He wants me to be his "RN first assist" until I graduate. Will I have to take more school for this? I know Oklahoma doesn't have an RNFA program so I'm confused at the training I would need. He seems to believe he could train me. Now here in Oklahoma its dominated by PAs so I didn't want him to be confusing NP rules with PA rules. I have read everything on the board of nursing and can't find anything.

Thanks in advance for any tips you may have!

Brandi

Well since I can't lurk in the online thread any more;).

Like most scope questions this has to be answered on multiple levels.

First of all the difference between RNFA and "RN first assist". RNFA is a title that AORN has the copyright to and only AORN can bestow the certification (CRNFA). On the other hand RN first assist is in the public domain and can be any RN who first assists. To become an RNFA:

1. Must be currently licensed as an RN without provision or condition in the country where currently practicing.

2. Must be a CNOR or an advanced registered nurse practitioner certified in their specialty at the time of application.

3. Must have a Baccalaureate degree and a copy of diploma must accompany application.

4. Must have completed at least 2,000 documented hours of practice as an RNFA. This practice includes pre-, intra-, and postoperative patient care. The pre- and postoperative patient care does not necessarily have to be connected to cases on which the applicant has assisted.

* The 2,000 hours may include practice in an RNFA internship or practicum, but may not include attendance of classes, programs, or seminars.

* 500 of these hours must have been within the two years immediately preceding application.

* Six hundred (600) of the 2,000 hours required for eligibility may be pre- and postoperative patient care, and at least

1,400 hours must be intraoperative practice.

* Written documentation of the 2,000 hours of practice must accompany the application (see page 7).

5. Must have completed an acceptable formal RNFA program.

You don't say whether you have OR experience, CNOR or a BSN. If you don't have this becoming an CRNFA in the near future is unlikely.

Next is the state licensure. A quick perusal of the state law shows that it does not appear to address RN first assists. RNFAs practice within the state so this appears to be within the RN scope of practice.

Finally credentialling. First let me explain the old way of doing things. The surgeon would take someone from his office. RN, LPN, MA, Janitor whomever. He would show them where to dress and then go to the scrub nurse and tell them to show the person how to scrub. That person was now the first assist.

Unfortunately for these surgeons the Joint Commission in 2007 brought out new rules for privileges and credentialing. Part of this is that you must be able to demonstrate basic competence before setting foot into the operating room. This has essentially ended on the job training in the OR.

So this should not be possible in the current regulatory era. However, there are a lot of hospitals, especially small hospitals that think that JC rules only apply when JC is there. So this probably happens more than people think.

First step would be to talk to credentialing and find out what are the requirements are to first assist. Also find out if the surgeon will be allowed to train you. It would probably help if you take a RNFA course. The NIFA course can be completed in one week plus the online portions ($$$)

https://www.rnfa.org/

The other issue is reimbursement. The reason that PAs are preferred providers in the OR is that surgery is part of PA training so there is no need to demonstrate any more training to be credentialed. PAs, NPs, CNS and CNM are the only providers that Medicare will reimburse. Regardless of any other qualifications once you have your NP you will be reimbursed by Medicare. As an RN even a CRNFA you will not be reimbursed by Medicare. This was examined as recently as 2006 and Medicare decided that RNFAs were not APNs. Other insurance companies may or may not reimburse you. As an RN you would also not be able to bill. However, since many surgical procedures are covered under the global fee you could preform aftercare. As an FNP student you also have to know what the local policies are toward FNPs doing inpatient work if you want to work there once you graduated.

Finally as a word of warning be prepared for significant blow back by the OR nurses if you manage to get into the OR for training. CNOR is a very difficult certification and they don't take kindly to people short circuiting the process.

So, overall its doable, but there are many obstacles to doing this. I think that the surgeon (like many) is unfamilar with the current regulatory environment. On the other hand if this is a small hospital there may be opportunity here that does not exist in other places.

David Carpenter, PA-C

ANPFNPGNP · Dec 11, 2008

core0 said:

Well since I can't lurk in the online thread any more;).
Like most scope questions this has to be answered on multiple levels.

First of all the difference between RNFA and "RN first assist". RNFA is a title that AORN has the copyright to and only AORN can bestow the certification (CRNFA). On the other hand RN first assist is in the public domain and can be any RN who first assists. To become an RNFA:

1. Must be currently licensed as an RN without provision or condition in the country where currently practicing.

2. Must be a CNOR or an advanced registered nurse practitioner certified in their specialty at the time of application.

3. Must have a Baccalaureate degree and a copy of diploma must accompany application.

4. Must have completed at least 2,000 documented hours of practice as an RNFA. This practice includes pre-, intra-, and postoperative patient care. The pre- and postoperative patient care does not necessarily have to be connected to cases on which the applicant has assisted.

* The 2,000 hours may include practice in an RNFA internship or practicum, but may not include attendance of classes, programs, or seminars.

* 500 of these hours must have been within the two years immediately preceding application.

* Six hundred (600) of the 2,000 hours required for eligibility may be pre- and postoperative patient care, and at least

1,400 hours must be intraoperative practice.

* Written documentation of the 2,000 hours of practice must accompany the application (see page 7).

5. Must have completed an acceptable formal RNFA program.

You don't say whether you have OR experience, CNOR or a BSN. If you don't have this becoming an CRNFA in the near future is unlikely.

Next is the state licensure. A quick perusal of the state law shows that it does not appear to address RN first assists. RNFAs practice within the state so this appears to be within the RN scope of practice.

Finally credentialling. First let me explain the old way of doing things. The surgeon would take someone from his office. RN, LPN, MA, Janitor whomever. He would show them where to dress and then go to the scrub nurse and tell them to show the person how to scrub. That person was now the first assist.

Unfortunately for these surgeons the Joint Commission in 2007 brought out new rules for privileges and credentialing. Part of this is that you must be able to demonstrate basic competence before setting foot into the operating room. This has essentially ended on the job training in the OR.

So this should not be possible in the current regulatory era. However, there are a lot of hospitals, especially small hospitals that think that JC rules only apply when JC is there. So this probably happens more than people think.

First step would be to talk to credentialing and find out what are the requirements are to first assist. Also find out if the surgeon will be allowed to train you. It would probably help if you take a RNFA course. The NIFA course can be completed in one week plus the online portions ($$$)

https://www.rnfa.org/

The other issue is reimbursement. The reason that PAs are preferred providers in the OR is that surgery is part of PA training so there is no need to demonstrate any more training to be credentialed. PAs, NPs, CNS and CNM are the only providers that Medicare will reimburse. Regardless of any other qualifications once you have your NP you will be reimbursed by Medicare. As an RN even a CRNFA you will not be reimbursed by Medicare. This was examined as recently as 2006 and Medicare decided that RNFAs were not APNs. Other insurance companies may or may not reimburse you. As an RN you would also not be able to bill. However, since many surgical procedures are covered under the global fee you could preform aftercare. As an FNP student you also have to know what the local policies are toward FNPs doing inpatient work if you want to work there once you graduated.

Finally as a word of warning be prepared for significant blow back by the OR nurses if you manage to get into the OR for training. CNOR is a very difficult certification and they don't take kindly to people short circuiting the process.

So, overall its doable, but there are many obstacles to doing this. I think that the surgeon (like many) is unfamilar with the current regulatory environment. On the other hand if this is a small hospital there may be opportunity here that does not exist in other places.

David Carpenter, PA-C

I think 2,000 hours is absolutely ludicrous! One of my PA friends spent a total of 6 weeks in surgery and he told me he barely got his feet wet! Why on earth do we as NP's have to complete so many clinical hours? We may as well go to medical school! Also, check with your BON and find out which first assist schools they accept. I believe the TX BON will only accept 2 programs and neither are located in TX!

core0 · Dec 11, 2008

I think 2,000 hours is absolutely ludicrous! One of my PA friends spent a total of 6 weeks in surgery and he told me he barely got his feet wet! Why on earth do we as NP's have to complete so many clinical hours? We may as well go to medical school! Also, check with your BON and find out which first assist schools they accept. I believe the TX BON will only accept 2 programs and neither are located in TX!

I would agree. This is essentially a guild rule. I would also point out that its possible to become a CRNFA without being able to scrub. I think that the four weeks or so of surgical time that most PAs get will make some one minimally competent. Additional training is going to be up to the surgeon.

David Carpenter, PA-C

*RN123ABC* · Dec 12, 2008

I think I'm falling in love with David C. I love smart men. Seriously, I don't have a dog in this fight, but I for one appreciate all the time you devote to answering questions so professionally and without prejudice. I learn a lot from reading your posts.

jer_sd · Dec 12, 2008

I think 2,000 hours is absolutely ludicrous! One of my PA friends spent a total of 6 weeks in surgery and he told me he barely got his feet wet! Why on earth do we as NP's have to complete so many clinical hours? We may as well go to medical school! Also, check with your BON and find out which first assist schools they accept. I believe the TX BON will only accept 2 programs and neither are located in TX!

The 2,000 hours is for the CRNFA exam not for a NP, that is designed primarily for a RN who has passed the CNOR examaintion, completion of a recognized RNFA program to become nationally certified.

At one hospital I have clinical privilages all NPs/PAs can 1st assist, at the other a PA can first assist, but the NP must have CNOR and completion of a RNFA educational program. At both hospitals a RN must have current CRNFA certification.

Jeremy

core0 · Dec 12, 2008

The 2,000 hours is for the CRNFA exam not for a NP, that is designed primarily for a RN who has passed the CNOR examaintion, completion of a recognized RNFA program to become nationally certified.
At one hospital I have clinical privilages all NPs/PAs can 1st assist, at the other a PA can first assist, but the NP must have CNOR and completion of a RNFA educational program. At both hospitals a RN must have current CRNFA certification.
Jeremy

Actually if you look at the requirements they are cumulative.

You have to have an RN license

You must either have your CNOR or NP

You must have 2000 hours as an RNFA

You must have a bachelors degree

So if you are an NP with a certificate and 2000 hours as an RNFA you still cannot get a CRNFA. 1400 hours of this must as part of interoperative care. Theoretically you could circulate for 1400 hours and get your CRNFA. I'm not sure how you could circulate for 1400 hours as an RNFA though. Apparently early on in the process someone used this rule to get their CRNFA who had never scrubbed. Actually as I read the rules and applications an NP or DNP that did not get a BSN along the way would also not be eligible. Hmm, what a tangled web we weave.

The real issue is that CMS has decided that first assisting is an ANP skill while nursing has decided to make it broader. Since there is not a surgical NP program (UAB being somewhat of the exception) this leaves the field open to interpretation.

David Carpenter, PA-C

jer_sd · Dec 13, 2008

Actually if you look at the requirements they are cumulative.
You have to have an RN license
You must either have your CNOR or NP
You must have 2000 hours as an RNFA
You must have a bachelors degree
So if you are an NP with a certificate and 2000 hours as an RNFA you still cannot get a CRNFA. 1400 hours of this must as part of interoperative care. Theoretically you could circulate for 1400 hours and get your CRNFA. I'm not sure how you could circulate for 1400 hours as an RNFA though. Apparently early on in the process someone used this rule to get their CRNFA who had never scrubbed. Actually as I read the rules and applications an NP or DNP that did not get a BSN along the way would also not be eligible. Hmm, what a tangled web we weave.
The real issue is that CMS has decided that first assisting is an ANP skill while nursing has decided to make it broader. Since there is not a surgical NP program (UAB being somewhat of the exception) this leaves the field open to interpretation.
David Carpenter, PA-C

That is if a NP wanted to get certified as a CRNFA they would need to meet the minimum requirements similar to a RN only just without the CNOR.

But if a NP wanted to function as a first assistant they would be able to do so after completing a RNFA program with 160 hours of patient contact. Then if they want to keep accruing hours for extra certification they could do so and work upto a CRNFA if wanted. But they can bill first assisting based upon NP credentials no need to go through a RNFA program.

Now a BSN is not requried, this is the first time any BA/BS will meet certification requirements.

I do agree that if a NP wants to first assist they should have a structured education to support it. Nurse midwives have a nice protocol on obtaining 1st assist skill set. Just training a NP on the job would leave a lot to be desired.

Jeremy

JDCitizen · Dec 13, 2008

I am reading this with some interest since it probably can be linked to procedures NPs can do in the hospital. So now it's really as clear as mud. What happened to protocols? Doctor signs it and agrees to it and the state accepts it but the hospital can still say no under JACO regulations?

core0 · Dec 13, 2008

That is if a NP wanted to get certified as a CRNFA they would need to meet the minimum requirements similar to a RN only just without the CNOR.
But if a NP wanted to function as a first assistant they would be able to do so after completing a RNFA program with 160 hours of patient contact. Then if they want to keep accruing hours for extra certification they could do so and work upto a CRNFA if wanted. But they can bill first assisting based upon NP credentials no need to go through a RNFA program.
Now a BSN is not requried, this is the first time any BA/BS will meet certification requirements.
I do agree that if a NP wants to first assist they should have a structured education to support it. Nurse midwives have a nice protocol on obtaining 1st assist skill set. Just training a NP on the job would leave a lot to be desired.
Jeremy

You are correct on the bachelors requirement. I was looking at the original proposed certification requirements. As far as RNFA vs. CRNFA it depends on the hospital. From a Medicare standpoint there is no requirement outside of the NP license. I have seen hospitals require CRNFA for all RNs (including NPs) to first assist which is a much more difficult hurdle to overcome.

David Carpenter, PA-C

core0 · Dec 13, 2008

I am reading this with some interest since it probably can be linked to procedures NPs can do in the hospital. So now it's really as clear as mud. What happened to protocols? Doctor signs it and agrees to it and the state accepts it but the hospital can still say no under JACO regulations?

Its not under JC regulations. A hospital has the right to decide which providers have which privileges pretty much without oversight. The only real rule is they cannot use privileging to deny providers entry when they meet the basic qualifications. You see this among physicians all the time. For example GI fellows are required to have 500+ endoscopies to graduate, while the FPs think that 50 is enough. If GI is running the department they can require 500 endoscopies to become credentialled.

The states job is to protect the public and follow state law. The hospital credentialing committees job is to protect the public and the hospital. Different requirements, different regulations.

David Carpenter, PA-C