- Email: [email protected]
Implementation of the RN First Assistant Role
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JANUARY 1997. VOL 65, NO 1 Poe Bubb Freeman
Implementation of the RN First Assistant Role perating room nurses began to function as first assistants during World War I1 when there was a shortage of qualified surgeons and residents.’ Through the years, the role of RNs as assistants to surgeons has continued to evolve. Today, as managed care contractors seek to provide surgical care at reduced costs, removing the second surgeon from the surgical field and replacing him or her with a nurse first assistant has been advocated as a cost-saving measure. Norfolk, Va, and its surrounding communities are known as Tidewater. The region has a surgical assistant training program, but few RNs are graduates of this program. Trainees from the Tidewater surgical assistant’s program include Navy and Army medical technicians, paramedics, and other individuals who, at the completion of the course, are called second assistants (2As). These 2As normally do not possess certification or licensure. Before 1990, their services continued to be in demand in Tidewater because the RN first assistant (RNFA) role was not well accepted in the region. The situation changed, however, when selected nurses at the Children’s Hospital of the King’s Daughter’s (CHKD), Norfolk, Va, received their RNFA training from a recognized program at Delaware County Community College in Media, Pa. Support for RNs, rather than unlicensed 2As, as first assistants
started when the first CHKD nurses returned from their RNFA course and were assigned to surgeons who oversaw the completion of their practice requirements. After being credentialed by CHKD, these RNFAs were granted expanded practice privileges and expanded professional practice levels. IDEA DlEvELopMEwT
A multidisciplinary continuous quality improvement (CQI) committee at CHKD whose function was to improve OR efficiency recommended that the hospital implement the RNFA role. The expected benefits were flexibility of the RNFA’s being able to function in other roles (eg, scrub, circulator, educator), consistent application of the nursing process for all patients, professional and technical assistance for the surgeon, morale booster for RNs selected for the program, possible aid to RN recruitment and retention, career opportunity for RNs who wanted expanded practice roles, more cost-effective than establishing a 2A program because RNFAs could function in multiple roles, marketability of the program to current and potential staff surgeons, and no additional full-time equivalents (FTEs) required to implement the role. IMPLEMENTATION
A B S T R A C T The RN first assistant (RNFA) program at Children‘s Hospital of The King’s Daughters in Norfolk, Va, began as a dream in which RNs could expand their role within a cost-effective. hospital-based implementation of the RNFA role. Our dream included a career development path for perioperative nurses who had few other career options within the surgical arena. This article describes how the dream came true. AORN J 65 (Jan 1997) 32-41.
wuonrnls
After the CQI committee members defined the program benefits, the hospital’s priorities were to seek support from surgeons and senior administrative officers to implement the role. The next steps were to determine which RNs qualified for the role B
DONNA POE, RN; DENISE MARIE BUBB, RN; LAURA K . FREEMAN, RN
32 AORN JOURNAL
JANUARY 1997,VOL 65, NO 1 Poe Bubb Freeman
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and design the professionalpractice model. Support for the role. Senior CHKD administrative officers approved the proposal for an RNFA training role based on cost-effective financial analysis, an appraisal of the professional nursing benefits to CHKD’s F W staff members, and a written plan for implementation. Active staff surgeons endorsed the role, volunteered to serve as mentors, and agreed to request RNFAs as first assistants after they completed their training program. Operating for the training- room staff nurses applied -positions, and a team of managers and peers assisted in the selection Drocess. Candidate &leetion process. We used the Delaware County Community College RNFA program model to develop CHKD’s RNFA candidate selection process. The requirements for the initial group of RNs applying for the RNFA role at CHKD were as follows. The RN must possess a current nursing license and have two years of perioperative experience, possess current cardiopulmonary resuscitation (CPR) certification, be credentialed as a CNOR, have personal liability insurance, commit to one year’s employment at CHKD, have received a “commendable” rating on the most recent performance appraisal, demonstrate punctuality, have less than a 4% absenteeism rate within the past year, demonstrate use of conflict resolution skills, exhibit problem-solving skills, and be able to manage the cost of the RNFA course until reimbursed. Three RNs were chosen and sent to Delaware
County Community College for their formal trainmg. On their return, the RNFA as first assistant in the OR became a reality at CHJCD. When the time came to evaluate the second group of applicants for the role, we modified the selection criteria. The new criteria stated that candidates must possess a current nursing license and have two years of perioperative experience, possess current CPR certification and pediatric advanced life support certification, be credentialed as a CNOR, commit to one year’s employment at CHKD, have completed at least one full year of employment at CHKD, have an “excellent” rating on the most recent performance appraisal, demonstrateassertivenessskills, maintain a positive approach to problem solving, be an active participant in peer review, demonstrateleadership capability, contribute to the professional growth of peers and others, show proof of personal liability insurance,and have no unresolved record of tardiness. In addition, members of the second class of candidates were required to submit essays in which they reswnded to the followha questions. What are your objeckGes in pursuing RNFA training? * What are your expectationsof the RNFA role? What are your visions of how the RNFA role embraces perioperativenursing practice? What are your plans to meet the various RNFA responsibilities? What is your commitment to the RNFA professional nursing model? Selection committee members (ie, . . nurse managers, RNFAs) read and evaluated the essays for clarity, content, and applicability. Applicants also interviewed with nurse managers, surgical staff members, practicing RNFAs, and surgeons. The final selection was based on qualifications,interview evaluations, and essay content and was determined by selection committee consensus. -yIwyRw
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Three RNs initially were trained as RNFAs. As time passed, the OR nurse managers determined the need for more RNFAs based on the number of requests for RNFAs to first assist in surgical procedures. Surgical residents from Eastern Virginia 36
AORN JOURNAL
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JANUARY 1997, VOL 65, NO 1 Poe Bubb Freeman.
Table 1 SAMPLE RN FIRST ASSISTANT JOB DESCRIPCION
Job title: RN First Assistant-OR Department: Operating room Position code:
Fair Labor Standards Act status: Nonexempt Job group: Bloodborne pathogen class:
General summary: The RN first assistont carries out functions that will assist the surgeon in performing a safe surgical procedure with optimum results for the patient. The RN first assistant practices perioperative nursing, functions directly under the supervision of the surgeon during the surgical procedure, and does not function simultaneously as the scrub nurse.
Principal duties: Understandsthe professional accountability as the RN first assistant. Responsibilities of the RN first assistant may include, but are not limited to: a. Handling tissue b. Providing exposure c. Using instruments d. Suturing e. Providing hemostasis functions interdependentlywith the operating surgeon.
Knowledge, skills, and abilities required: Qualifications for the RN first assistant include, but ore not limited to, the following: 1 . Current Virginia RN license, pediatric advanced life support and CNOR certification as documented in the human resources department. 2.
Proficiency in perioperative nursing practice as both scrub and circulator.
3.
Knowledge and skill in applying principlesof asepsis and infection control.
4.
Knowledge of surgical anatomy, physiology, and surgical techniques related to the specific surgical procedures in which the RN assists.
5. Demonstratedability to perform cardiopulmonary resuscitation. 6.
Demonstrated ability to perform effectively in stressful and emergency situations.
7.
Demonstratedability to recognize safety hazards and initiates appropriate preventive and corrective action,
8.
Demonstrated ability to perform effectively and harmoniously as a member of the surgical team.
(Adopted with permission from Children‘s Hospital of The King’s Daughters, Norfolk, Va)
Medical School, Norfolk, Va, were available for most procedures; however, residents from certain subspecialties were not available. When requests for hours of assistance became greater than the number of nursing resource hours available, we selected and trained two more RNs. At the present time, CHKD has five nurses qualified to practice as W A S . Hospital administrators initially approved onehalf FTE (ie, 1040 hours per calendar year). No additional FTEs were added to the OR nursing staff to cover this M A position. The ability to preserve an existing staffing allocation without adding resources illustrates the flexibility of the RN functioning as f i s t assistant and the cost-effectiveness of the RNFA program.
STRATEGIC PLAN
We developed and implemented a strategic plan that included the RNFA role as part of the surgical services department business plan. The RNFA portion of the plan defined the RNFA’s role; included a job description (Table 1) for RNs who function in the expanded practice model; listed the RNFA’s scope of practice; delineated the qualifications t o become an RWA, and described procedures, preparation of the RNFA, and the establishment of practice privileges for RNFAs. Several of the documents contained in this 37
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JANUARY 1997, VOL 65, NO I Poe Bubb Freemun
strategic plan were taken from the “AORN Position Statement on RN First Assistants.”* Excerpts from CHKD’s strategic plan for RNFAs follow. Goals and plans are presented with the justification for each. Goal statement 1. Staff development will be a continuous process in order to provide adequate RNFA coverage, maintain standards of surgical practice, and meet the needs of the professional
credentialed W A S , and known or anticipated changes in surgical residency programs. BElyEpcts OF TME RNFA ROLE
There are three major benefits of the CHKD RNFA role. They are the definition, development, and implementation of a professional nursing practice model. Staff. Definition and development of a professional Justification: The RNFA model represents model. As the three initial RNFAs demonstrated new expanded perioperative nursing practice. Virginia professionalism, hospital administrators enhanced state nursing regulations and CHKD policy dictate their expanded practice stature and established them the scope of the RNFA practice. Meeting the as members of the CHKD’s professional staff. The demand for RNs to serve as assistants in the provi- hospital’s professional staff members previously had sion of surgical care will be provided through a pro- recognized and credentialed advanced practice RNs. gram that educates nurses, provides opportunities for The following steps were taken to establish the ongoing clinical practice, promotes professional RNFA credentialingprocess. RNFA clinical privileges were delineated. development, and maintains a pool of RNFAs who Active members of the CHKD professional staff respond to requests for their services in a timely and competent manner. sponsored individual RNFAs. Strategylplan: RNs will be educated in an Hospital administrators developed compensation approved RNFA program and receive their clinical packages commensurate with the RNFAs’ training in supervised clinical internships. Annual expanded practice responsibilities. Moving the RNFAs from hourly to salaried performance evaluations and biannual reappointment procedures will be used to monitor ongoing progress. positions initially resulted in an annual cost savings Goal statement 2. The surgical services depart- to the hospital of $19,572. The benefit package ment will contain costs and promote efficient use of included mechanisms for the RNFAs to increase personnel through the flexibility of RNFAs who will their earning capabilities. Their salaried positions scrub, circulate, first assist, and perform nondirect include full-time (ie, 80 hours per two weeks) hours, care activities. RNFA call hours, and hours during which the Justijkation: The demand for RNFA services is RNFAs accept professional responsibility for patient unpredictable. The RNFA is able to perform multi- care beyond scheduled working hours. In addition, ple perioperative functions that cannot be performed they can supplement their base salaries by taking general surgery or cardiac surgery call when they are by non-RN surgical assistants. Strategylplan: Continue to monitor and build not performing RNFA duties. the RNFA role and reject options of hiring lesser Application process for professional staff privileges. On completion of the didactic and clinical eletrained and/or less flexible surgical assistants. Goal statement 3. Provide an adequate RNFA ments of the RNFA course, the RNs apply for propool that proactively responds to changes in surgical fessional staff privileges and credentialing to pracresidency programs at East Virginia Medical tice as RNFAs at CHKD. Although they are School/CHKD. employees of CHKD, the RNFAs’ expanded pracJustijication: As the surgical specialists’ needs tice position allows them to share in the rights and for assistance change due to fewer residents and resi- privileges of the professional staff members. dent schedules, it is prudent to use RNFAs to first Applicants file formal applications for clinical assist to fill vacancies that result from the loss of the privileges with clearly delineated practice paramesurgical residency programs. ters. Clinical privilege application processes differ Strutegylplan: Develop a list of criteria by from institution to institution, so the RNFAs which first assistant requests will be managed. Crite- who seek privileges must contact specific instituria may include the following: tions’ professional staff offices for credentialing number of requests received in a given time information. frame, Credentialing at CHKD follows the format number of RNFA hours available in a given time approved by Joint Commission on Accreditation frame, of Healthcare Organizations, with the hospital board status of RNFA staffing patterns and number of giving the final approval after acceptance by the 38 AORN JOURNAL
JANUARY 1997, VOL 65, NO 1 Poe * Bubb Freeman * 9
Table 2 credentials and executive medical SAMPLE RN FIRST ASSISTANT EVALUATION TOOL committees of the medical staff. CommentsMeeds Every two years, RNFAs are Completed reevaluated by peers and surgeons A. Demonstratesthe following skills. for continuation of practice privisuturing leges (Table 2). The CHKD polipreparation of surgical site cy for delineation of RNFA pracdraping tice privileges states that it is the retracting responsibility of each surgery hemostasis department to provide surgical dressing application assistance. Surgeons can choose manual dexterity to use licensed surgical assistants knowledge of procedure and/or physicians for all major anatomy surgical procedures, and RNFAs ability to follow directions may serve in this role under the ability to anticipate surgeon/ direct supervision of the attending procedure needs surgeon as defined in the RNFA B. Performs preoperative and job description. postoperativevisits on patients Cost analysis. We completed a when possible and maintains financial analysis of hiring RNFAs documentation. rather than 2As to cover requests for surgical first assistance. The C. Participates in biannual RN first results clearly indicated that it was assistant (RNFA) forums. more cost-effective to hire RNFAs because of their ability to function D.Participates in RNFA monthly journal club. in other perioperative roles. We also analyzed the differ- E. Assists in training nursing stoff ences in salary and benefits (ie, members on new equipment and hourly versus salaried positions) procedures. for RNs in the expanded practice RNFA role. We determined cost F. Completes annual self-performance appraisal in collaboration with savings were greater for RNFAs surgical staff members. than 2As and for RNFAs in the salaried rather than in hourly posi- G.Seeks out opportunities for continuing tions (Table 3). education. Implementation. When the program began, the three full-time H.Assists in surgical procedures during scheduled shifts as needed. RNFAs scheduled themselves for the following days' procedures. I. Performs duties of a perioperative staff As the program developed and as nurse when not assigned to the the procedure load increased, the RNFA role. RNFA team leader made weekly assignments for five full-time J. Complies with RNFA program policies. RNFAs. K. Assists in surgical procedures for the Surgeons request RNFAs by entirely of procedures. preference when scheduling their patients. The RNFAs' experience L. Assists nursing staff members in assigned room/procedure. in a variety of surgical subspecialty services allows them to work with all participating surgeons. (Adapted with permission fom Children's Hospital of The King's Daughters, The RNFAs are equally well Norfolk, Va) 39 AORN JOURNAL
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JANUARY 1997, VOL 65, NO 1 Poe Buhh Freeman
prepared for emergency and call-back procedures. As members of the RNFA group continue to develop their clinical skills, surgeons are delegating more responsibilities for surgical patients’ care. Procedure load is the single most important factor in determining RNFA staffing needs. The RNFAs’ procedure load at CHKD has increased steadily since the program’s inception (Figure 1). Specialty surgical services presently covered by the RNFA group include cardiothoracic, plastic and reconstructive, urology, general, ophthalmology, neurosurgery, orthopedics, and laparoscopic procedures. In most procedures, RNFAs complete wound closure while the surgeons prepare their next patient in another room. The surgeons remain directly available to the RNFA as he or she completes the wound closure and transports the patient to the appropriate postoperative care unit. This practice of the RNFA completing one patient’s care while the surgeon prepares the next patient is cost-effective, efficient, and safe. Liability and malpractice consideralions. In the past, nurses who functioned as first assistants learned their surgical skills under the direct observation of
Figure 1 RN first assistant (RNFA) procedure load increases since implementationof the RNFA role at Children‘s Hospital of The King’s Daughters, Norfolk, Va.
surgeons. In this position, they were somewhat protected from liability and malpractice suits. As the RNFA role continues to develop and as nurse practice acts give the RNs more responsibility and accountability for their actions, RNs’ skills, knowledge, and influence significantly affect the care of surgical patients. When practicing in the RNFA expanded role, nurses experience greater liability for malpractice and other errors. pR0RssHmALDRIEU)pMEM
BEYOND THE CUNlCAL SElllNG
The RNFA program at CHKD has evolved to include a journal club, case reviews for ongoing education, committee work, and regional Table 3 meetings in Virginia. To date, all COST ANALYSIS FOR RN FIRST ASSISTANTS (RNFAs) RNFAs at CHKD have attended Nonsalaried RNFA Salaried RNFA Second assistant (2A) out-of-state RNFA programs. The Top of range $47,340 $58,240 $40,000 RNFA group plans to investigate the possibility of establishing a $12,792 0 $12,792 On-call costs local RNFA program in which we Call-back costs $17,680 0 $15,002 could serve as instructors and Training costs $2,100* $2,1 00* mentors. Total cost $79,912** $60,340** $147,794** *Additional expenses for the RNFAs were one-time expenses of training, averaging $2,100 per siudent. **The 1990 start-up cost comparison included $6,240 in salary a@ustments for three RNFAs as compared to the new hire costs of $120,O00 for hree 2A surgical assistants. (Adapted wiih permission from Children’s Hospital of The King’s Llaughters, Norfolk, Va) 40 AORN JOURNAL
THE -RE OF THE RNFA P R O O M
The future of the RNFA role at CHKD appears bright and rewarding. Continuing positive benefits of having RNFAs at CHKD are increased quality of patient care due to effective patient
JANUARY 1997, VOL 65, NO 1 Poe Bubb Freeman
advocacy and improved communication with surgeons, perioperative nurses, and other OR team members; distinct, identifiable, successful recruitment strategy; benefit for surgeons; professional growth for perioperative nurses; and cost-effectiveness. The RNFA group - is self-governing. Members establish and monitor practice guidelines, participate in ongoing peer review, guarantee members’ availability for service and coverage, and resolve and manage conflict. The RNFA role is expanding with development of skills beyond the walls of the traditional OR. For example, the RNFAs have met with staff members from the surgical cluster unit that has postoperative care as its focus. Guidelines are being developed for greater involvement of the RNFAs in preoperative and postoperative patient care. Surgeons may request RNFAs to make rounds on their patients, perform wound care, assess patients’ conditions, and teach patients and family members about preoperative and postoperative care. The RNFAs also provide education and information to the surgical cluster nursing staff members. SUMMMY
The RNFAs at CHKD have established themselves as a dependable, proficient, and highly motivated group. Physician feedback is very positive, and the surgeons routinely schedule their patients with the W A S . With mandated cost cutting and the uncertainty of the health care environment, the RNFAs are well positioned to be an economically desirable entity in the OR at CHKD. As reimbursement for physicians as first assistants vanishes, RNFAs are indispensable. In the foreseeable future when surgeons perform surgery from off-site locations with the help of virtual reality, computers, and robotics, RNFAs will be in the ORs providing direct care for patients and ensuring that the NOTES 1. M Breakiron, “A salute to the nurses of World War II,”AORN Jour-
nal 62 (November 1995) 710-722. 2. “Position statement on RN first
assistants,” AORN Standards and Recommended Practices (Denver: Association of Operating Room N-s, hc, 1996) 19-20. SUGGESTED READING “American College of Surgeons:
surgical procedures go well. The senior vice president for clinical services at CHKD says, The RNFA role is one of the rare win-win solutions that we have achieved during these turbulent times in health care. The erosion of residency support and the implosion of reimbursement structures have created tremendous financial, practice, and patient care challenges for surgeons and the health care system. The RNFA role at CHKD exempl$es the best of work redesign and reengineering outcomes. The needs of surgeons and patients are met, staff members benefit professionally, operational flexibility is achieved, the reputation of the service is enhanced, and costs are contained. The role is truly an improvement in all senses of the word and is a sterling example of problem solving through creativity, collaboration, and ingenuity. The f u t u r e a t CHKD will include the RNFA model as a vanguard program that represents progressive care delivery, proactive surgical leadership, and$scal responsibility. A Donna Poe, RN,BS, CNUR, is director of surgical services at Children’s Hospital of The King’s Daughters,
Norjolk, Va. Denise Marie Bubb, RN, CNOR, is an RNfirst assistant and staff nurse at Children’sHospital of The King’s
Daughters,Norfolk, Va. Laura K . Freeman, RN, CNOR, is an RNfirst assistant
and stajJnurse at Children’sHospital of The King’s Daughters,Norfolk, Va. The authors wish to thank Ruth Waibel,RN,PhD, CHE, professor in the health sciences department,Ohio University,Athens, Ohio,for her assistance in preparing this article. She was an OR staff nurse at Children’sHospital of The King’s Daughters,Norfolk, Va,at the time this article was written.
Qualifications of the fmt assistant in the operating room.” AORN Journal 32 (December 1980) 1012. “AORN recommended education standards for RN fmt assistant programs.” (Position statement)AORN Journal 61 (March 1995) 476-478. Mathias, J M. “OR of the future: Remote surgery and virtual endoscopy on the horizon.” OR Manager 12 (February 1996) 9-10. Rothrock, J C. “The nurse practice 41 AORN JOURNAL
act and expanded roles.” In The RN First Assistant: An Expanded Perioperative Nursing Role, second ed,J C Rothrock,ed,17-36. Philadelphia: J B Lippincott Co, 1993. Siefert, P. “The RN first assistant and collaborative practice.” In The RN First Assistant: An Expanded Perioperative Nursing Role, second ed, J C Rothrock, ed,288-307. Philadelphia: J B Lippincott Co, 1993.
JANUARY 1997. VOL 65, NO 1 Poe Bubb Freeman
Implementation of the RN First Assistant Role perating room nurses began to function as first assistants during World War I1 when there was a shortage of qualified surgeons and residents.’ Through the years, the role of RNs as assistants to surgeons has continued to evolve. Today, as managed care contractors seek to provide surgical care at reduced costs, removing the second surgeon from the surgical field and replacing him or her with a nurse first assistant has been advocated as a cost-saving measure. Norfolk, Va, and its surrounding communities are known as Tidewater. The region has a surgical assistant training program, but few RNs are graduates of this program. Trainees from the Tidewater surgical assistant’s program include Navy and Army medical technicians, paramedics, and other individuals who, at the completion of the course, are called second assistants (2As). These 2As normally do not possess certification or licensure. Before 1990, their services continued to be in demand in Tidewater because the RN first assistant (RNFA) role was not well accepted in the region. The situation changed, however, when selected nurses at the Children’s Hospital of the King’s Daughter’s (CHKD), Norfolk, Va, received their RNFA training from a recognized program at Delaware County Community College in Media, Pa. Support for RNs, rather than unlicensed 2As, as first assistants
started when the first CHKD nurses returned from their RNFA course and were assigned to surgeons who oversaw the completion of their practice requirements. After being credentialed by CHKD, these RNFAs were granted expanded practice privileges and expanded professional practice levels. IDEA DlEvELopMEwT
A multidisciplinary continuous quality improvement (CQI) committee at CHKD whose function was to improve OR efficiency recommended that the hospital implement the RNFA role. The expected benefits were flexibility of the RNFA’s being able to function in other roles (eg, scrub, circulator, educator), consistent application of the nursing process for all patients, professional and technical assistance for the surgeon, morale booster for RNs selected for the program, possible aid to RN recruitment and retention, career opportunity for RNs who wanted expanded practice roles, more cost-effective than establishing a 2A program because RNFAs could function in multiple roles, marketability of the program to current and potential staff surgeons, and no additional full-time equivalents (FTEs) required to implement the role. IMPLEMENTATION
A B S T R A C T The RN first assistant (RNFA) program at Children‘s Hospital of The King’s Daughters in Norfolk, Va, began as a dream in which RNs could expand their role within a cost-effective. hospital-based implementation of the RNFA role. Our dream included a career development path for perioperative nurses who had few other career options within the surgical arena. This article describes how the dream came true. AORN J 65 (Jan 1997) 32-41.
wuonrnls
After the CQI committee members defined the program benefits, the hospital’s priorities were to seek support from surgeons and senior administrative officers to implement the role. The next steps were to determine which RNs qualified for the role B
DONNA POE, RN; DENISE MARIE BUBB, RN; LAURA K . FREEMAN, RN
32 AORN JOURNAL
JANUARY 1997,VOL 65, NO 1 Poe Bubb Freeman
Final
s&&on is
based on gualificatioOw ~t€!I’VieW
eVdUti0-
and
essaycontent.
and design the professionalpractice model. Support for the role. Senior CHKD administrative officers approved the proposal for an RNFA training role based on cost-effective financial analysis, an appraisal of the professional nursing benefits to CHKD’s F W staff members, and a written plan for implementation. Active staff surgeons endorsed the role, volunteered to serve as mentors, and agreed to request RNFAs as first assistants after they completed their training program. Operating for the training- room staff nurses applied -positions, and a team of managers and peers assisted in the selection Drocess. Candidate &leetion process. We used the Delaware County Community College RNFA program model to develop CHKD’s RNFA candidate selection process. The requirements for the initial group of RNs applying for the RNFA role at CHKD were as follows. The RN must possess a current nursing license and have two years of perioperative experience, possess current cardiopulmonary resuscitation (CPR) certification, be credentialed as a CNOR, have personal liability insurance, commit to one year’s employment at CHKD, have received a “commendable” rating on the most recent performance appraisal, demonstrate punctuality, have less than a 4% absenteeism rate within the past year, demonstrate use of conflict resolution skills, exhibit problem-solving skills, and be able to manage the cost of the RNFA course until reimbursed. Three RNs were chosen and sent to Delaware
County Community College for their formal trainmg. On their return, the RNFA as first assistant in the OR became a reality at CHJCD. When the time came to evaluate the second group of applicants for the role, we modified the selection criteria. The new criteria stated that candidates must possess a current nursing license and have two years of perioperative experience, possess current CPR certification and pediatric advanced life support certification, be credentialed as a CNOR, commit to one year’s employment at CHKD, have completed at least one full year of employment at CHKD, have an “excellent” rating on the most recent performance appraisal, demonstrateassertivenessskills, maintain a positive approach to problem solving, be an active participant in peer review, demonstrateleadership capability, contribute to the professional growth of peers and others, show proof of personal liability insurance,and have no unresolved record of tardiness. In addition, members of the second class of candidates were required to submit essays in which they reswnded to the followha questions. What are your objeckGes in pursuing RNFA training? * What are your expectationsof the RNFA role? What are your visions of how the RNFA role embraces perioperativenursing practice? What are your plans to meet the various RNFA responsibilities? What is your commitment to the RNFA professional nursing model? Selection committee members (ie, . . nurse managers, RNFAs) read and evaluated the essays for clarity, content, and applicability. Applicants also interviewed with nurse managers, surgical staff members, practicing RNFAs, and surgeons. The final selection was based on qualifications,interview evaluations, and essay content and was determined by selection committee consensus. -yIwyRw
RRsTrarma.mDowENEED~
Three RNs initially were trained as RNFAs. As time passed, the OR nurse managers determined the need for more RNFAs based on the number of requests for RNFAs to first assist in surgical procedures. Surgical residents from Eastern Virginia 36
AORN JOURNAL
-
JANUARY 1997, VOL 65, NO 1 Poe Bubb Freeman.
Table 1 SAMPLE RN FIRST ASSISTANT JOB DESCRIPCION
Job title: RN First Assistant-OR Department: Operating room Position code:
Fair Labor Standards Act status: Nonexempt Job group: Bloodborne pathogen class:
General summary: The RN first assistont carries out functions that will assist the surgeon in performing a safe surgical procedure with optimum results for the patient. The RN first assistant practices perioperative nursing, functions directly under the supervision of the surgeon during the surgical procedure, and does not function simultaneously as the scrub nurse.
Principal duties: Understandsthe professional accountability as the RN first assistant. Responsibilities of the RN first assistant may include, but are not limited to: a. Handling tissue b. Providing exposure c. Using instruments d. Suturing e. Providing hemostasis functions interdependentlywith the operating surgeon.
Knowledge, skills, and abilities required: Qualifications for the RN first assistant include, but ore not limited to, the following: 1 . Current Virginia RN license, pediatric advanced life support and CNOR certification as documented in the human resources department. 2.
Proficiency in perioperative nursing practice as both scrub and circulator.
3.
Knowledge and skill in applying principlesof asepsis and infection control.
4.
Knowledge of surgical anatomy, physiology, and surgical techniques related to the specific surgical procedures in which the RN assists.
5. Demonstratedability to perform cardiopulmonary resuscitation. 6.
Demonstrated ability to perform effectively in stressful and emergency situations.
7.
Demonstratedability to recognize safety hazards and initiates appropriate preventive and corrective action,
8.
Demonstrated ability to perform effectively and harmoniously as a member of the surgical team.
(Adopted with permission from Children‘s Hospital of The King’s Daughters, Norfolk, Va)
Medical School, Norfolk, Va, were available for most procedures; however, residents from certain subspecialties were not available. When requests for hours of assistance became greater than the number of nursing resource hours available, we selected and trained two more RNs. At the present time, CHKD has five nurses qualified to practice as W A S . Hospital administrators initially approved onehalf FTE (ie, 1040 hours per calendar year). No additional FTEs were added to the OR nursing staff to cover this M A position. The ability to preserve an existing staffing allocation without adding resources illustrates the flexibility of the RN functioning as f i s t assistant and the cost-effectiveness of the RNFA program.
STRATEGIC PLAN
We developed and implemented a strategic plan that included the RNFA role as part of the surgical services department business plan. The RNFA portion of the plan defined the RNFA’s role; included a job description (Table 1) for RNs who function in the expanded practice model; listed the RNFA’s scope of practice; delineated the qualifications t o become an RWA, and described procedures, preparation of the RNFA, and the establishment of practice privileges for RNFAs. Several of the documents contained in this 37
AORN JOURNAL
JANUARY 1997, VOL 65, NO I Poe Bubb Freemun
strategic plan were taken from the “AORN Position Statement on RN First Assistants.”* Excerpts from CHKD’s strategic plan for RNFAs follow. Goals and plans are presented with the justification for each. Goal statement 1. Staff development will be a continuous process in order to provide adequate RNFA coverage, maintain standards of surgical practice, and meet the needs of the professional
credentialed W A S , and known or anticipated changes in surgical residency programs. BElyEpcts OF TME RNFA ROLE
There are three major benefits of the CHKD RNFA role. They are the definition, development, and implementation of a professional nursing practice model. Staff. Definition and development of a professional Justification: The RNFA model represents model. As the three initial RNFAs demonstrated new expanded perioperative nursing practice. Virginia professionalism, hospital administrators enhanced state nursing regulations and CHKD policy dictate their expanded practice stature and established them the scope of the RNFA practice. Meeting the as members of the CHKD’s professional staff. The demand for RNs to serve as assistants in the provi- hospital’s professional staff members previously had sion of surgical care will be provided through a pro- recognized and credentialed advanced practice RNs. gram that educates nurses, provides opportunities for The following steps were taken to establish the ongoing clinical practice, promotes professional RNFA credentialingprocess. RNFA clinical privileges were delineated. development, and maintains a pool of RNFAs who Active members of the CHKD professional staff respond to requests for their services in a timely and competent manner. sponsored individual RNFAs. Strategylplan: RNs will be educated in an Hospital administrators developed compensation approved RNFA program and receive their clinical packages commensurate with the RNFAs’ training in supervised clinical internships. Annual expanded practice responsibilities. Moving the RNFAs from hourly to salaried performance evaluations and biannual reappointment procedures will be used to monitor ongoing progress. positions initially resulted in an annual cost savings Goal statement 2. The surgical services depart- to the hospital of $19,572. The benefit package ment will contain costs and promote efficient use of included mechanisms for the RNFAs to increase personnel through the flexibility of RNFAs who will their earning capabilities. Their salaried positions scrub, circulate, first assist, and perform nondirect include full-time (ie, 80 hours per two weeks) hours, care activities. RNFA call hours, and hours during which the Justijkation: The demand for RNFA services is RNFAs accept professional responsibility for patient unpredictable. The RNFA is able to perform multi- care beyond scheduled working hours. In addition, ple perioperative functions that cannot be performed they can supplement their base salaries by taking general surgery or cardiac surgery call when they are by non-RN surgical assistants. Strategylplan: Continue to monitor and build not performing RNFA duties. the RNFA role and reject options of hiring lesser Application process for professional staff privileges. On completion of the didactic and clinical eletrained and/or less flexible surgical assistants. Goal statement 3. Provide an adequate RNFA ments of the RNFA course, the RNs apply for propool that proactively responds to changes in surgical fessional staff privileges and credentialing to pracresidency programs at East Virginia Medical tice as RNFAs at CHKD. Although they are School/CHKD. employees of CHKD, the RNFAs’ expanded pracJustijication: As the surgical specialists’ needs tice position allows them to share in the rights and for assistance change due to fewer residents and resi- privileges of the professional staff members. dent schedules, it is prudent to use RNFAs to first Applicants file formal applications for clinical assist to fill vacancies that result from the loss of the privileges with clearly delineated practice paramesurgical residency programs. ters. Clinical privilege application processes differ Strutegylplan: Develop a list of criteria by from institution to institution, so the RNFAs which first assistant requests will be managed. Crite- who seek privileges must contact specific instituria may include the following: tions’ professional staff offices for credentialing number of requests received in a given time information. frame, Credentialing at CHKD follows the format number of RNFA hours available in a given time approved by Joint Commission on Accreditation frame, of Healthcare Organizations, with the hospital board status of RNFA staffing patterns and number of giving the final approval after acceptance by the 38 AORN JOURNAL
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Table 2 credentials and executive medical SAMPLE RN FIRST ASSISTANT EVALUATION TOOL committees of the medical staff. CommentsMeeds Every two years, RNFAs are Completed reevaluated by peers and surgeons A. Demonstratesthe following skills. for continuation of practice privisuturing leges (Table 2). The CHKD polipreparation of surgical site cy for delineation of RNFA pracdraping tice privileges states that it is the retracting responsibility of each surgery hemostasis department to provide surgical dressing application assistance. Surgeons can choose manual dexterity to use licensed surgical assistants knowledge of procedure and/or physicians for all major anatomy surgical procedures, and RNFAs ability to follow directions may serve in this role under the ability to anticipate surgeon/ direct supervision of the attending procedure needs surgeon as defined in the RNFA B. Performs preoperative and job description. postoperativevisits on patients Cost analysis. We completed a when possible and maintains financial analysis of hiring RNFAs documentation. rather than 2As to cover requests for surgical first assistance. The C. Participates in biannual RN first results clearly indicated that it was assistant (RNFA) forums. more cost-effective to hire RNFAs because of their ability to function D.Participates in RNFA monthly journal club. in other perioperative roles. We also analyzed the differ- E. Assists in training nursing stoff ences in salary and benefits (ie, members on new equipment and hourly versus salaried positions) procedures. for RNs in the expanded practice RNFA role. We determined cost F. Completes annual self-performance appraisal in collaboration with savings were greater for RNFAs surgical staff members. than 2As and for RNFAs in the salaried rather than in hourly posi- G.Seeks out opportunities for continuing tions (Table 3). education. Implementation. When the program began, the three full-time H.Assists in surgical procedures during scheduled shifts as needed. RNFAs scheduled themselves for the following days' procedures. I. Performs duties of a perioperative staff As the program developed and as nurse when not assigned to the the procedure load increased, the RNFA role. RNFA team leader made weekly assignments for five full-time J. Complies with RNFA program policies. RNFAs. K. Assists in surgical procedures for the Surgeons request RNFAs by entirely of procedures. preference when scheduling their patients. The RNFAs' experience L. Assists nursing staff members in assigned room/procedure. in a variety of surgical subspecialty services allows them to work with all participating surgeons. (Adapted with permission fom Children's Hospital of The King's Daughters, The RNFAs are equally well Norfolk, Va) 39 AORN JOURNAL
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prepared for emergency and call-back procedures. As members of the RNFA group continue to develop their clinical skills, surgeons are delegating more responsibilities for surgical patients’ care. Procedure load is the single most important factor in determining RNFA staffing needs. The RNFAs’ procedure load at CHKD has increased steadily since the program’s inception (Figure 1). Specialty surgical services presently covered by the RNFA group include cardiothoracic, plastic and reconstructive, urology, general, ophthalmology, neurosurgery, orthopedics, and laparoscopic procedures. In most procedures, RNFAs complete wound closure while the surgeons prepare their next patient in another room. The surgeons remain directly available to the RNFA as he or she completes the wound closure and transports the patient to the appropriate postoperative care unit. This practice of the RNFA completing one patient’s care while the surgeon prepares the next patient is cost-effective, efficient, and safe. Liability and malpractice consideralions. In the past, nurses who functioned as first assistants learned their surgical skills under the direct observation of
Figure 1 RN first assistant (RNFA) procedure load increases since implementationof the RNFA role at Children‘s Hospital of The King’s Daughters, Norfolk, Va.
surgeons. In this position, they were somewhat protected from liability and malpractice suits. As the RNFA role continues to develop and as nurse practice acts give the RNs more responsibility and accountability for their actions, RNs’ skills, knowledge, and influence significantly affect the care of surgical patients. When practicing in the RNFA expanded role, nurses experience greater liability for malpractice and other errors. pR0RssHmALDRIEU)pMEM
BEYOND THE CUNlCAL SElllNG
The RNFA program at CHKD has evolved to include a journal club, case reviews for ongoing education, committee work, and regional Table 3 meetings in Virginia. To date, all COST ANALYSIS FOR RN FIRST ASSISTANTS (RNFAs) RNFAs at CHKD have attended Nonsalaried RNFA Salaried RNFA Second assistant (2A) out-of-state RNFA programs. The Top of range $47,340 $58,240 $40,000 RNFA group plans to investigate the possibility of establishing a $12,792 0 $12,792 On-call costs local RNFA program in which we Call-back costs $17,680 0 $15,002 could serve as instructors and Training costs $2,100* $2,1 00* mentors. Total cost $79,912** $60,340** $147,794** *Additional expenses for the RNFAs were one-time expenses of training, averaging $2,100 per siudent. **The 1990 start-up cost comparison included $6,240 in salary a@ustments for three RNFAs as compared to the new hire costs of $120,O00 for hree 2A surgical assistants. (Adapted wiih permission from Children’s Hospital of The King’s Llaughters, Norfolk, Va) 40 AORN JOURNAL
THE -RE OF THE RNFA P R O O M
The future of the RNFA role at CHKD appears bright and rewarding. Continuing positive benefits of having RNFAs at CHKD are increased quality of patient care due to effective patient
JANUARY 1997, VOL 65, NO 1 Poe Bubb Freeman
advocacy and improved communication with surgeons, perioperative nurses, and other OR team members; distinct, identifiable, successful recruitment strategy; benefit for surgeons; professional growth for perioperative nurses; and cost-effectiveness. The RNFA group - is self-governing. Members establish and monitor practice guidelines, participate in ongoing peer review, guarantee members’ availability for service and coverage, and resolve and manage conflict. The RNFA role is expanding with development of skills beyond the walls of the traditional OR. For example, the RNFAs have met with staff members from the surgical cluster unit that has postoperative care as its focus. Guidelines are being developed for greater involvement of the RNFAs in preoperative and postoperative patient care. Surgeons may request RNFAs to make rounds on their patients, perform wound care, assess patients’ conditions, and teach patients and family members about preoperative and postoperative care. The RNFAs also provide education and information to the surgical cluster nursing staff members. SUMMMY
The RNFAs at CHKD have established themselves as a dependable, proficient, and highly motivated group. Physician feedback is very positive, and the surgeons routinely schedule their patients with the W A S . With mandated cost cutting and the uncertainty of the health care environment, the RNFAs are well positioned to be an economically desirable entity in the OR at CHKD. As reimbursement for physicians as first assistants vanishes, RNFAs are indispensable. In the foreseeable future when surgeons perform surgery from off-site locations with the help of virtual reality, computers, and robotics, RNFAs will be in the ORs providing direct care for patients and ensuring that the NOTES 1. M Breakiron, “A salute to the nurses of World War II,”AORN Jour-
nal 62 (November 1995) 710-722. 2. “Position statement on RN first
assistants,” AORN Standards and Recommended Practices (Denver: Association of Operating Room N-s, hc, 1996) 19-20. SUGGESTED READING “American College of Surgeons:
surgical procedures go well. The senior vice president for clinical services at CHKD says, The RNFA role is one of the rare win-win solutions that we have achieved during these turbulent times in health care. The erosion of residency support and the implosion of reimbursement structures have created tremendous financial, practice, and patient care challenges for surgeons and the health care system. The RNFA role at CHKD exempl$es the best of work redesign and reengineering outcomes. The needs of surgeons and patients are met, staff members benefit professionally, operational flexibility is achieved, the reputation of the service is enhanced, and costs are contained. The role is truly an improvement in all senses of the word and is a sterling example of problem solving through creativity, collaboration, and ingenuity. The f u t u r e a t CHKD will include the RNFA model as a vanguard program that represents progressive care delivery, proactive surgical leadership, and$scal responsibility. A Donna Poe, RN,BS, CNUR, is director of surgical services at Children’s Hospital of The King’s Daughters,
Norjolk, Va. Denise Marie Bubb, RN, CNOR, is an RNfirst assistant and staff nurse at Children’sHospital of The King’s
Daughters,Norfolk, Va. Laura K . Freeman, RN, CNOR, is an RNfirst assistant
and stajJnurse at Children’sHospital of The King’s Daughters,Norfolk, Va. The authors wish to thank Ruth Waibel,RN,PhD, CHE, professor in the health sciences department,Ohio University,Athens, Ohio,for her assistance in preparing this article. She was an OR staff nurse at Children’sHospital of The King’s Daughters,Norfolk, Va,at the time this article was written.
Qualifications of the fmt assistant in the operating room.” AORN Journal 32 (December 1980) 1012. “AORN recommended education standards for RN fmt assistant programs.” (Position statement)AORN Journal 61 (March 1995) 476-478. Mathias, J M. “OR of the future: Remote surgery and virtual endoscopy on the horizon.” OR Manager 12 (February 1996) 9-10. Rothrock, J C. “The nurse practice 41 AORN JOURNAL
act and expanded roles.” In The RN First Assistant: An Expanded Perioperative Nursing Role, second ed,J C Rothrock,ed,17-36. Philadelphia: J B Lippincott Co, 1993. Siefert, P. “The RN first assistant and collaborative practice.” In The RN First Assistant: An Expanded Perioperative Nursing Role, second ed, J C Rothrock, ed,288-307. Philadelphia: J B Lippincott Co, 1993.