Frequently Asked Querstions


Answered by: Grace Groetzsch, RN, BScN, MEd, CPN(C), CRNFA

What if the surgeon drops dead intraoperatively? Who will complete the surgery?

Officially I do not know any hospital who has an official policy regarding this issue. It was, however, recognized in Ontario by the Ontario Medical Association and the College of Family Physicians that generally GPs who assist at surgery, like RNFAs, do not have the ability to complete an operative procedure should something untoward happen to the surgeon during a case. The only time that an assistant might have the ability is if they themselves are 1. a surgeon or 2. a senior resident or fellow. A junior resident/medical student likewise does not have the ability to finish a procedure. This information was verified with the College of Nurses of Ontario at a meeting of the above parties and myself, plus the College of Nurses in October 1997.

What would happen if a surgeon becomes ill and a RNFA is assisting is identical to what happens if a GP assistant is assisting - another surgeon is called in. RNFAs and GP assistants do not finish the surgery. Jane Rothrock wrote a classic response to the question which is published in the May/June 1995 issue of the Canadian Operating Room Nursing Journal, in an article entitled 'RN First Assistant: The Perioperative Role of the Future', pages 6 - 14. The section is written somewhat tongue in cheek, but what she said is valid:

"but .... if the surgeon drops dead, my RNFA will not finish the surgery, but, if you are bleeding I promise they will stop it. If they are in the middle of an anastomosis, I promise you they will try to get things back together, they will throw a wet sponge on, they will keep you stable, physiologically they know exactly what to look for until another surgeon comes in" p. 11.

If the hospital/physicians are worried, write a protocol to cover this instance - another surgeon will be called.


Does an RNFA require liability insurance separate from that provided by the hospital?

In Ontario, our professional nursing body, the Registered Nurses Association of Ontario (RNAO) offers liability coverage for nurses who are working in expanded roles such as RNFAs. The program is called NurseInsure and offers liability coverage from 1 - 5 million dollars, plus additional insurance if required. All the RNFAs that I know of in Ontario who are working have this coverage at the 3 - 5 million level.

It costs about $300 per year, plus your RNAO membership fee. As any lawyer will tell you, you can never have enough insurance. Generally they recommend that you have insurance separate from that of the hospital. Should both the hospital and RNFA be named in a suit, you can guess whose interests the hospital is going to be focused on .... not the RNFA.


Can the scrub nurse act as an assistant to the surgeon?

No. The College of Nurses of Ontario clearly states that acting as a first assistant to the surgeon is beyond the scope and education of a scrub nurse.

"It is consistent with the scope of practice model of the Regulated Health Professions Act that nurses who have the necessary additional education and demonstrate the competencies required for the role may practice in extended or expanded roles. No additional regulatory or legislative authority is required for nurses to practice in the role of surgical first assistant.

It is very important that nurses wishing to practice in the RNFA role recognize that additional expertise and education are required. The depth and breaddh of knowledge and skill is beyond that which is developed through years of experience in the scrub nurse role. The additional knowledge, skill and decision making abilities required for the RNFA role can be achieved through a formal first assistant educational program that includes a surgeon-mentored clinical component. Any nurse acting as first assistant is accountable for her/his own practice and competence." (Communique, June 2000, page 37).


Can the name, RNFA be changed?

The name, RNFA originated in the U.S.A. and has been utilized for the past two decades. It is a term that most perioperative nurses recognize internationally. ORNAC originally coined the phrase Perioperative Nurse - Surgery (PNS), which people found confusing. The name PNS gave no one any idea of what the role entailed. In order to further the role (name recognition), the term RNFA was adopted by ORNAC in 1999.

Reference: Groetzsch, Grace (1998). What's In A Name? A Canadian RNFA's Perspective. Canadian Operating Room Nursing Journal 16(1), 29-30.


Do nursing staff accept this role? Is there any resentment?

Nursing generally looks on the role as positive, although there are always exceptions. A RNFA helps all health care team members, which includes the scrub and circulating nurses. It's an extra pair of educated hands for nursing. And generally, you don't have to go hunting e.g. page them/track them down, for a RNFA - she/he is there and willing to work.


Does the RNFA report to nursing or medicine?

It depends on the model the hospital adopts. In my situation, I have a dual reporting mechanism to both nursing and medicine.


I am an American educated RNFA. Is the American program acceptable if I wish to work in Ontario?

In most instances yes. The RNFA program needs to be one that is offered by an accredited educational institution and you need a letter of completion or certificate. There are several of us who are American educated in Ontario. We completed the program prior to any Canadian RNFA programs being available. Ultimately, however, you need to verify this information with the hospital where you would like to gain employment.


What are some of the challenges for the role?

The major impediment to more RNFA positions, is lack of funding. Hospitals traditionally have not had to pay for surgical assistants. Thus those who have implemented RNFA positions have recognized that there are not enough physician assistants and in order for surgery to occur, RNFA positions are a necessity. No one likes to cancel surgeries. Another issue that hospitals are facing, is the 'aging' physician assistant. Demographics show that not only will nurses be retiring en masse in the next 10 - 15 years, so will physicians.

One of the challenges that a working RNFA has, is working the long hours required of the position - physically and mentally it can be very tiring. Some days there just isn't enough of you to go around. With creative scheduling and flexibility this can, however, be managed.


I am looking at hiring an RNFA. What type of technical questions should I ask during the interview process?

Technical aspects of the job can be learned by most RNFAs. Probably what is more important is finding individuals who have a strong work ethic and a personality that is compatible with the rest of the team. You do not want anyone who thinks that they are better than everyone else, nor someone who has forgotten that they are a nurse. You want someone who is keen to learn and can cope with difficult situations. You also want someone, who is smart, can see the big picture e.g. is not tunnel 'visioned' and fully understands their scope of practice.

There are some individuals who are professionally committed to being an RNFA. They belong to RNAO, they have additional liability insurance as a RNFA (NurseInsure through RNAO), they belong to their regional OR group and they actively participate in the ORNAO RNFA Interest Group.

What makes a good RNFA?

  • Member of local perioperative group
  • Registered Nurses Association of Ontario member
  • Excellent communication skills
  • Excellent critical thinking skills
  • Able to deal with uncertainty in a mature, quiet manner
  • Flexible in their approach to things
  • Interested in the entire spectrum of the RNFA role - are just not interested in learning to suture
  • Professional in all their work dealings
  • Has the ability to get along with all personality types
  • Articulate - in both the spoken and written word
  • Intelligent, but has common sense
  • Good manual dexterity and hand-eye coordination
  • Able to remain calm in stressful situations
  • A sense of humour