|A Canadian Perspective
During the Crimean War of 1854, Florence Nightingale and her staff of "nurses" were called to care for the sick and injured in the Barrack Hospital in Turkey. As part of this care, the nurses prepared wounds for surgery, assisted during the procedure and maintained the surgical site post-operatively to prevent infection and promote healing.
Many of the measures instituted by Nightingale and her colleagues, became the basis for aseptic and sterile technique in and out of the operating theater. The role of the nurse was a holistic one and included what we now recognize as pre-operative assessment and preparation of the patient, intra-operative assistance and post-operative evaluation.
During the evolution of formalized Schools of Nursing during the early and mid 1900's, it was an accepted and expected practice for graduate nurses to assist in surgery. Nurses were instructed (by nursing instructors and literature) in the use of surgical instruments, hemostasis, and surgical knot tying. This practice continued on into the 1960's.
The term Registered Nurse First Assistant commonly referred to as a RN First Assistant or RNFA stems from the United States. The Association of periOperative Registered Nurses (AORN) formally recognized the role in 1982 and Delaware County Community College, under the leadership of Jane Rothrock, offered the first formal RNFA program in 1985.
Unlike the United States of America, Canada appears to have little formal history of nurses functioning in a RN first assistant role prior to the 1990's. Differences in health care funding practices and participation in five major wars in the 2000 century has necessitated, and allowed American nurses to function in the role of RN first assistant for numerous decades.
The Operating Nurses Association of Canada (ORNAC) in April 1992 initiated a project to investigate expanded role opportunities for perioperative nurses (Stephens, 1993). Ongoing personnel and fiscal changes within the perioperative environment provided the impetus to clearly articulate the current and future roles of perioperative nurses. Results of a surgery indicated that the majority of respondents felt that the first assistant role was an appropriate role for the perioperative nurse to assume with advanced educational preparation.
In April 1994 ORNAC ratified the following definition of Perioperative Nursing Practice - Surgery:
The operating room registered nurse practices advanced perioperative nursing in surgery. The increasing complexity of surgery compels a higher level of expertise than was previously required of the scrub nurse. The operating room nurse with advanced perioperative nursing education functions collaboratively with the surgeon during the preoperative, intraoperative and postoperative phases, relating to the surgical intervention(p. 4).In 1994, ORNAC established a seven member "Advanced Practice" Committee whose, focus was specifically the Perioperative Nurse - Surgery (PNS) and Perioperative Nurse - Anaesthesia(PNA) roles. The Advanced Practice Committee(ORNAC 1996) developed a blueprint for PNS curriculum development and defined the Perioperative Nurse Surgery as:
"The registered nurse with advanced perioperative nursing education and skills provides assistance during the surgical intervention under the direction of the surgeon. This role has separate responsibilities to that of the scrub role. The PNS collaborates with the surgical team to coordinate the care of the client throughout the perioperative period. This new perioperative role requires a different body of knowledge and skills than was previously required of the scrub nurse. PNS practice may vary depending on patient populations, practice environments, services provided, accessibility of human and fiscal resources, institutional policy and provincial regulations of nursing practice"(p. 17).An informal survey conducted by Groetzsch in 1997 identified individuals acting in the role of RN first assistant in various geographical regions in Canada.
The first Canadian province/territory to formally recognize the RN first assistant role was Quebec in September 1994. Informal lobbying began in 1980(Perazzelli, 1997) with the first proposal brought forward in 1991 at the Annual Meeting of the Ordre des infirmieres et infirmiers du Quebec[OLLQ]. OLLQ (1995) developed and published a position paper entitled Perioperative Nursing Care: The Role of the Nurse First Assistant and concludes "that the role of nurse first assistant has a place in the evolving context of professional practice. It answers the community's health-care needs and meets the demands of the health and social services system in the province of Quebec"(p. 15). Original perquisites for consideration in the program included a minimum of five years of perioperative experience, experience in the appropriate surgical service as a scrub nurse, and certification in perioperative nursing from the Canadian Nurses' Association. As of September 1997, three years of perioperative experience will be adequate for entrance into a RNFA program. With a Bachelor's degree(complete or in process) two years of perioperative experience will suffice.
Although Quebec now endorsed the RN first assistant role, no training programs existed. To bridge the gap until a formalized program could be established in an educational institution, two nurses were trained by a cardiac surgeon at the Heart Institute of Montreal starting in early 1996.
Curriculum from the Heart Institute of Montreal(1995) was divided into three modules. The didactic portion of the course(186 hours) was heavily weighted towards the technical aspects of the intraoperative role. Preoperative and postoperative functions appeared to be minimal. Participation in 30 operative procedures with evaluation by the mentor surgeons resulted in successful completion of the third module. Nurses assumed the role of first assistant during single cardiac revascularizations and single valvular replacement procedures only. During complex procedures, the Professional Corporation of Physicians of Quebec stipulated that a medical assistant be in attendance(Daigle, 1996).
In September 1996 a plastic program was started at Ste. Justine, Montreal with two nurses enrolled. One nurse, however, left the program for family reasons. The plastic program involved 186 structured classroom and study hours, followed by 390 clinical hours, with a stipulated minimum number of specific plastic surgical cases.
The programs at the Heart Institute of Montreal and Ste. Justine were replaced by a RNFA program at the University of Trois-Rivieres which accepted the first 42 applicants in the fall of 1996 (Perazzelli, 1997).
1996 saw Newfoundland gain recognition for a RN first assistant program. The Newfoundland & Labrador Operating Room Nurses Association (N&LORNA) began lobbying the Association of Registered Nurses of Newfoundland(ARNN) in 1992. In 1995 a document was published which addressed the issue of advanced nursing practice and the need for nurses to take on expanded roles. No position was maintained on the RN first assistant role by the ARNN until November 1996 at which time it positively endorsed the concept of registered nurses functioning as first assistants. The RNFA program is jointly offered by the Centre for Nursing Studies, and the Perioperative Program of the Health Care Corporation of St. John's, Newfoundland.
In Ontario, the College of Nurses of Ontario(CNO) was lobbied by members of the periOperatve Registered Nurses Association of Ontario(ORNAO) starting in 1993. In a letter to Tyndall(1995) the CNO acknowledged that the expectations within the preoperative and postoperative components of the Perioperative Nurse - Surgery role were within the scope of practice of nursing. Concern was expressed relating "to the overall accountability the nurse assumes when she/he formally functions in the "first assistant" role, than to the performance of specific procedures, such as cautery, suturing etc." (p.2). Through dialogue with the CNO by Groetzsch, their concerns were addressed and in 1999, the CNO acknowledged that the RNFA functioned within the scope of nursing practice.
Ward (1997) relates that the Orthopaedic & Arthritic Hospital, Toronto was founded in 1955 by two orthopaedic surgeons, Drs. Bateman and Wright. All operating room nurses were certified by Miss O'Connor, the Chief Nursing Officer, to first assistant at surgery. Operating room nurses routinely sutured, retracted and cauterized vessels until affiliation of the Department of Orthopaedic Surgery with the University of Toronto in 1981. With the introduction of additional orthopaedic surgeons, orthopaedic fellows, and the retirement of Dr. Bateman in 1983, nurses no longer were able to first assist.
The Toronto Western Hospital (Dale, 1996) introduced the concept of a registered nurse surgical assistant for cardiovascular surgery in 1981 receiving approval for the position, from nursing administration, for a "physician assistant" in 1983, just as the Orthopaedic & Arthritic Hospital was phasing out the use of nurses as assistants. A reduction in the number of surgical residency positions, an expansion of the cardiac program and the requirement for consistency in patient care was the impetus for the founding of this nursing position, physician assistant (p. 10). The physician assistant role at The Toronto Hospital, Western Division encompasses the preoperative, intraoperative and postoperative phases of a client's surgical experience, plus research activities. Preparation for the role has primarily been based on the apprentice model, with no formal educational preparation. In 1994 the role underwent a title change to "surgical assistant" in 1995 to avoid confusion with a nurse clinician role on the cardiac unit.
Groetzsch, who was educated as a RNFA via the program at Delaware County Community College, PA, US, obtained all her clinical hours within Canada and in 1997 became the first formally educated RNFA to obtain a full-time position with the cardiac surgeons at Sunnybrook Health Sciences Centre, Toronto, Ontario. Blaskovits, in Alberta likewise was educated as a RNFA, but was unable to obtain a RNFA position at this time.
Although first assisting in the Calgary region had not yet come to fruition, in January 1997 a RN Surgical Assistant program was implemented in nearby Edmonton. Application to the program was restricted to registered nurses employed in the operating room suite of the University of Alberta Hospital (1997). The program was limited in its didactic and clinical components to the intraoperative phase of surgery. Impetus for the program was surgeon driven as the number of surgical residency positions declined.
The Registered Nurses Association of British Columbia (RNABC) recognized the RNFA role as being within the scope of nursing practice in 1997 (Simon). The British Columbia Operating Room Nurses Group (BCORNG) began lobbying RNABC in 1991. BCORNG and the British Columbia Institute developed a business plan to bring a RNFA program to English speaking Canada and in 1998 curriculum development began. In 1999 a pilot RNFA program was started with 22 students. Currently the program accepts approximately 20 students from across the country annually. Revisions to the curriculum were made in the year 2002.
In 1996, the Saskatchewan Union of Nurses approached the Saskatchewan Registered Nurses Association(SRNA) regarding the RNFA role. SRNA was described by Farley (1997) as being silent, but supportive. RNFA practice would be covered under the current scope of nursing practice, but would require a legislative change to the Public Hospital Act. The act specified that only a physician could assist during surgery for reimbursement. The Saskatchewan Operating Room Nurses Association (SORNA) lobbied the government and a change to the Public Health Act occurred in 1999. SORNA set monies aside for a pilot project, which began in 2000 with two of BCIT's RNFA graduates.
The ORNAO RNFA Interest Group in Ontario was formally established in 2000. Prior to this, RNFAs and interested individuals met regularly to discuss issues relevant to RNFA practice. In 2001, this group became an associated interest group of the Registered Nurses Association of Ontario (RNAO). RNFA Fact Sheets have been developed in conjunction with RNAO and a relationship has been established with the nursing union, the Ontario Nurses' Association (ONA).ONA recognizes the RNFA role and several hospitals have successfully negotiated RNFA positions.
As of 2000, all provinces within Canada acknowledge that the RNFA role falls within the scope of nursing practice. Within Canada, the role of the RN as first assistant has thus come full circle and perioperative nurses with additional educated are being looked to as the most appropriate and best prepared member of the health care team to assume the role of first assistant at surgery. At the 2001 ORNAC meeting in Banff, Alberta during the RNFA information session an Ad Hoc committee was struck of RNFA representatives from most provinces. The objective of this committee is to seek affiliate status with ORNAC by the 2003 ORNAC conference in Winnipeg. In 2002 the committee re-named itself RNFA Network of Canada.
In 2000 the first officially recognized RNFA position was advertised for in The Globe and Mail newspaper by Trillium Health Centre,
At the 2001 ORNAC meeting in
The mission of the RNFA Network of Canada (RNFANC) is to advocate, promote and guide the Registered Nurse First Assistant (RNFA) as a unique and expanded peioperative nursing role in the pursuit of excellence in surgical patient care.
The vision of RNFANC is to establish and enhance a network of RNFAs across
The RNFANC's objectives are
More information on the RNFA Network of Canada can be found on the ORNAC website www.ornac.ca
The HealthForceOntario strategy has three components, the first one being to:
Create four new roles in areas of need
In 2007, the Ontario Ministry of Health and Long Term Care began funding 50% of RNFA positions in order to decrease wait times for orthopaedic surgery and evaluate the role for a two-year period. Round 1 funded organizations were able to start funding positions as of January 2007 but needed to be linked to high volume orthopaedic centres.
In Round 2 funded organizations, the 50% funding formula was effective
The funding is being monitored via the Nursing Secretariat's office of the Ontario MOHLTC. Only RNFAs are being funded through the HealthForceOntario strategy under the Surgical First Assist title.
In 1999 The Competency & Credentialing Institute (CCI) in the United Sates determined that the CNOR and CPN(C) certification exams were similar in content and focus. This was done by reviewing the eligibility requirements, competency statements, the test blueprint and recommended study materials. This allowed Groetzsch to obtain her certification as a CRNFA in 1999 with her CPN(C) certification.
In 2008, CCI received requests and clarification regarding one certification requirement listed in the "AORN Standards for RN First Assistant Education Programs." The standard for admission requirements to the program states: "The nurse must be CNOR or CNOR eligible and obtain the CNOR before program completion." In April 2008, CCI sent out communication to all the RNFA programs in the United States that meet specific criteria to be accepted by CCI as acceptable programs for CRNFA eligibility stating that the CPN(C) can be accepted in lieu of CNOR certification.
The BCIT RNFA program is currently the only RNFA program in
In the fall of 2008,