Regulatory Issues/Scope of Practice

The College of Nurses of Ontario (www.cno.org) acknowledged the RNFA to be within the scope of nursing practice in July 1999. In the June 2000 Communique this was communicated to all nurses in Ontario in the column entitled ‘You Asked Us: Can RNs act as surgical first assistants?’

“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 breadth 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.” (Page 37)

The College of Nurses of Ontario governs RNFAs as registered nurses via the Regulated Health Professions Act, 1991 (RHPA) and the Nursing Act, 1991.

Nurses are authorized to perform three (3) of the 13 controlled acts outlined by the RHPA. A controlled act is one that is considered to be potentially harmful if performed by unqualified persons. The controlled acts that nursing has authorization for are:

· Performing a prescribed procedure below the dermis;
· Administering a substance by injection or inhalation; and
· Putting an instrument, hand or finger beyond a body orifice or artificial opening to the body.

Almost all of the unique RNFA intra-operative behaviours (handling tissue, providing exposure, using instruments, suturing and parts of hemostasis) are covered by access to the above listed controlled acts.

What is NOT covered, is use of electrosurgery. The controlled act of ‘applying or ordering the application of a form of energy prescribed by the regulations under this Act’ is not one that nursing is directly authorized to perform.

A medical directive is required in order for a RNFA in Ontario to utilize electrosurgery. A medical directive must be written and is usually approved of by the Medical Advisory Committee (MAC) of a hospital.

The following is an example from Trillium Health Centre, Mississauga, Ontario:


Trillium Health Centre Delegated Controlled Act
Registered Nurse Flrst Assistant (RNFA)

Delegated Controlled Act:
Cauterizing Blood Vessels During Cardiac Surgery

Goal of Designated Act:
· To stop bleeding from blood vessels during surgery.

Description of Medical Directive:
The RNFA identifies the indication for and skilfully applies clectrosurgery to blood vessels minimizing necrosis to surrounding tissues

Indications/Clinical Criteria:
· Bleeding from blood vessels in the operative field are identified

Contra-indications:
· Absence of bleeding from blood vessels in the operative field

Resources available to manage potential complications:
The RNFA performs use of electrosurgery only in the presence of the surgical team who is immediately available to manage any potential complications

Required Documentation:
Specific documentation concerning electrosurgery during surgery is not required. The RNFA is listed on the operating room record as a surgical assistant. Any complications associated with electrosurgery by the RNFA are documented in the operative note by the surgeon.

Tracking, Monitoring and Evaluation Plan:
The RNFA evaluates the effectiveness of electrosurgery at the time of application and continues as necessary to control bleeding during surgery. The RNFA receives feedback from the operating surgeon as to the adequacy of electrosurgery and extent of tissue damage during each case.

Education Plan:
The RNFA successfully completes a recognized educational program, which prepares the registered nurse for the role of the RNFA. This educational program provides the RNFA with the necessary knowledge, skills and judgement to perform electrosurgery to blood vessels during surgery. Each RNFA is responsible for identifying their own learning needs related to performing this delegated controlled act and for developing a learning plan to meet these needs.

Communication Plan:
Prior to approval of this delegated controlled act, the cardiac surgery RNFA will meet with key administrative individuals and nursing / physician groups. Processes and implications of implementing this delegated controlled act will be discussed and reviewed.

Electrosurgery Skills Checklist: Cauterization
Verbalizes understanding of principles of performing safe effective use of electrosurgery.
Correctly identifies bleeding areas in the operative field
Applies just enough electrosurgery to control bleeding
Protects the surrounding tissue while utilizing electrosurgery


REFERENCES:
College of Nurses of Ontario (2000). The Regulated Health Professions Act, Part A: An Overview for Nurses for Registered Nurses and Registered Practical Nurses in Ontario.

College of Nurses of Ontario (2000). The Regulated Health Professions Act, Part B: Scope of Practice, Controlled Acts Model for Registered Nurses and Registered Practical Nurses in Ontario

College of Nurses of Ontario (2000). When, Why and How to Use Medical Directives for Registered Nurses and Registered Practical Nurses in Ontario.

Rodgers, Sylvia (2000). “You Asked Us: Can RNs act as surgical first assistants?” College of Nurses of Ontario Communique, June 2000, page 37.