How to Become a Registered Nurse First Assistant (RNFA)

An RNFA is a perioperative registered nurse who functions as a first assistant during surgical operations. They collaborate with the surgeon and healthcare team members to improve patient outcomes.

The Association of Perioperative Registered Nurses (AORN) notes that RNFAs practice intraoperatively at a surgeon's direction while not concurrently functioning as scrub nurses.

RNFAs must earn additional education and credentials that certify their ability to perform in this expanded role. To become an RNFA, you'll take advanced coursework, earn certifications, and undergo an extensive training process.

RNFA roles and responsibilities vary depending on their workplace and the surgeons they work with. An RNFA nurse performs preoperative, intraoperative, and postoperative care beyond the scope of an OR nurse. Working at the immediate direction of the surgeon, an RNFA helps develop treatment plans, perform advanced intraoperative tasks, and assist in post-op management.

RNFA Duties

RNFAs and scrub nurses perform similar tasks, but the real difference is an RNFA's increased abilities in the operating room. Some advanced intraoperative RNFA duties include the following:

• Using instruments and medical devices
• Providing surgical site exposure
• Handling and/or cutting tissue 
• Providing hemostasis
• Suturing
• Wound management

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The average annual RNFA salary is $125,000 per year, as reported by Payscale in 2025. Similarly, a report by ZipRecruiter in May 2025 found that RNFAs earn $113,214 per year or $54 per hour in the United States. 

These reports suggest that RNFAs earn far more than the average for all registered nurses, which is $93,600 per year, $45.00 per hour annually per the BLS.

Highest-Paying RNFA States

State	Annual Salary	Hourly Wage
Washington	128,226.00	$61.65
District of Columbia	127,935.00	$61.51
New York	$123,860	$59.55
Massachusetts	$123,643	$59.44
Newfoundland	$122,495	$58.89

Source: ZipRecruiter, Extracted May 2025

RNFA Salary Considerations

Some RNFA jobs pay an hourly wage, while others pay an annual salary. Those who work hourly jobs have the opportunity to accrue overtime, which can increase their annual income. Salary workers may be able to negotiate overtime but don't always get it.

Additionally, salary is just one of several factors to consider when deciding on a job. The full compensation package includes non-monetary benefits that may be just as important as the pay itself. The benefits you receive will vary from employer to employer but may include the following:

• Health, dental, and vision insurance 
• Retirement plans
• Maternity and paternity leave
• Paid time off and paid holidays
• AORN membership benefits
• Tuition reimbursement
• Attendance at nursing conferences

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1. Become a Registered Nurse

Becoming an RNFA starts with earning your registered nursing license. You can achieve this milestone by attending an accredited Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) program. Then, you'll sit the National Council Licensure Examination for RNs (NCLEX -RN) to earn your registered nursing license.

Several RNFA programs require a bachelor's degree in any field, making it easier for ADN-RNs with previous degrees to become eligible. Others may need to take additional coursework to earn a bachelor's or attend an RN to BSN program before applying to an RNFA program.

2. Gain Experience & Perioperative Nursing Certifications

On-the-job training programs will get your foot in the door of surgical nursing. From there, you'll build the foundation of knowledge necessary to become an RNFA, earning hands-on experience completing pre-, intra-, and post-surgical tasks. 

RNFA programs require at least two years of this vital and relevant nursing experience. It will also qualify you for the Certified Perioperative Nurse (CNOR) exam, which is a required credential for most RNFA schools.

3. Attend an RNFA Program

RNFA schooling builds upon the basic fundamentals and focuses on surgical anatomy, procedures, and techniques. These programs vary in length from one to three years, with different course requirements at each institution. To get into most RNFA programs, you'll need at least:

• An active and unencumbered RN license
• Two years of perioperative nursing experience
• The CNOR designation

Most importantly, you should ensure the program you select is approved by the AORN. You can view a list of approved programs here.

4. Earn RNFA Certifications

You can work as an RNFA without a certification. However, earning one affirms your education and professional achievements and endorses your dedication to patient safety and care. The National Assistant at Surgery Certification (NASC) is the certifying body for RNFAs and offers two credentials.

Registered Nurse Assistant at Surgery – Certified (RNAS-C)

RNAS-C is a lower-level certification for newer RNFAs. This certification does not require a bachelor's degree but does require at least 120 practice hours, the CNOR designation, and current RN licensure. Learn more about RNAS-C requirements here.

Certified Registered First Nurse Assistant (CRNFA)

CRNFA is an advanced credential for experienced RNFAs. To become a CRNFA, you need a bachelor's degree, current RN licensure, CNOR designation, and at least 2,000 RNFA practice hours. You can find other certification requirements here.

>> Explore RNFA Certification Review Materials* 

As a CRNFA, you'll be a more competitive job candidate and have more leverage in salary negotiations. So, while the certification isn't necessary, it's highly valuable and recommended.

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To help you find a program that suits your needs, our nurse panel ranked the ten best RNFA programs based on Nurse.org's proprietary ranking methodology.

Because individual nursing pathways and careers take various forms, the top 10 registered nurse first assistant programs are ranked in no particular order.

Ranking Factors

 Nurse Panel

• Tracy Everhart, MSN, RN, CNS
• Tyler Faust, MSN, RN
• Kathleen Gaines, MSN, BSN, RN, BA, CBC

 

 

 

 

 

 

 

 

As a registered nurse first assistant, you can work at any surgical facility. These include hospitals, surgery centers, plastic surgery centers, and more. Dental offices, delivery rooms, and postoperative care units also benefit from an RNFA's skillset.

Notably, academic teaching hospitals do not regularly use RNFAs due to the presence of surgical residents and fellows.

According to the BLS, there's a predicted 6% (Faster than average) growth rate for RNs over the next decade. This figure includes perioperative nurses like RNFAs, showing a promising outlook for this specialty. 

Other factors that indicate a growing need for RNFAs include the increasing number of same-day surgery centers and more medical and surgical organizations recognizing RNFA roles. These organizations include the following:

Whether you're just beginning your nursing journey or already have some experience under your belt, becoming an RNFA is within your reach. Browse the following resources to learn more about joining this exciting and vital career field.

• For RNFA Program Information: Association of periOperative Registered Nurses
• For CNOR Certification: Competency and Credentialing Institute
• For RNAS-C and CRNFA Certification: National Assistant at Surgery Certification

 

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$70,000 - $90,000 Perioperative Bedside RN