Career Guide: Registered Nurse First Assistant (RNFA)

    June 4, 2018
    Nurse handing doctor medical tools during surgery

    Interested in learning more about becoming an RNFA? Find out what a Registered Nurse First Assistant is, what their duties are, how much they make, and how to become one in this comprehensive career guide. 

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    Part One What is a Registered Nurse First Assistant (RNFA)?

    A Registered Nurse First Assistant, or RNFA, is a perioperative registered nurse that functions as a first assistant during surgical operations. 

    According to the Association of periOperative Registered Nurses (AORN), an RNFA is defined by the following: 

    • works in collaboration with the surgeon and other healthcare team members to achieve optimal patient outcomes;  
    • has acquired the necessary knowledge, judgment, and skills specific to the expanded role of RNFA clinical practice;  
    • intraoperatively practices at the direction of the surgeon; and  
    • does not concurrently function as a scrub person. 

    The aforementioned definition is the standard to which RNFA’s practice and allows these individuals to practice beyond the normal scope of practice. First Assistants are required to take advanced coursework, additional certifications, and orientation in order to be credentialed.

    Part Two What Does an RNFA do?

    The role of the RNFA will vary on the surgical institution and will also vary depending on the surgeon. It’s important to know that many academic teaching hospitals do not regularly use RNFAs due to the presence of surgical residents and fellows. After obtaining credentialing, a First Assistant can perform duties during the preoperative, intraoperative, and postoperative care. These nurses have the ability to help develop treatment plans in conjunction with the lead surgeons and then assist in postoperative management. While nurses can generally perform similar tasks, the real differences are their increased abilities in the operating room. 

    RNFA Duties

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

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    Part Three Registered Nurse First Assistant (RNFA) Salary

    According to, the average salary for an RNFA is $117,000 per year. Unfortunately, due to the specialization of this field salary data is extremely limited. The U.S. Bureau of Labor Statistics provides salary figures for all registered nurses combined rather than for particular specializations. As of May 2019, the average annual salary was $75,510.

    The BLS identifies the following as the highest paying states for nursing:

    State Hourly Mean Wage Annual Mean Wage


    Hawaii $47.16 $98,080
    District of Columbia $44.40 $92,350
    Massachusetts $44.30 $92,140
    Oregon $43.79 $91,080

    In the same year, the BLS ranked the highest mean annual salaries for nurses, and the top ten were in California. The top five from the list are as follows:

    Metropolitan Area Hourly Mean Wage Annual Mean Wage (2)
    Salinas, CA $63.32 $131,710
    San Fransico-Oakland0Hayward, CA $62.01 $128,990
    San Jose-Sunnyvale-Santa Clara, CA $61.83 $128,610
    Santa Cruz-Watsonville, CA $61.27 $127,440
    Sacramento-Roseville-Arden-Arcade, CA $57.95 $120,530

    Most health care systems pay nurses on an hourly scale while others have a fixed annual salary, such as nurses in a free-standing surgical center. Those paid on an hourly scale are able to earn overtime pay whereas salary employees would need to discuss that with the hiring committee. 

    Overall, pay generally correlates with cost of living for a specific geographical area. As indicated above, nurses in Oklahoma earn significantly less than their counterparts on the west coast regardless of specialization. Despite having the same job title, the cost of living in California is much higher and thus equaling a greater pay. 

    As with all jobs in the nursing field, earning potential increases with additional education and experience. Nurses typically are awarded a raise during annual employee performance reviews. Certifications can give nurses an additional bump in their paycheck. Furthermore, nurses who agree to precept new nurse employees can also receive additional compensation. 

    Regardless of the workplace setting, full time and part-time RNFA  enjoy similar benefits. While actual benefits may vary depending on the institution most include the following:

    • Health insurance 
    • Retirement Options
    • Family Leave of Absence
    • Maternity Leave
    • Dental Insurance
    • Vision Insurance
    • Discounts
    • AORN membership benefits
    • Tuition Reimbursement
    • Attendance at nursing conferences

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    Part Four How to Become an RNFA

    To become an RNFA, first, the nurse must have substantial perioperative experience as this advanced training builds upon the basic fundamentals and focuses on surgical anatomy, procedures, and techniques. Courses vary throughout the country in regard to credit hours needed in order to work as an RNFA. Prerequisites also vary on the institution but generally consist of:

    • Active RN license
    • At least two years of perioperative nursing experience
    • Certified Nurse Operating Room (CNOR) designation, offered by the Competency and Credentialing Institute (CCI)

    Regardless of the program chosen it must be approved by the AORN. You can see a list of approved programs here. After successfully finishing the RNFA courses, individuals should work towards becoming certified. It is important to clarify there is a difference between an RNFA and a CRNFA. 

    To become a certified RNFA, the nurse must have a CNOR certification, active and unencumbered RN license, a bachelor’s degree as well as 2,000 hours of experience working as an RNFA. 

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    Part Five RNFA Career Outlook

    With the increasing number of same-day surgery centers opening across the country, the need for RNFAs will steadily continue to grow. Furthermore, a larger number of medical and surgical organizations are recognizing the role and importance of the RNFA. A few of these organizations include:

    • American College of Surgeons
    • American Academy of Ophthalmology
    • American Academy of Orthopaedic Surgeons
    • American Academy of Otolaryngology – Head and Neck Surgery
    • American Association of Neurological Surgeons
    • American Pediatric Surgical Association
    • American Society of Colon and Rectal Surgeons
    • American Society of Plastic Surgeons
    • American Society of Transplant Surgeons
    • American Urological Association
    • Congress of Neurological Surgeons
    • Society for Surgical Oncology
    • Society for Vascular Surgery
    • Society of American Gastrointestinal Endoscopic Surgeons
    • The American College of Obstetricians and Gynecologists
    • The Society of Thoracic Surgeons

    Part Six Where to Learn More About Becoming an RNFA

    The best resource for nurses wanting to pursue an RNFA certification should turn to the Association of Perioperative Registered Nurses website. Here individuals can find a list of schools that offer the program, information regarding job opportunities, and educational material. 

    Another helpful resource is the website for the Competency and Credentialing Institute. Nurses can find information regarding additional certifications and credentialing. 

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