How to Become a Registered Nurse First Assistant (RNFA)

10 Min Read Published February 2, 2024

Registered nurse first assistants (RNFAs) are perioperative nurses who play a significant role in aiding surgeons in the operating room. Read this guide to learn what it takes to join this elite nursing specialty, including schooling, certifications, and salary expectations.

How to become an RNFA

Registered Nurse First Assistant (RNFA) Fast Facts

Annual Salary


Career Outlook

6% Growth 2022-2032

Program Length

1-3 Years

What is an 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.

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    What Does an RNFA do?

    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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    Registered Nurse First Assistant (RNFA) Salary

    The average annual RNFA salary is $110,000 or $40.22 per hour, as reported by Payscale in August 2023. Similarly, a report by ZipRecruiter in January 2024 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 $81,220 annually per the BLS.

    Highest-Paying RNFA States

    State Annual Income Hourly Wage
    New Jersey $125,457 $60.32
    Wisconsin $122,520 $58.90
    Alaska $119,487 $57.45
    Massachusetts $119,325 $57.37
    Oregon $118,941 $57.18

    Source: ZipRecruiter, Extracted Feb 1, 2024

    Highest Paying RNFA Cities

    State Annual Income Hourly Wage
    Santa Cruz, CA $142,931 $68.72
    Sunnyvale, CA $140,360 $67.48
    Livermore, CA $140,286 $67.45
    Arlington, VA $139,653 $67.14
    St. Helens, OR $136,372 $65.56

    Source: ZipRecruiter, Extracted Feb 1, 2024

    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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    How to Become an RNFA

    The total time it takes to become a registered nurse first assistant ranges from six to nine years. This timeline includes your initial education and registered nursing licensure, two years of relevant experience, an RNFA program, and certification. 

    The following is a detailed breakdown of what it takes to become an RNFA:

    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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    Top 10 Registered Nurse First Assistant Programs

    To help you find a program that suits your needs, our nurse panel ranked the ten best RNFA programs based on'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

    • Reputation

    • NCLEX pass rate
    • Acceptance rate

    • AORN approval
    • Tuition

    • Online availability

     Nurse Panel

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

    Delaware County Community College's RNFA program is based in the township of Marple, located just outside of Philadelphia. This six-credit program combines online and in-person education, splitting the two required courses over two semesters. The first-semester course requires a five-day visit to campus, and the rest is completed online. The second-semester course is an independent internship completed wherever the student wants. Nurses can accelerate the internship, and they graduate once the internship is finished. 

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    One of the more comprehensive RNFA programs is offered by NIFA, a Colorado-based organization that focuses solely on first assisting education. Currently, the largest RNFA program in the nation, NIFA uses three- and five-day workshops to teach nurses basic RNFA skills and requirements. Nurses then complete an internship to finish the program. Any graduates who feel they haven't mastered the subject matter can take the program again at no cost. While the program takes up to two years, most students graduate in 5-8 months.

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    Located in Edgewood, Kentucky, St. Elizabeth Healthcare is a local leader in medical services. The healthcare center's RNFA program, offered in conjunction with Northern Kentucky University, begins with a five-day face-to-face experience in Northern Kentucky. Next, students begin a clinical internship worth at least 130 hours. Upon finishing the program, students earn six college credits from NKU and a certificate of completion. Many students finish this program in just one semester. 

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    Gulf Coast State College, located in Panama City, Florida, is intended specifically for RNs who want a fast track to the surgical department. Like most RNFA programs, Gulf Coast's program blends online learning with on-campus education and takes roughly two semesters to complete. Students can choose to either complete their clinicals in their hometown or gain clinical experience on-site in Florida. Graduates of this program enjoy a 100% RNFA job placement rate. 

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    Created for APRNS or certified operating room nurses (CNOR), the University of Rochester's RNFA program sets relatively strict admission requirements. However, the university offers flexibility in how students complete the program. First, students complete courses from a distance, and courses fit around nurses' schedules. Next, nurses attend an in-person lab day. Finally, students complete a 50-hour internship in the state where they hold their RN license. While the program takes 2-3 semesters, most nurses study part-time. 

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    Created for both RNs and APRNs, the University of Tennessee's RNFA program requires three courses completed over a year. The first two courses, completed during the fall and spring semesters, are both online, except for a 40-hour on-campus workshop during the first course. The third course requires 180 clinical hours in perioperative practicum. As with most programs, students complete their internships in their home state or at the University of Tennessee's campus in Memphis. 

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    The University of Massachusetts' RNFA program is in collaboration with UMass Chan Medical School and is open to BSN-prepared RNs with a CNOR, advanced practice nurses, or students who are currently in an advanced practice graduate program.  There are two required courses. The first course uses a hybrid format, teaching three live classes in person on Saturdays in Worcester, Massachusetts. The second course is essentially an internship requiring students to complete 270 precepted hours, allowing nurses to gain clinical experience. While most students can finish this program in just two semesters, some may take more time on their internship.

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    Unlike other RNFA programs, the University of Alabama at Birmingham offers its RNFA option as an MSN subspecialty; however, BSN-prepared nurses must have their CNOR at the time of application. The RNFA subspecialty requires three courses, one of which consists only of clinical experience. Admission is limited to fall entry only for this program. 

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    The University of California Los Angeles offers an RNFA program for current RNs and APRNs. The program begins with a six-day, 52-hour course completed at UCLA. Next, students must complete a 120-hour independent preceptorship. However, students must set up their own preceptorships, and UCLA sets preceptorship requirements during the program's first course. Any APRNs who do not have two years of operating room experience can sign up for a one-day program to prepare them for the RNFA program. 

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    Located in Cottleville, Missouri, St. Charles Community College begins its six-credit RNFA program with six days of on-campus study. Next, students complete a three-credit internship program to gain clinical experience. This internship must consist of at least 120 hours, though students can complete it wherever they want. Note that St. Charles Community College only accepts students who completed a BSN. 

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    Where Can RNFAs Work?

    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.

    RNFA Career Outlook

    From 2022 to 2032, the registered nursing field will grow at a rate of 6%, according to the BLS, which is twice the average for all occupations. 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:

    • American College of Surgeons

    • 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

    • Congress of Neurological Surgeons

    • Society for Surgical Oncology

    • Society for Vascular Surgery

    • Society of American Gastrointestinal Endoscopic Surgeons

    • The Society of Thoracic Surgeons

    Where to Learn More About Becoming an RNFA

    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.

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