Regulating first assistants

AORN Journal,  August, 2004  by Frederick P. Franko

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Whereas the "health policy issues" column in the June 2004 issue of the AORN Journal describes in very general terms various groups providing first assisting services, this article sheds further light on the first assistant role and the legal environment that allows a number of different individuals to practice in this role. Additionally, this article poses questions that OR supervisors and circulating RNs should seek to answer, such as the following.

* Has the state board of nursing issued any guidance statements regarding the RN first assistant (RNFA)?

* Are there individual state laws or regulations pertaining to RNs practicing as first assistants?

* What do the medical practice acts and medical regulations say about physicians delegating medical tasks in the OR?

* What do individual states' laws, regulations, or board statements say about the use of unlicensed personnel as first assistants?

OPINIONS FROM STATE BOARDS OF NURSING

Throughout the 1980s and into the early 1990s, AORN periodically surveyed state boards of nursing regarding their positions on RN first assisting. Eventually, through education, communication, and influence, the practice of first assisting was recognized as being within the scope of nursing in all 50 states.

Most states do not have laws or regulations pertaining to RNFAs, but a number of state boards of nursing have issued some type of opinion regarding RNFAs. States have different names for these opinions, including advisory statements, position statements, policy statements, and advisory rulings. Board opinions usually are issued in response to a specific inquiry from a nurse. The opinion can be broad, such as the following advisory opinion on RNFAs issued by the Arizona State Board of Nursing.

   The Board of Nursing endorses the
   1998 AORN official statement on
   RN First Assistants.
   The institutions where
   the RN First Assistant
   will function are to
   delineate the parameters
   of actions allowed to be
   performed by the professional
   nurse. Once having
   met the educational
   and experiential requirements,
   the RNFA
   is encouraged to achieve
   and maintain certification
   (CRNFA) for this
   specific role. (1)

Other boards go beyond stating that first assisting is within the scope of practice of the RN and provide some level of detail as to what is within the RN's scope of practice. Considerably more extensive than the Arizona State Board of Nursing's opinion is the statement issued by the California Board of Registered Nursing, titled, "The RN as first assistant to the surgeon." The statement provides a list of technical functions that an RNFA may perform but notes that the statement and list are guidelines and

   should not preclude the performance
   of other duties which, in the
   judgment of the surgeon, can be
   successfully accomplished by the
   RN First Assistant (2)

To address questions regarding the practice of the RN as first assistant, nurses first must determine whether their state's board of nursing has issued an opinion. In many cases, it appears on the board's web site.

LAWS AND REGULATIONS PERTAINING TO RNs PRACTICING AS FIRST ASSISTANTS

The 10 states that require some type of reimbursement for the services of RNFAs are Florida, Georgia, Louisiana, Kentucky, Maine, Minnesota, Rhode Island, Texas, Washington, and West Virginia. These states offer definitions of the RNFA in the law and regulations and cite qualifications necessary for RNFAs to receive reimbursement.

For example, Louisiana's 2003 Senate Bill 138 (ie, Act number 190) offers the following definition of the RNFA:

   (3) "Registered nurse first
   assistant" or "RNFA"
   means a person who has
   met all of the following
   requirements: (a) is
   licensed as a registered
   nurse in accordance with
   state law; (b) is experienced
   in perioperative
   nursing; (c) has successfully
   completed a recognized
   program. (3)

MEDICAL PRACTICE ACT AND REGULATIONS

In most states, physicians have broad authority to delegate certain tasks to personnel supervised by the licensed physician. These statutes and regulations give a physician in the OR the authority to delegate to an individual in the first assistant role. For example, the Code of Virginia states in section 54.1-2901,

   The provisions of this
   chapter shall not prevent
   or prohibit:

   6. Any practitioner
   licensed or certified by the
   Board from delegating to
   personnel supervised by
   him, such activities or
   functions as are nondiscretionary
   and do not require
   the exercise of professional
   judgment for their performance
   and which are
   usually or customarily delegated
   to such persons by
   practitioners of the healing
   arts, if such activities or
   functions are authorized
   by and performed for such
   practitioners of the healing
   arts and responsibility for
   such activities or functions
   is assumed by such practitioners
   of the healing arts. (4)