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Registered Nurse First Assistant Network of Canada (RNFANC)

Registered Nurse First Assist Competencies

Competency 1:

The registered nurse first assist (RNFA) is competent to apply the nursing process in all facets of the nurse first assist role.

Measurable Criteria:

Applies the nursing process in the RNFA role as the theoretical framework for patient care.

Examples:

• Possesses and applies expert knowledge of the principles of biological, physical, and behavioral sciences; clinical observation; and communication theory to contribute to the surgical patient’s optimal outcome.
• Evaluates each patient individually and determines appropriate application of knowledge and skills according to patient’s needs.

Measurable Criteria:

Conducts systematic, ongoing assessment of the patient’s health status throughout the perioperative experience.

Examples:

• Collects data from the appropriate multiple sources (eg, physician’s office, clinic, admissions system, operating room, post-anesthesia care unit [PACU]), continuing throughout the patient’s postoperative course. Recognizes the importance of chronic or concomitant diseases; malignancies; routine or preoperative prescribed, herbal, and over-the-counter medications; previous surgery or injuries; and/or preexisting infections that may affect the patient’s health status and the outcome of the planned surgical interventions and takes appropriate action.
• Performs an appropriate and focused nursing assessment based on the planned surgical intervention(s). Assesses for possible risk factors that may be present (eg, age, weight, nutritional status, developmental stage, medical history, diagnosis[es], laboratory values, immunological/hydration/perfusion status, comorbidity).
• Assesses patient’s intraoperatively for prevention or early detection of perioperative complications (eg, recognizes early symptoms of cardiac complications secondary to acid-based imbalance, cardiac dysfunction, cervical spine injury, electrolyte imbalance, anesthetic agents, medications, vagal stimulation, surgical manipulation). Monitors and assesses patient’s immediate postoperative status to determine progress toward expected outcomes or signs and symptoms of potential postoperative complications.

Measurable Criteria:

Formulates and modifies nursing diagnoses based on patient assessment throughout the perioperative continuum.

Examples:

• Synthesizes and interprets health assessment data to identify and prioritize patient health problems amenable to collaboratively prescribed intervention(s).
• Demonstrates ability to support nursing diagnoses with current scientific knowledge and/or research.
• Documents and communicates identified nursing diagnoses based on patient’s condition and clinical situation.
• Communicates changes in patient’s situation to appropriate members of the health care team as intervention progresses

Measurable Criteria:

Identifies and communicates desired patient outcomes.

Examples:

• Establishes individualized, realistic outcomes with patient based on the identified nursing diagnoses. Communicates patient’s goals to appropriate members of the health care team.
• Outcome statements specify measurable criteria for determining the relationship between nursing intervention and outcome achievement.

Measurable Criteria:

Develops an individualized plan of care that directs the intervention(s) of the RNFA.

Examples:

• Selects, analyzes, and interprets relevant assessment data to develop a plan of care that meets individual patient needs, is age specific, and reflects professionally recognized standards of care based on the nursing process.
• Addresses collaborative problems* and potential complications with physicians to achieve consensus regarding delegated medical functions and prescribed nursing interventions.
• Communicates RNFA plan of care with other members of the surgical team to achieve consistency of purpose and action during the intraoperative phase of care.

Measurable Criteria:

Implements and manages the perioperative plan of care consistent with RNFA practice.

Examples:

• Reviews and uses history, physical assessment, and preoperative test results to establish a physiologic baseline.
• In collaboration with the surgeon, anesthesia care provider, and other perioperative team members, initiates interventions efficiently, safely, and skillfully using sound clinical judgement.
• Provides knowledge-based technical assistance to the surgeon during the operative procedure according to licensure, provincial/territorial regulation, and facility/practice protocols. (See Competency 4 for intraoperative assisting knowledge and skills)
• Works closely with RN circulator, and scrub nurse (RN/LPN/RPN), collaborating with and participating in perioperative nursing interventions as appropriate.
• Serves as an information resource for RN circulator and scrub nurse (RN/LPN), and other member of the surgical team throughout the perioperative course by applying/sharing expert surgical knowledge of aseptic practice, hemostasis, tissue handling, wound healing, and surgeon’s preferences. Intervenes as appropriate to specific circumstance(s).
• Applies principles of problem solving in response to changes in the patient’s condition during any/all phase(s) of the surgical encounter. Modifies, communicates, and implements plan of care accordingly.
• Maintains flexibility and adaptability when emergencies or unanticipated events occur.
• Documents patient/family preoperative care and teaching, operative notes following surgical procedure, postoperative care/assessment, and discharge planning, as determined by guidelines of practice and institutional policy.

Measurable Criteria:

Evaluates the effect of RNFA/nursing interventions as part of the ongoing assessment process.

Examples:

• In collaboration with the patient, evaluates patient outcomes by comparing patient responses to nursing interventions, current practice standards, and anticipated outcomes.
• In collaboration with surgeon and other members of the perioperative team, evaluates personal surgical performance and patient outcomes.
• Attends postoperative visits in clinic to assess patient surgical outcomes (ie: wound healing).

Competency 2:

The RNFA is competent to exercise critical thinking skills in all aspects of the RNFA role.

Measurable Criteria:

Uses critical thinking theory in the application of nursing knowledge and perioperative patient care.

Examples:

• Analyzes and synthesizes as a means of approaching a situation, issue, or decision.
• Exercises analytical problem-solving techniques and sound principles of proficient decision making when encountering new situations.
• Bases critical thinking on previous experience and theoretical knowledge. Continuously builds acquired knowledge as a result of critical thinking.

Competency 3:

The RNFA is competent to establish and maintain a safe perioperative environment.

Measurable Criteria:

As a primary patient advocate is continually vigilant, using acquired and intuitive knowledge to anticipate, prevent, and/or respond to circumstances that could compromise the patient’s well-being.

Examples:

• Recognizes potential hazards and initiates preventive and/or corrective actions at any time throughout the perioperative continuum.
• Ensure safe, aseptic environment consistent with infection control principles and safe operating procedures.
• Transfers patient safely (eg, locks transport vehicle wheels; secures IV lines, catheters, feeding tubes; protects patient’s extremities during transfer; uses transfer devices as appropriate).
• In partnering with the surgeon, the RNFA directs, manages, and/or participates in positioning the anesthetized patient.
• In collaboration with the surgeon and anesthesia care provider, assumes accountability for positioning patient safely. Demonstrates expert knowledge of anatomy and physiology, safe positioning principles, and the function and correct use of positioning equipment to avoid circulatory and neurological compromise.
• Protects patient from thermal, electrical, chemical, and/or mechanical injury.

Measurable Criteria:

Is cognizant of and can recognize possible adverse reactions patient may experience during the surgical encounter.

Examples:

• Anticipates and assesses the effects of routine and preoperative pharmacological agents and herbal remedies. Intervenes as appropriate to the situation.
• Verifies patient allergies. Reviews, analyzes, and interprets information from the patient’s history and physical examination noting any intolerance that might signify an unsafe surgical encounter.

Measurable Criteria:

Accountable for verification of the correct surgical site.

Examples:

• Verifies site with patient, surgeon, and other members of surgical team.

Measurable Criteria:

Demonstrates knowledge of patient safety standards published by regulatory bodies.

Examples:

• Volunteers to participate in facility-wide safety programs. Seeks opportunities to promote patient safety as work ethic. Teaches colleagues. Models desired behaviors.

Competency 4:

The RNFA is competent to provide technical first assistance to the primary surgeon in the operating room and throughout the perioperative period.

Measurable Criteria:

Demonstrates clinical expertise.

Examples:

• Is familiar with proposed surgical procedures, surgeon's approach, and clinical anatomy. Recognizes anatomical abnormalities that may impact the surgical intervention.
• Applies cognitive and technical skills obtained throughout the continuum of basic nursing education, perioperative nursing education, and formal RNFA educational programs.

Measurable Criteria:

Possesses the essential mental discipline and fine motor skills to provide technical assistance to the surgeon.

Examples:

• Continually demonstrates attention to detail, thoroughness, stamina, continued competence of surgical assisting skills, and concentration during the surgical procedure.

Measurable Criteria:

Strictly adheres to principles of aseptic technique to prevent infection and promote optimal wound healing.

Examples:

• Demonstrates knowledge and command of principles of surgical asepsis.
• Creates and monitors sterile field. Identifies and corrects breaks in aseptic technique. Identifies and addresses factors that place the patient at risk for infections.

Measurable Criteria:

Accepts appropriate delegated restricted activities as defined within the RNFA scope of practice.

Examples:

• Performs preoperative activities as ordered by surgeon (eg, venipuncture for preoperative blood test.
• Initiates and performs intraoperative activities as directed by the surgeon.
• Monitors wound healing.

Measurable Criteria:

Uses surgical instruments to assist the surgeon and facilitate the surgical intervention.

Examples:

• Demonstrates thorough understanding of the underlying principles for using surgical instruments. Understands the design and use principles/action of surgical instruments used and the resultant effect on tissue.
• Demonstrates skill and manual dexterity in instrument use.

Measurable Criteria:

Handles tissue safely.

Examples:

• Employs principles of safe tissue handling. Handles tissues with a gentle touch to preserve neurovascular structures and promote wound healing.
• Applies knowledge regarding tissue response to injury, wound healing, and wound classification (ie, identifies and assesses risk factors that impair wound healing and/or encourage wound complications).
• Exercises independent clinical judgement when identifying specific types of tissue and selecting appropriate instrument(s) for handling that tissue (eg, muscle, fat, and most organ tissues are easily lacerated when clamped or pulled; skin, fascia, cartilage, ligament, and bone tissues are generally tough and may be handled with toothed tissue forceps or Kocker clamps).

Measurable Criteria:

Provides exposure of operative site to promote a safe and effective surgical procedure.

Examples:

• Exercises independent judgement in selecting and employing various methods to provide exposure of the surgical site, including patient positioning, use of retractors and other instruments, retraction sutures, and/or packing materials as dictated by procedural need.
• Selects, places, and moves proper retractor(s) to provide surgical site exposure and reduce tissue injury.
• Packs wound as appropriate.
• Suctions surgical site as necessary to remove smoke, blood, and fluids from the site to improve visualization and decrease biohazard exposure.

Measurable Criteria:

According to individual provincial/territorial regulation and facility policy, dissects tissue as delegated and supervised by the primary surgeon.

Examples:

• Under the direction of the operating surgeon, uses appropriate tissue dissection techniques to facilitate an optimum surgical outcome. For example, privileges may be granted to qualified RNFAs to perform specialized tissue handling, such as trocar placement, preparation of allografts, and saphenous vein harvesting.

Measurable Criteria:

According to individual provincial/territorial regulation and facility policy assists with and/or performs wound closure.

Examples:

• Uses suture and suturing techniques in a manner consistent with principles that promote wound healing.
• Differentiates one type of suture from another, having knowledge of the physical characteristics and biological responses to various suture materials.
• Selects appropriate suture material for the type of closure to be performed.
• Demonstrates proficiency in knot-tying techniques with consideration to knot security, suture selection, and tissue characteristics.
• Demonstrates proficiency in wound closure using a skin stapler.

Competency 5:

The RNFA is competent to work as a professional colleague with the physician and to enhance the effectiveness of patient care.

Measurable Criteria:

Partners with the physician to collaboratively direct the patient’s perioperative course.

Examples:

• Prepares the patient preoperatively for surgical intervention, performs intraoperative surgical assisting, and collaboratively manages the patient’s postoperative regimen.
• Understands and applies current theories and concepts of antimicrobial prophylaxis, ensuring that the appropriate medication is administered at the correct time to maximize effectiveness.
• Participates with physician in determining product use and/or therapies to be used.
• In collaboration with surgical team, directs and/or manages patient care activities during the intraoperative phase of care.
• Implements and directs (as appropriate) use of environmental control measures and standard/transmission-based precautions to prevent undue patient and provider exposure to and infection from bloodborne pathogens.
• Accepts appropriate responsibility if surgeon becomes incapacitated; protects the surgical wound, maintains hemostasis, and maintains sterility of the operative field until the replacement surgeon accepts responsibility for procedure completion.
• Makes postoperative rounds in conjunction with or at the direction of physician.
• Plans and/or collaborates, with other members of the health care team, for patient discharge, accessing community resources as appropriate.

Measurable Criteria:

Serves as educator, mentor, consultant, and resource to patients, colleagues, other heath care professionals, and the community.

Examples:

• Provides individualized patient and family education by applying principles of learning, actively involving the learner, and providing and environment conducive to teaching/learning.
• Consults effectively with the surgeon and other member of the health care team to promote efficient use of time, supplies, equipment, and personnel.
• Monitors emerging technology. Analyzes new products to determine risk/benefit for patients and the facility.
• Participates in and consults on facility and nursing committees, nursing associations, and medical/industry focus groups.
• Serves as a source of information, including procedural instruction and/or policies and procedures to both nursing colleagues and multidisciplinary students (ie: surgical procedure, urinary catheterization, wound closure, and use of various surgical equipment).
• Serves as a community resource to educate the public and promote quality patient care.
• Educates the public and other health care professionals about the role of the RNFA.

Competency 6:

The RNFA is competent to promote professionalism and to model professional behaviors to other health care providers.

Measurable Criteria:

Bases professional and practice behaviors on the knowledge and application of the scope of practice for the specific job category as defined by the provincial/territorial licensing bodies, professional practice standards, and facility guidelines to practice.

Examples:

• Possesses knowledge of and works within appropriate regulatory guidelines and legal constraints, exercising caution to not extend into the practice of medicine.
• Completes credentialing process as defined by facility(ies) in which the RNFA practices.
• Obtains and maintains clinical privileges for activities to be performed.
• Practices according to recognized standards of nursing practice, such as the ORNAC “Recommended Stantards, Guidelines, and Position Statements for Perioperative Registered Nursing Practice” { and the AORN “Standards of perioperative professional performance.”}

Measurable Criteria:

Maintains professional credentials.

Examples:

• Meets the necessary requirements to obtain and maintain certification- CPN(C), advanced cardiac life support – ACLS, pediatric advanced life support - PALS.
• Actively participates in self, peer, and colleague review processes.

Measurable Criteria:

Demonstrates knowledge of risk management, professional liability, and malpractice issues.

Examples:

• Is encouraged to secure and maintain individual liability insurance, either independently or as a member of a Professional Regulatory body or physician practice group (if so employed).
• Collaborates with facility risk manager to identify potential risk- inducing behaviors in the practice arena. Initiates appropriate teaching and/or practice change to reduce risk.
• Is vigilant in staying abreast of patient safety issues and published standards to promote patient safety.

Measurable Criteria:

Practices in an ethical manner.

Examples:

• Respects patient’s dignity and autonomy. Maintains patient confidentiality.
• Actively participants in and accesses expert resources to resolve ethical dilemmas.

Measurable Criteria:

Seeks out and participates in lifelong learning opportunities.

Examples:

• Builds upon the knowledge base and skill level of an assistant-at-surgery through experiential learning and ongoing education.
• Pursues formal advanced education to further his/her nursing career (ie, baccalaureate/graduate degrees).
• Networks with other health care professionals to promote the practice of RNFAs and to discuss practice issues.
• Participates in professional nursing activities at the local, provincial, and federal levels.
• Attends local and national conferences and specialty forums to expand knowledge base and stay abreast of emerging technology.

Measurable Criteria:

Participates in professional activities and defined processes directed towards improving patient care.

Examples:

• Actively participates in multidisciplinary activities in the workplace (eg, institutional grand rounds, committees, quality improvement activities).
• Identifies and analyzes situations in which collaborative consensus for patient care interventions cannot be attained. Takes actions appropriate to the specific situation.
• Initiates process review mechanisms.
• Influences interdisciplinary relationships by enhancing collaborative processes, “corporate culture,” institutional values, and professionalism.
• Identifies situations in which additional education and/or disciplinary action is indicated and takes appropriate action.
• Considers factors such as developmental age or cultural background when planning effective education for patients and families.

Measurable Criteria:

Participates in the research process to build and promote RNFA clinical practice thereby contributing to the body of nursing knowledge, with particular interest in perioperative nursing and the RNFA role.

Examples:

• Searches the literature to identify pertinent existing research data.
• Evaluates and interprets published research for its relationship to clinical practice.
• Conducts and/or participates in research studies to advance not only RNFA practice, but all nursing practice.
• Uses evidenced-based practices relevant to perioperative patient care management and RNFA practice.
• Seeks publication of articles and/or research studies pertinent to RNFA practice.

Measurable Criteria:

Participates in public policy development.

Examples:

• Maintains awareness of proposed/pending legislation affecting nursing and the RNFA role.
• Makes contact with provincial/territorial and federal legislators and administrators, as appropriate, to provide information and insight regarding health care issues and regulations.
• Actively supports public policy promoting quality care and RNFA practice.
• Campaigns and contributes to success of candidate(s) of choice who promote(s) RNFA practice and quality patient care.

*Collaborative problem: Patient problems requiring intervention using both a medical and nursing model.

Adapted with permission from AORN, RN First Assistant Guide to Practice, 2^nd edition.
Copyright 2005 © AORN, Inc, 2170 S Parker Road, Suite 300, Denver, CO 80231