Massachusetts Board of Registration in Nursing

Advisory Ruling on Nursing Practice

Title:  Nurse Practitioner as First Assistant in Cardiac Catheterization

Advisory Ruling Number: 0201

The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.G.L.) c. 13, §§ 13, 14, 14A, 15 and 15D, and G.L. c. 112, §§ 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education.  In addition, M.G.L. c.30A, § 8 authorizes the Board to make advisory rulings with respect to the applicability to any person, property or state of facts of any statute or regulation enforced or administered by the Board.  Each nurse is required to practice in accordance with accepted standards of practice and is responsible and accountable for his or her nursing judgments, actions, and competency.  The Board’s regulation at 244 CMR 9.03(6) requires all nurses to comply with any other law and regulation related to licensure and practice.

Date Issued: July 10, 2002

Date Revised:  March 9, 2016

Scope of Practice: Certified Nurse Practitioner

To guide the practice of the Certified Nurse Practitioner (CNP) who functions as First Assistant at cardiac catheterization procedures to meet client goals including, but not limited to, health promotion, client teaching, health risk reduction, and promotion of safety and comfort.

Cardiac catheterization is an invasive procedure performed in the cardiac catheterization laboratory or electrophysiology laboratory in which one or more catheters are introduced into the heart and selected blood vessels to measure pressure, perform angiography, record electrical activity or perform interventional procedures such as angioplasty and ablation.

For each cardiac catheterization in which the CNP is designated as the First Assistant, there must be a clearly identified primary operator.  A primary operator is a physician who is credentialed and experienced in all aspects of the performance of the procedure, including pre-procedural and post-procedural care of the patient.  The primary operator must be scrubbed and able to provide hands-on supervision during the cardiac catheterization.  CNPs are not authorized to perform cardiac catheterization as the primary operator.

The CNP will only assume those duties and responsibilities within his or her scope of practice and for which he or she has acquired and maintained necessary knowledge, skills, and abilities and only after appropriate education and demonstrated clinical competency.  Competencies the CNP as First Assistant must acquire and maintain, include, but are not limited to:

  1. Pre-procedural assessment and evaluation;
  2. Indications, risks and benefits;
  3. Cardiac anatomy, physiology and pathophysiology;
  4. Technical proficiency;
  5. Emergency and resuscitative measures;
  6. Radiation safety;
  7. Management of complications; and
  8. Post-procedural care.

Education and Training

In addition, the CNP must comply with institutional based training consistent with the initial and continuing educational and clinical requirements specified in 105 CMR 120.405(K)(3):

 (a) Didactic Content

1. Digital image acquisition and display;

2. Contrast media;

3. Fluoroscopic unit operation and safety;

4. Image analysis;

5. Radiation biology;

6. Radiation production and characteristics; and

7. Radiation protection.

(b) Clinical Component

1. Clinical competency requirement: 40 clinical hours performing fluoroscopic procedures in a fluoroscopic suite under the direct supervision of a physician who meets the requirements of 105 CMR 120.405(K)(1)(a) or (b), a medical physicist, or a radiography educator.  “Direct supervision,” means physically present where the fluoroscopic procedure is being performed and immediately available and able to provide assistance and direction throughout the procedure;

2. Fluoroscopic device orientation: safe and proper manipulation of the fluoroscopic device.


Verification of competence must be determined by the credentialing criteria of the employing agency.  The range of technical procedural duties for which the CNP may be privileged by the employing agency include diagnostic and/or therapeutic (interventional) fluoroscopic procedures, including operation of the fluoroscopic system when required for the production and display of serial x-ray images for the purpose of observing real-time motion of anatomical structures.  Pursuant to the employing agency policies and procedures, the range of technical procedural duties may extend into additional clinical areas when the CNP meets the requirements of this Advisory Ruling.

CNPs employed as a First Assistant at cardiac catheterization practice only in facilities that have institutionally generated, approved and signed policies, procedures and protocols indicating the role and functions of the CNP as a member of the cardiac catheterization team.

Informed Consent

The patient will be informed of the role and functions of the CNP as First Assistant at cardiac catheterization and demonstrate acknowledgement in a manner determined by the employing agency.


CNP as First Assistant at Cardiac Catheterization will make accurate, complete, and legible entries (pre-procedural, intra-procedural, and post-procedural) in the medical record as indicated by policies and procedures of the employing agency, Federal and State requirements, and accepted standards of nursing practice.



105 CMR 120.400: X-Rays in the Healing Arts

105 CMR 130.000: Hospital Licensure

ACE Standards for Catheterization Laboratory Accreditation, Accreditation for Cardiovascular Excellence (2011).  Accessed 1/9/15 at

2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions Expert Consensus Document on Cardiac Catheterization Laboratory Standards Update, J Am Coll Cardiol. 2012;59(24):2221-2305. doi:10.1016/j.jacc.2012.02.010.  Accessed 1/9/15 at


This information is provided by the Division of Health Professions Licensure within the Department of Public Health.