Title: Advanced Practice Registered Nurses as First Assist at Surgical Procedures

(Formally Nurse Midwife as First Assist at Surgical Procedures)

Advisory Ruling Number: 9902

Authority: The Massachusetts Board of Registration in Nursing (Board) issues this Advisory Ruling on Nursing practice pursuant to Massachusetts General Laws (M.G.L.), chapter 30A, section 8 and chapter 112, section 80B.

Date of Issue: Aug 12, 1998

Revised: September 9, 1998, September 8, 2010, June 11, 2014

Scope of Practice: Advance Practice Registered Nurse (APRN) authorized by the Board with documented competency in perioperative nursing practice.

Purpose: To guide the practice of the APRN who functions in the perioperative setting who:

  • Functions autonomously as part of the surgical health care team to achieve optimal patient outcomes in the pre-operative and post-operative management of surgical patients and their complex responses to the surgical process; and
  • Functions intra-operatively in a coordinated manner with the surgeon while using instruments and medical devices, providing surgical site exposure, handling and/or cutting tissue, providing hemostasis, suturing, and wound management.

Such practice must be in compliance M.G.L. c. 112, s. 80B, 80C, 80E, 80G and 80H; 244 CMR 4.00: Massachusetts Regulations Governing the Practice of Nursing in the Expanded Role; 244 CMR 9.03(2): Practice as Advanced Practice Nurse; 244 CMR 9.03(5): Adherence to Standards of Nursing Practice; 244 CMR 9.03 (8): Identification Badge; 244 CMR 9.03(9): Responsibility and Accountability; 244 CMR 9.03(10): Acts within Scope of Practice; 244 CMR 9.03(11): Performance of Techniques and Procedures; 244 CMR 9.03(12): Competency; 244 CMR 9.03(14): Asepsis and Infection Control; 244 CMR 9.03(34): Misrepresentation of Credentials; 244 CMR 9.03(44): Documentation; 244 CMR 9.04: Standards of Conduct for Advanced Practice Nurses.


An APRN whose practice includes first assist duties will assume only 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 documented competency in perioperative nursing practice consistent with standards established by the Association of periOperative Registered Nurses (AORN).

For the purposes of this advisory ruling, competencies are categorized as general, pre-operative phase, intra-operative phase, and post-operative phase.

General Competencies

General competencies include, but are not limited to:

  • Knowledge of surgical anatomy, physiology, and pathophysiology;
  • Knowledge of operative techniques related to the procedures in which the APRN assists;
  • Perform CPR;
  • Perform effectively in stressful & emergency situations;
  • Recognize safety hazards and initiate appropriate preventive and corrective action;
  • Adhere to standard precautions and to principles of asepsis and infection control and would not place self, patient or others at risk for infectious disease transmission; and
  • Ensure documentation is complete, accurate and legible in all records required by federal and state law.

Pre-operative Phase Competencies

Pre-operative competencies for the management of patients in collaboration with other health care providers include, but are not limited to:

  • Formulate clinical decisions in managing acute and chronic illnesses by assessing, diagnosing, and prescribing treatment modalities, including pharmacologic agents;
  • Patient and family education;
  • Review and analysis of patient data; and
  • Communicate with other health care providers about the patient’s plan of care.

Intra-operative Phase Competencies

In order to attain the knowledge and skills needed to provide safe, competent surgical first assist intra-operative competence, the APRN must meet AORN educational standards for APRNs for the performance of surgical first-assisting* techniques, including, but not limited to:

  • Use instruments and medical devices,
  • Perform surgical site exposure,
  • Handle tissue,
  • Cut tissue,
  • Provide hemostasis,
  • Suture, and
  • Wound management.

* The APRN may not concurrently function as a scrub nurse 

Post-operative Phase Competencies

Post-operative competencies for the management of patients in collaboration with other health care providers include, but are not limited to:

  • Diagnose and treat the responses of the operative or other invasive procedure by assessing, diagnosing, and prescribing treatment modalities, including pharmacologic agents ;
  • Communicate with other health care providers about the patient’s plan of care; and
  • Assist with or arrange discharge planning and identify appropriate community resources as needed.

Additional Considerations

The nurse in the management role is responsible to ensure organizational policy development includes a system to validate APRN education, training, and experience that demonstrate competence in first assist duties.

Specific to Certified Nurse Midwives (RN/NM)

The RN/NM who functions as a first assist at obstetric and gynecologic surgery, including, but not limited to cesarean sections and tubal ligations, must successfully complete formal study, supervised practice, and comprehensive evaluation, as required in the American College of Nurse Midwives' Guidelines for the Incorporation of New Procedures into Midwifery Practice.


  • www.aorn.org - AORN Position Statement on Advanced Practice Registered Nurses in the Perioperative Environment; accessed 5/30/14
  • www.aorn.org - AORN Standards for RN First Assistant Education Programs; accessed 5/30/14
  • www.midwife.org - Position Statement: Certified Nurse-Midwife/Certified Midwife as First Assistant during Surgery; accessed 5/30/14

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