Title: Registered Nurses as First Assistants at Surgery

Advisory Ruling Number: 9901


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: February 26, 1986

Date Revised: July 1992, April 1995, August 1998, and September 1998, May 2002, June 11, 2014, June 14, 2017

Scope of Practice: Registered Nurse with documented competency in perioperative nursing practice.

Purpose: To guide the practice of a Registered Nurse who, through additional, extensive education and training practices in collaboration with and interdependently with a surgeon licensed in the Commonwealth in providing an optimal perioperative experience for the patient. 


The RN First Assistant (RNFA) is a Registered Nurse with specialized education and documented competency in perioperative nursing practice consistent with the RNFA Standards of Practice established by the Association of periOperative Registered Nurses (AORN) through successful completion of a post-basic nursing education program whose intent is the preparation of registered nurses to practice as first assistants at surgery.

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 RNFA 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:

  • Perform focused preoperative assessments;
  • Provide patient and family education;
  • Review and analyze patient data; and
  • Communicate with other health care providers about the patient’s plan of care.

Intra-operative Phase Competencies

Intra-operative competence for the performance of surgical first-assisting* techniques, include, but are not limited to:

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

* The RNFA 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:

  • Participate in or perform postoperative rounds (may include wound management, dressing changes, suture and/or drain removal, other type of catheter & IV removal and as ordered by the duly authorized prescriber);
  • Communicate with other health care providers about the patient’s plan of care; and
  • Assist with or arrange discharge plan and identify appropriate community resources as needed.

Additional Practice Considerations

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

RNFA practice in an organization that maintains current policies and procedures related to RNFA practice.


  • www.aorn.org Position StatementRN First Assistants; accessed 2/2/17
  • www.aorn.org AORN Standards for RN First Assistant Education Programs; accessed 2/2/17


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