How to Become an RNFA

Meg Lambrych, RN-BC
Updated June 11, 2024
Edited by
After years of training and experience as an operating room nurse, you can become a registered nurse first assistant and assist the doctor during surgery.
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A registered nurse first assistant (RNFA) is a highly trained nurse who works closely with surgical teams. After completing advanced training, education, and certification, many RNFAs serve as surgeons’ assistants.

Becoming an RNFA can be an excellent career choice for people who are interested in surgery and want to help deliver complex, life-saving patient care. Discover details about required certifications, education, and a career outlook for this advanced nursing role.

How Long to Become
6-8 years

Degree Required


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What is an RNFA?

RNFAs are operating room (OR) or perioperative registered nurses (RN) or advanced practice registered nurses (APRN). These professionals have the expertise to work as surgeons’ first assistants during invasive and non-invasive medical procedures.

These nurses can practice beyond the standard scope because of the advanced training and certification required to prepare for the role.

Specific duties for an RNFA may include:

  • Preparing patients for surgery
  • Handling and using surgical devices
  • Draping surgical site and maintaining the sterile field
  • Performing and suturing incisions
  • Taking part in postoperative patient care
  • Achieving hemostasis through the controlling of incisional bleeding
  • Educating patients and their families
  • Postoperative incision assessment and care

Not all hospitals hire RNFAs, as some prefer to have two surgeons in the OR instead. Nevertheless, RNFAs are a key part of many surgery teams.

Steps to Becoming an RNFA

Wondering how to become an RNFA? The education process is fairly intensive. Ambitious nurses focused on gaining expertise can achieve RNFA certification after years of experience in the OR. The National Assistant at Surgery Certification (NASC) and the Association of periOperative Registered Nurses (AORN) set specific requirements for RNFA credentials. Under NASC, the requirements are:

  • Working a minimum of 2,000 relevant experience hours
  • Earning a bachelor’s degree (or higher) in any field
  • Holding current CNOR certification
  • Maintaining an unrestricted RN license
  • Completing a program that meets AORN standards

In addition to the above, NASC requirements for APRNs involve completing a certified APRN program before applying. Under AORN, there are separate requirements for RNs and APRNs:

Requirements for RNs

  1. Earning a BSN degree (with the exception of RNFAs practicing before Jan. 1, 2020, who are allowed to have ADN degrees only)
  2. Passing the NCLEX-RN
  3. Maintaining unrestricted RN licensure
  4. Achieving basic life support, advanced cardiac life support, and pediatric advanced life support certifications
  5. Earning clinical nurse-operating room (CNOR) certification
  6. Completion of an accredited RNFA program that meets AORN standards
  7. A minimum of 2,000 hours of relevant documented practice

Requirements for APRNs

  1. Earning APRN certification by an accredited program
  2. Holding current, unrestricted RN licensure
  3. Completing an accredited RNFA program that meets AORN standards for education
  4. Obtaining a minimum of 2,000 documented relevant practice hours
  1. 1

    Earn an ADN or BSN Degree From an Accredited Program

    Community colleges commonly offer associate degrees in nursing (ADN). This entry-level nursing degree typically requires two years of full-time enrollment, although it may take longer without first completing prerequisite courses. As of Jan. 1, 2020, nurses pursuing ADNs must complete BSN programs to apply for certification and practice as RNFAs.

    A bachelor of science in nursing (BSN) is a four-year degree. Nurses with ADNs can enroll in RN-to-BSN programs. These degree tracks last 9-24 months, and many programs are geared toward working nurses.

    Candidates with bachelor’s degrees in non-nursing fields can complete accelerated BSN programs. This entry-level degree track offers transfer-friendly policies for enrollees to bring past credits. Accelerated programs use an intensive course of study over 11-18 months.

  2. 2

    Pass the NCLEX Exam to Receive RN Licensure

    All ADN and BSN students must pass the National Council Licensure Examination (NCLEX-RN) to earn their nursing licensure. Recent graduates can take the exam within one month of graduation.

    The NCLEX-RN exam applies to ADN and BSN graduates, while the NCLEX-PN exam is for those who have graduated from practical nurse certificate programs. Approximately 80% of first-time candidates passed the NCLEX-RN in 2024 so far.

  3. 3

    Gain Experience in Surgical Nursing

    Many employers may require candidates to have at least 1-2 years of experience in medical-surgical environments or other acute care settings. This requirement applies because of the high-stakes nature of the OR and the critical-thinking skills required to succeed. However, some hospitals offer new graduate residency programs for the OR.

  4. 4

    Consider Becoming Certified or an APRN

    To become an RNFA, you must gain operating room experience and become certified as a CNOR or become an APRN. An RN with an unrestricted license and at least two years of experience in a perioperative setting can take the national certification exam to become a CNOR.

    RNs who choose to earn MSNs can become APRNs. Most MSN programs take around two years to complete. Each APRN needs to complete an assessment covering competency in preoperative and postoperative care from a program instructor.

  5. 5

    Complete an AORN-Approved RNFA Program

    Finally, RNs can validate their knowledge and experience by earning specialty board certification as RNFAs. To do so, they must first complete an AORN-approved RNFA program. Nurses have two years to complete the program, but many APRNs graduate as early as 5-8 months.

RNFA Education

All RNFAs certified after Jan. 1, 2020, must have BSN degrees. According to the AORN Standards for RN First Assistant Education Programs, all candidates for RNFA certification must also complete six credits of post-RN education.

These programs must include:

  • Didactic education (with specific requirements outlined in detail by the AORN)
  • Clinical training of at least three credit hours (with specific requirements outlined in detail by the AORN)

ADN Degree

ADN programs are common at community colleges. This degree fulfills the minimum eligibility to sit for the NCLEX and earn RN licensure. Completing an ADN takes around two years, although prerequisites can lengthen the process for some students.

  • Admission Requirements: High school diploma or GED certificate with 2.5 GPA; completed application with transcripts; 2.5 college GPA (if previous college experience); HESI Exam (scored subtests: math, reading comprehension, vocabulary and general knowledge, grammar)
  • Program Curriculum: Clinical assignments, nursing care, pathophysiology, physical assessment, psychosocial assessment
  • Time to Complete: 2 years
  • Skills Learned: Nursing assessment, critical thinking, nursing process, hands-on patient care, psycho-emotional and psychosocial assessment

BSN Degree

Earning a BSN degree is an important step toward becoming an RNFA. A traditional BSN program covers English, math, and other general education courses plus microbiology, anatomy, and physiology, and 2-3 years of lecture-based education and clinical hands-on training. A BSN is often considered the minimum degree required to pursue a master’s degree in nursing.

Many hospital employers require all nurse candidates to hold BSNs, so earning this degree is a smart career move for most nurses interested in working in acute care settings.

  • Admission Requirements: 2.5-3.0 GPA; college and high school transcripts; completed application, often with personal essay; successfully completed prerequisites; SAT or ACT scores; CV or resume
  • Program Curriculum: Clinical assignments, nursing care, pathophysiology, physical assessment, management and supervision, delegation, community health, population health, evaluation of scientific research
  • Time to Complete: 4 years for a traditional program, less for RN-to-BSN or accelerated BSN programs
  • Skills Learned: Nursing assessment, critical thinking, nursing process, hands-on patient care, psycho-emotional and psychosocial assessment, management and supervision, delegation, community health assessment, evaluation of research

MSN Degree

A master of science in nursing (MSN) expands nurses’ career potential. The MSN is the minimum requirement to become an APRN and suits nurses seeking increased specialization, autonomy, and/or clinical responsibility.

  • Admission Requirements: BSN degree, unless enrolled in an RN-to-MSN bridge program
  • Program Curriculum: Advanced pharmacology and pathophysiology; legal and ethical issues in nursing; theory and research; advanced physical assessment; diverse populations; practicum or capstone experience
  • Time to Complete: 2-3 years
  • Skills Learned: Advanced physical assessment, management of nurses and direct reports, research, advanced pharmacology, diagnosis, treatment of common diseases

Finding an RNFA Program

There are several reliable resources to help nurses find approved RNFA programs. According to the NASC list of acceptable RNFA programs, no program is directly affiliated with NASC, and each will have its own eligibility requirements.

NASC lists programs in Alabama, California, Colorado, Florida, Illinois, Kentucky, Massachusetts, Michigan, Missouri, New York, North Carolina, Pennsylvania, and Tennessee.

Each candidate applying for CRNFA certification through NASC must submit a copy of a certificate of completion from an acceptable RNFA program. AORN links the accepted programs in its RNFA resources.

RNFA Licensure and Certification

RNs and APRNs can serve as RNFAs, depending on the requirements of the employing institution. An active RN license is required to practice as an RNFA. Maintaining RN licensure is based on the continuing education (CE) requirements of the state where a nurse lives and works. Successful completion of 30 CE hours every two years is common in many states.

According to the AORN’s RNFA position statement, qualifications for serving as an RNFA include:

  • CNOR certification
  • Completion of an RNFA program that meets the “AORN standards for RN first assistant education programs”
  • Compliance with institutional and state regulations, statutes, and policies
  • BSN degree, with the exception of RNFAs practicing before Jan. 1, 2020
  • Completion of AORN requirements of six hours of post-RN RNFA education provided by an accredited school of nursing. This requirement includes three credits of didactic and three credits of clinical RNFA training as outlined by the AORN

Sitting for the CNOR exam and earning the CNOR credential is achieved by fulfilling the following requirements:

  • Unrestricted RN license
  • Currently working full-time or part-time in perioperative clinical practice, education, or research
  • Completing a minimum of two years and 2,400 hours in perioperative nursing practice, with at least 1,200 hours in the intraoperative setting

Certification as an RNFA is required for clinical practice.

Working as an RNFA

RNFAs command competitive salaries and expanded professional opportunities. Successfully finding a position as an RNFA will depend on many factors, such as:

  • Education
  • Experience
  • Professional recommendations
  • Evaluation of the RNFA job market in the nurse’s specific geographic area
  • Networking and job-hunting skills
  • Interview and negotiation skills

Since RNFAs are intraoperative nursing professionals, candidates can find employment in acute care hospital facilities and surgical centers.

Frequently Asked Questions About Becoming an RNFA

An RN is a registered nurse, which is a broad profession covering numerous jobs. A registered nurse first assistant (RNFA) is an RN who has received special training and certification to handle special duties in the operating room, including directly assisting the surgeon.