August 9, 2022
How to become an RNFA

Interested in learning more about becoming an RNFA? Find out what a Registered Nurse First Assistant - RNFA - is, what their duties are, how much they make, and how to become one in this comprehensive career guide. 

Part One What is a Registered Nurse First Assistant (RNFA)?

A Registered Nurse First Assistant, or RNFA, is a perioperative registered nurse that functions as a first assistant during surgical operations. 

According to the Association of periOperative Registered Nurses (AORN), an RNFA is defined by the following: 

  • works in collaboration with the surgeon and other healthcare team members to achieve optimal patient outcomes;  
  • has acquired the necessary knowledge, judgment, and skills specific to the expanded role of RNFA clinical practice;  
  • intraoperatively practices at the direction of the surgeon; and  
  • does not concurrently function as a scrub person. 

The aforementioned definition is the standard to which RNFA’s practice and allows these individuals to practice beyond the normal scope of practice. First Assistants are required to take advanced coursework, additional certifications, and orientation in order to be credentialed.

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Part Two What Does an RNFA do?

The role of the RNFA will vary on the surgical institution and will also vary depending on the surgeon. It’s important to know that many academic teaching hospitals do not regularly use RNFAs due to the presence of surgical residents and fellows. After obtaining credentialing, a First Assistant can perform duties during the preoperative, intraoperative, and postoperative care. These nurses have the ability to help develop treatment plans in conjunction with the lead surgeons and then assist in postoperative management. While nurses can generally perform similar tasks, the real differences are their increased abilities in the operating room. 

RNFA Duties

  • Using instruments and medical devices
  • Providing surgical site exposure
  • Handling and/or cutting tissue 
  • Providing hemostasis
  • Suturing
  • Wound management

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Part Three Registered Nurse First Assistant (RNFA) Salary

According to, the average salary for an RNFA is $104,000 per year. Unfortunately, due to the specialization of this field salary data is extremely limited. The U.S. Bureau of Labor Statistics provides salary figures for all registered nurses combined rather than for particular specializations. As of May 2021, the median annual salary was $77,600.

The BLS identifies the following as the highest paying states for nursing:

State Hourly Mean Wage Annual Mean Wage


Hawaii $51.22 $106,530
Oregon $47.42 $98,630
District of Columbia $47.38 $98,540
Alaska $46.74 $97,230

In the same year, the BLS ranked the highest mean annual salaries for nurses, and the top ten were in California. The top five from the list are as follows:

Metropolitan Area Hourly Mean Wage Annual Mean Wage (2)
San Jose-Sunnyvale-Santa Clara, CA $74.63 $155,230
San Francisco-Oakland-Hayward, CA $72.90 $151,640
Vallejo - Fairfield, CA $70.37 $146,360
San Francisco-Oakland-Hayward, CA $68.00 $141,440
Napa, CA $67.15 $139,680

Most health care systems pay nurses on an hourly scale while others have a fixed annual salary, such as nurses in a free-standing surgical center. Those paid on an hourly scale are able to earn overtime pay whereas salary employees would need to discuss that with the hiring committee. 

Overall, pay generally correlates with cost of living for a specific geographical area. For example, nurses in Oklahoma earn significantly less than their counterparts on the west coast regardless of specialization. Despite having the same job title, the cost of living in California is much higher and thus equaling a greater pay. 

As with all jobs in the nursing field, earning potential increases with additional education and experience. Nurses typically are awarded a raise during annual employee performance reviews. Certifications can give nurses an additional bump in their paycheck. Furthermore, nurses who agree to precept new nurse employees can also receive additional compensation. 

Regardless of the workplace setting, full time and part-time RNFA  enjoy similar benefits. While actual benefits may vary depending on the institution most include the following:

  • Health insurance 
  • Retirement Options
  • Family Leave of Absence
  • Maternity Leave
  • Dental Insurance
  • Vision Insurance
  • Discounts
  • AORN membership benefits
  • Tuition Reimbursement
  • Attendance at nursing conferences

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Part Four How to Become an RNFA

To become an RNFA, first, the nurse must have substantial perioperative experience as this advanced training builds upon the basic fundamentals and focuses on surgical anatomy, procedures, and techniques. Courses vary throughout the country in regard to credit hours needed in order to work as an RNFA. Prerequisites also vary on the institution but generally consist of:

  • Active RN license
  • At least two years of perioperative nursing experience
  • Certified Nurse Operating Room (CNOR) designation, offered by the Competency and Credentialing Institute (CCI)

Regardless of the program chosen it must be approved by the AORN. You can see a list of approved programs here. After successfully finishing the RNFA courses, individuals should work towards becoming certified. It is important to clarify there is a difference between an RNFA and a CRNFA. 

>> Explore RNFA Certification Review Materials* 

To become a certified RNFA, the nurse must have a CNOR certification, active and unencumbered RN license, a bachelor’s degree as well as 2,000 hours of experience working as an RNFA. 

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Part Five What are the Best Registered Nurse First Assistant Programs?

Top 10 Registered Nurse First Assistant Programs


This list is based on a number of factors including:

  • Reputation
  • NCLEX pass rate
  • Tuition
  • Acceptance rate, when available
  • Only AORN approved programs are eligible

Nurse Panel

Our selection panel is made up of 3 Registered Nurses with years of experience and multiple degrees:

  • Tracy Everhart, MSN, RN, CNS
  • Tyler Faust, MSN, RN
  • Kathleen Gaines, MSN, BSN, RN, BA, CBC

There are numerous registered nursing first assistant programs and our panel of nurses ranked them based on factors mentioned in the methodology. Because individual nursing pathways and careers take various forms, the top 10 registered nurse first assistant programs are ranked in no particular order. 

1. Delaware County Community College

In-State Program Tuition: $1,500 Out-of-State Program Tuition: $2,250

Online: Hybrid

Program Length: 2 semesters

Delaware County Community College's RNFA program is based in the township of Marple, located just outside of Philadelphia. This six-credit program combines online and in-person education, splitting the two required courses over two semesters. The first-semester course requires a five-day visit to campus, and the rest is completed online. The second-semester course is an independent internship completed wherever the student wants. Nurses can accelerate the internship, and they graduate once the internship is finished. 

2. National Institute of First Assisting

Program Tuition: Up to $5171.25

Online: Hybrid

Program Length: Up to 2 years

One of the more comprehensive RNFA programs is offered by NIFA, a Colorado-based organization that focuses solely on first assisting education. Currently, the largest RNFA program in the nation, NIFA uses three- and five-day workshops to teach nurses basic RNFA skills and requirements. Nurses then complete an internship to finish the program. Any graduates who feel they haven't mastered the subject matter can take the program again at no cost. While the program takes up to two years, most students graduate in 5-8 months.

3. St. Elizabeth Healthcare

In-State Program Tuition: $2,478 Out-of-State Program Tuition: $4,968 AND $1,650 due to St. Elizabeth Healthcare

Online: No

Program Length: 2 semesters

Located in Edgewood, Kentucky, St. Elizabeth Healthcare is a local leader in medical services. The healthcare center's RNFA program, offered in conjunction with Northern Kentucky University, begins with a five-day face-to-face experience in Northern Kentucky. Next, students begin a clinical internship worth at least 130 hours. Upon finishing the program, students earn six college credits from NKU and a certificate of completion. Many students finish this program in just one semester. 

4. Gulf Coast State College

Program Tuition: $4,019

Online: Hybrid

Program Length: 2 semesters

Gulf Coast State College, located in Panama City, Florida, is intended specifically for RNs who want a fast-track to the surgical department. Like most RNFA programs, Gulf Coast's program blends online learning with on-campus education and takes roughly two semesters to complete. Students can choose to either complete their clinicals in their hometown or gain clinical experience on-site in Florida. Graduates of this program enjoy a 100% RNFA job placement rate. 

5. University of Rochester

Program Cost: $4,000

Online: Hybrid

Program Length: 2-3 semesters

Created for APRNS or certified operating room nurses (CNOR), the University of Rochester's RNFA program sets relatively strict admission requirements. However, the university offers flexibility in how students complete the program. First, students complete courses from a distance, and courses fit around nurses' schedules. Next, nurses attend an in-person lab day. Finally, students complete a 50-hour internship in the state where they hold their RN license. While the program takes 2-3 semesters, most nurses study part-time. 

6. University of Tennessee

In-State Program Tuition: $4,195.50 Out-of-State Program Tuition: $4,429.50

Online: Hybrid

Program Length: 1 year

Created for both RNs and APRNs, the University of Tennessee's RNFA program requires three courses completed over a year. The first two courses, complete during the fall and spring semesters, are both online, except for a 40-hour on-campus workshop during the first course. The third course requires 180 clinical hours in perioperative practicum. As with most programs, students complete their internships in their home state, or at the University of Tennessee's campus in Memphis. 

7. University of Massachusetts

Program Tuition: $4,650

Online: Hybrid

Program Length: 2 semesters

The University of Massachusetts' RNFA program is in collaboration with UMass Chan Medical School and is open to BSN-prepared RNs with a CNOR, advanced practice nurses, or students that are currently in an advanced practice graduate program.  There are two required courses. The first course uses a hybrid format, teaching three live classes in-person on Saturdays in Worcester, Massachusetts. The second course is essentially an internship requiring students to complete 270 precepted hours, making nurses gain clinical experience. While most students can finish this program in just two semesters, some may take more time on their internship.

8. University of Alabama at Birmingham

Program Tuition: $5,904

Online: Hybrid

Program Length: 2-3 years

Unlike other RNFA programs, the University of Alabama at Birmingham offers its RNFA option as an MSN subspecialty; however, BSN-prepared nurses must have their CNOR at time of application. The RNFA subspecialty requires three courses, one of which consists only of clinical experience. Admission is limited to fall entry only for this program. 

9. University of California Los Angeles

Program Tuition: $5,500

Online: No

Program Length: 1-2 semesters

The University of California Los Angeles offers an RNFA program for current RNs and APRNs. The program begins with a six-day, 52-hour course completed at UCLA. Next, students must complete a 120-hour independent preceptorship. However, students must set up their own preceptorships, and UCLA sets preceptorship requirements during the program's first course. Any APRNs who do not have two years of operating room experience can sign up for a one-day program to prepare them for the RNFA program. 

10. St. Charles Community College

In-State Program Cost: $1,314 Out-of-State TuitionTuition: $2,304

Online: No

Program Length: 1-2 semesters

Located in Cottleville, Missouri, St. Charles Community College begins its six-credit RNFA program with six days of on-campus study. Next, students complete a three-credit internship program to gain clinical experience. This internship must consist of at least 120 hours, though students can complete it wherever they want. Note that St. Charles Community College only accepts students who completed a BSN. 

Part Six RNFA Career Outlook

With the increasing number of same-day surgery centers opening across the country, the need for RNFAs will steadily continue to grow. Furthermore, a larger number of medical and surgical organizations are recognizing the role and importance of the RNFA. A few of these organizations include:

  • American College of Surgeons
  • American Academy of Ophthalmology
  • American Academy of Orthopaedic Surgeons
  • American Academy of Otolaryngology–Head and Neck Surgery
  • American Association of Neurological Surgeons
  • American Pediatric Surgical Association
  • American Society of Colon and Rectal Surgeons
  • American Society of Plastic Surgeons
  • American Society of Transplant Surgeons
  • American Urological Association
  • Congress of Neurological Surgeons
  • Society for Surgical Oncology
  • Society for Vascular Surgery
  • Society of American Gastrointestinal Endoscopic Surgeons
  • The American College of Obstetricians and Gynecologists
  • The Society of Thoracic Surgeons

Part Seven Where to Learn More About Becoming an RNFA

The best resource for nurses wanting to pursue an RNFA certification should turn to the Association of Perioperative Registered Nurses website. Here individuals can find a list of schools that offer the program, information regarding job opportunities, and educational material. 

Another helpful resource is the website for the Competency and Credentialing Institute. Nurses can find information regarding additional certifications and credentialing. 

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$70,000 - $90,000 Associate Bachelors Perioperative Bedside RN