Key Takeaways

You don’t have to leave the bedside to pivot.

RNFAs stay in the thick of patient care — scrubbed in, hands-on, and vital to every procedure.

OR nurses need autonomy, adaptability, and nerves of steel.

The OR is high-pressure and fast-moving. RNFAs must anticipate surgeon needs, lead in-room communication, and stay steps ahead.

Training takes time, but it’s worth it.

Lisa’s journey included years of circulating and scrubbing, national coursework, and OR certification. Some facilities require 5+ years of OR experience before training an RNFA.

You’ll learn every day.

New surgeons, procedures, and tools mean continuous growth. That’s what keeps Lisa excited about the work. Even after years as a RNFA, she still feels like she is learning and growing every day and never gets bored!

Shadowing is the best first step.

Not sure if you’re a good fit for the OR? Lisa recommends shadowing a surgical nurse to see the workflow and team dynamics in action. Shadow experiences in nursing school don’t usually give you a great understanding of a “day in the life” of an OR nurse.

Career Deep Dive

Registered Nurse First Assistant

An RN First Assistant (RNFA) is a registered nurse with advanced training who directly assists the surgeon during operative procedures. This role goes beyond circulating or scrubbing — RNFAs are hands-on in the sterile field, helping to control bleeding, suture incisions, and manage surgical instruments. They anticipate what the surgeon needs before it’s said and act as a second set of eyes, hands, and judgment in the OR.

RNFAs also contribute before and after surgery, reviewing patient histories, preparing surgical plans, and managing post-op assessments. While they work under a surgeon’s supervision, RNFAs operate with a high level of autonomy and clinical skill.

This is not a beginner role — most RNFA programs require at least two years of perioperative experience, and many hospitals require much more. But for nurses who thrive in fast-paced, high-stakes settings and want to stay clinical without staying at the bedside, this path offers a whole new level of impact.

Perks

You are in the room making a real time difference.

There can be something so satisfying about hands on care, and just because a nurse is looking for something different doesn’t mean they always want to give that up. RNFAs aren’t watching from the sidelines. You’re scrubbed in, assisting with surgery, and playing a direct role in patient outcomes.

The opportunity for deep autonomy and trust.

Surgeons rely on RNFAs — not just to follow orders, but to anticipate needs and speak up when something doesn’t look right. You’re a key part of the surgical team.

You build elite skills.

From suturing to cauterizing to managing complications in real time, you’re constantly sharpening a skill set that’s both advanced and highly respected.

It keeps things fresh.

Every surgeon works differently. Every case is unique. If you like variety, critical thinking, and fast-paced environments, the OR never gets boring.

You don’t have to give up patient care to grow.

This is one of those roles where you level up clinically and professionally without stepping away from the kind of direct impact that drew you to nursing in the first place.

Challenges

Lack of exposure in nursing school

Most nurses enter the OR with zero formal training in perioperative care. Lisa noted, “Nurses get no training for surgery in nursing school… It could almost be a curriculum of its own.”

Big learning curve in the OR

From memorizing surgical instruments to mastering surgeon preferences, the OR demands fast learning under pressure. “There’s like five different shapes of knives that they use… and I had no idea which number knife blade that was,” Lisa shared about her early days.

Balancing the pressure between efficiency and safety

The OR runs on tight timelines. RNFAs must manage time well without compromising patient safety. Lisa emphasized the need to be “not in a hurry, but efficient.”

Long road to qualification

Becoming an RNFA isn’t instant. It requires years of experience, scrub time, passing the CNOR, and completing additional coursework — plus ongoing annual competency evaluations. This is why getting into the OR and exploring the field is important to see how you like the setting.

High-stress environment

Surgery is intense and fast-paced. It’s not for everyone. As Lisa put it, “Surgical nurses are a different breed… you have to thrive on change.”

Work-life balance

For Lisa, one of the first things that drew her to the OR was the opportunity to work a consistent day shift. “There’s a day shift in surgery… I said, well, okay, I can learn that,” she recalled. Unlike many bedside roles that require nights, weekends, and holidays, RNFA positions often follow a Monday through Friday schedule, which can make a big difference in overall quality of life. While being on call is still part of the job, Lisa saw it as a positive. “I liked the call involved because it gave me some versatility with my finances,” she said, explaining that she could pick up extra shifts if she wanted to boost her income. It is important to note that call burden can vary widely between facilities and should be explored on an individual basis.

But the biggest contributor to work-life balance for Lisa might be the nature of the role itself. “It’s different every day… that’s what keeps me from being burnt out,” she shared. The constant learning, teamwork, and autonomy provide fulfillment that helps counterbalance the stress and physical demands of the OR. While assisting in surgery can be intense and fast-paced, being part of a well-functioning team with clearly defined roles can help make the workload feel purposeful and sustainable.

Nursing Skills that Translate

These skills will translate well into a nursing role in the operating room, which will then set the stage for continuing into a role as an RNFA if desired.

Organization and time management

Efficiency is so important in the world of surgery and a well organized nurse who is conscious of time management is a necessity in this space.

Multitasking under pressure

You’ve probably already mastered the art of doing five things at once without dropping the ball. That kind of calm chaos management is exactly what you need in the OR.

Clear, confident communication

You’re anticipating needs, speaking up, and keeping the whole team on track. RNFAs are the glue between the surgeon and the rest of the room and effective communication is essential.

Strong Foundation in Anatomy and Physiology

If you loved A&P, this is your playground. You’re not just reading about organs — you’re right there, hands-on, seeing and assisting. Knowing your anatomy is a core building block of this role.

Commitment to continuous learning

No two days (or surgeons) are the same, and that is a part of the beauty of the role. But it also means you have to be open to constantly learning and adjusting as protocols, devices, and team dynamics evolve.

How Much Experience Do you Need?

If you’re already working as an OR nurse, you’re on the right track. But this role isn’t something you can jump into fresh out of school.

Lisa emphasized this in our interview:

“You need to be circulating and scrubbing cases before you can even apply… That experience is the base you build on.”

And that’s backed up by national standards. According to the ​Association of periOperative Registered Nurses (AORN) ​and the Competency & Credentialing Institute (CCI) — which oversees the CNOR credential — here’s what’s typically required:

According to AORN, to become a Registered Nurse First Assistant (RNFA), you must:

• Be a perioperative nurse with a current RN license
• Have at least a baccalaureate degree (required for RNFA programs after Jan 1, 2020)
• Hold ​CNOR certification​ (Certified Perioperative Nurse) which requires a minimum of 2 years and 2,400 hours of experience as a perioperative registered nurse. A minimum of 50% (1,200 hours) of those hours must be in the intraoperative setting.
• Complete an RNFA program that meets AORN standards and includes 6 semester credits’ worth of formal post-basic nursing education and clinical hours

Many surgical programs and hospitals set their own eligibility standards for when nurses can enroll in an RNFA program—often going beyond national minimums. For example, while AORN requires CNOR certification and a BSN, individual facilities may expect more. In our interview, Lisa shared that her hospital requires five full years of OR experience before a nurse is eligible to apply for RNFA training. It’s important to check with both your organization and your chosen program to understand their specific expectations.

Salary

According to ​Glassdoor​, the average base pay for a Registered Nurse First Assistant in the U.S. is approximately $107,000 per year, with total compensation often ranging from $90,000 to $130,000+, depending on experience, location, and employer.

The RNFA role comes with increased responsibility and hands-on involvement in surgery—factors that often contribute to higher compensation compared to other OR roles.

If you’re exploring this path, it’s smart to look up regional salary data and connect with RNFAs in your area to get a realistic picture of compensation in your setting.