States’ first assistant policies vary widely

Nonphysician first assistants in many states practice in limbo. Their practice is not defined or regulated, yet they may be under strong pressure to step into the role. If they are not directly employed by a physician, and their hospital does not have a means for credential- ing first assistants, nurses in this role may be uncertain whether they have malpractice cov- erage. They may also wonder if they are prac- ticing legally.

State policies on the first assistant are a patchwork of differing interpretations, AORN found during a recent survey. State boards of nursing were asked whether they had a policy on the role. Most said they did not.

Of 27 states that had responded as of mid- March, 16 had made no ruling. These were Arkansas, Delaware, Florida, Georgia, Mary- land, Missouri, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, Ten- nessee, Texas, Wisconsin, and Wyoming. Tennessee’s response implied first assisting might be a type of expanded nursing role.

AORN has also heard informally that three other states have the matter under study. They include Colorado, Massachusetts, and Missis- sippi.

Five states clearly stated that first assisting was not a nursing role. Pennsylvania was the most definite, stating, “The functions of the first surgical assistant, which include closure of wounds in surgery, are by their very nature clearly medical acts which require no knowl- edge of or expertise in professional nursing.” Montana, Minnesota, Nevada, and New Mexico gave similar responses, although

Legislation &

Nevada said it was “conceivable that a regis- tered nurse in an expanded role with additional preparation could be a first assistant.”

Idaho and Virginia are the only states to have published guidelines specifically for nurse first assistants. Both stipulate that there be specialized preparation for the nurse and written policies and procedures for the hospi- tal. A third state, Washington, also finds first assisting to be within the nursing practice act, but as a delegated medical function. Washing- ton expects the nurse first assistant to have “the necessary education, training, and com- petence” and to be “directly accountable and responsible to the individual consumer” for the care rendered. The board of nursing expects the nurse to use judgment, noting “there may be some things that a nurse simply cannot or should not do even if the directing physician is standing right next to her/him.”

South Carolina also finds first assisting to be a delegated medical act and leaves the deci- sion up to the individual institution. New York and Hawaii also leave the matter up to the hospital.

Louisiana has not endorsed first assisting as a nursing role but has said that retracting, suc- tioning, and tying and cutting sutures are within nursing “when competency to do so is achieved and maintained.” Removing sutures and atrial and ventricular pacing wires, sutur- ing, and cauterizing were not considered nurs- ing, however.

AORN has been suggesting that nurses concerned about first assisting ask for an in- terpretation from their state board of nursing. Recognizing this may not yield immediate an- swers, Dorris Davis, RN, consultative spe- cialist in the Education Department, believes it may help clarify the issue in the long run.

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In the survey, some states that had not taken a position said no one had ever asked them to. Once a state nursing board is asked for an interpretation, it will usually discuss the matter itself, perhaps over several months. Then the board may seek a conference with the state medical board and an opinion from the attor- ney general.

This is not of much help to the nurse who is scheduled to assist the next morning, but over time, more states may develop rulings that will be helpful to others in the future.

University officials have proposed closing the BSN program at the University of Califor- nia, Los Angeles (UCLA), and cutting the graduate nursing program in half. Rated as one of the country’s ten best nursing schools, it has one of the few baccalaureate programs in the country offering a clinical experience in operating room nursing.

Nursing school faculty and alumni charge that university administrators expect the school to bear the brunt of budget cuts for the health sciences.

“Ironically, the faculty of the UCLA School of Nursing and the community of nurse leaders were informed of the drastic cuts to the school’s programs at a time when the school should be expanding programs to meet those challenges,” the alumni association said, re- ferring to the nursing shortage.

University administrators argue the cuts would be consistent with a master plan that would place nursing and other undergraduate health programs in the California State Univer- sity System, not the University of California. The University of California would have gradu- ate programs only.

UCLA Chancellor Charles Young said he did not think nursing belonged in the university. Quoted in the UCLA newspaper, Young said, “Few schools grant MD and DDS but many provide RNs. It’s not necessary for universities to educate nurses.” He was apparently refer- ring to RN associate degree programs and more expensive private schools.

AORN has written to Gov Edmund G Brown protesting the proposed action saying it would be “a backward step for nursing education and a dangerous trend for the future of the profes- sion.“

Tips on contacting your state board Do you want an interpretation on the first assistant from your state board of nursing? Following these suggestions may help you in getting a ruling.

1. Call your state board of nursing and ask them what information they require.

2. Expect to submit your request for a ruling in writing. Address the inquiry either to the president or the executive director of the state board.

3. You will probably be asked to describe in writing the specific incident you would like a ruling on. You do not need to name the persons nor the hospital involved, although you may wish to indicate the area, for example, the Chicago area or a rural community.

4. You will probably be asked to define specific functions of the first assistant. The definition varies widely, and you will need to tell the board exactly what functions you want a ruling on.

5. You may be invited to appear at a meeting of the board of nursing to answer questions or elaborate on the material you have submitted.

6. If the board has not already taken a position, you can expect to wait for some time, since the board may need to consult the medical board and possibly the attorney general.

Once again, President Reagan is asking for big cuts in federal nursing education funds, as well as other health programs. The $12.5 mil- lion he proposes for nursing in 1983 would be 75% less than 1982 funding.

Patricia Patterson Associate editor

1226 AORN Journal, May 1982, Vol35, No 6