RNFAs one innovative solution as hospitals cope with doctor shortage


Canadian hospitals are turning to innovative solutions to cope with the shortage of family physicians. One vital – yet largely unrecognized – innovation has been the introduction of registered nurse first assistants (RNFAs) in critical operating room roles. RNFAs have helped trim wait times for patients needing elective surgery.

RNFAs assist surgeons, in a role traditionally occupied by general practitioners (GPs) at community hospitals or physicians-in-training at teaching hospitals. But with the lack of availability of doctors – the Ontario Medical Association estimates the province is short approximately 2,000 doctors, impacting on cancellations or delays of elective procedures.

At Trillium Health Centre, the hospital employs two full-time and two part-time RNFAs, including the first RNFA employed in Canada. Trillium and ten other Ontario hospitals that employ RNFAs, shorten elective lists by ensuring procedures do not get cancelled, but they also help to keep health-system costs down: in general, it costs the system less to use an RNFA than a GP in the first assistant role.

Grace Groetzsch is the pioneer, the first RNFA at a Canadian hospital. At Trillium, all the RNFAs work in the top-rated cardiac program at the hospital, which has sites in Mississauga and Etobicoke.

“I don’t see myself as a trailblazer, I see myself as defining the role,” says Groetzsch. “It”s a brand new role, like the nurse practitioner role was 20 or 30 years ago… There are always bumps on the road when your path is unknown. But I believe very strongly this is here to stay.”

Despite this, RNFAs remain a largely unrecognized presence among the public. Only five provinces – Alberta, Ontario, Quebec, Nova Scotia and Newfoundland – employ them. Of 83,000 RNs in Ontario, fewer than 20 work full-time as RNFAs. (There are more than 4,000 in the United States.)

Funding remains the main obstacle to introducing a larger presence of the RNFA role in the current health care system. Family doctors, surgeons, and surgical residents are funded by outside sources, such as the fee-for-service arrangement of Ontario”s health plan. But if a hospital wishes to hire RNFAs, the money must come from the hospital”s budget.

“I’d like to see all hospitals take Trillium’s lead in engaging more RNFAs,” said Dr. Charles Cutrara, a cardiac surgeon at Trillium. “It’s great to have the skill set that RNFAs possess, especially with the current doctor shortage. RNFAs work in the operating room daily so they”ve been able to hone their skills more than GPs.”

Like present-day Florence Nightingales, RNFAs assist with several aspects of critical surgery. At Trillium, for example, Groetzsch takes a leading role in cardiac surgery. In a bypass, veins or arteries are often required as new vessel material. Groetzsch would procure the radial (arm) artery and assist in other procedures.

RNFAs fulfill other roles, such as communicating with post-operative areas, including intensive care units. RNFAs also meet with patients and their families before and after an operation and they may engage in research, such as monitoring patient clinical outcomes when a hospital uses new medical devices in procedures.

Trillium’s Groetzsch has pushed a greater profile for RNFAs. She helped set up a Website and establish an RNFA interest section group within the Registered Nurses Association of Ontario (RNAO). The hope is that the RNAO will approach the provincial government and Ontario Hospital Association to promote the benefits of the RNFA in the health-care system.

RNFA expertise requires specialized education. In Groetzsch”s case, she had to go to the United States – there was no RNFA program in Canada at the time. Now, two schools offer a one-year program – beyond the basic requirements of an RN education and a minimum five years of operating room experience.

“We have a lot of education to do on the fact that we exist, who we are and what we bring to the patient”s experience that is positive,”” said Groetzsch. “”The RNFA role is really still in its infancy and will take time.”