SHOW ME THE $$$!

Groetzsch, Grace

FACTORS TO CONSIDER WHEN LOOKING TO FINANCE A RNFA POSITION

Auteure : Grace Groetzsch, infirmière autorisée, baccalauréat en sciences infirmières, maîtrise en éducation, CPN(C), CRFNA, est une infirmière immatriculé première assistante au service de chirurgie cardiaque au Trillium Health Centre à Mississauga, Ontario, et infirmière-monitrice des assistants chirurgicaux au British Columbia Institute of Technology.

MONTREZ-MOI UARGENT!

FACTEURS À CONSIDÉRER LORS DU FINANCEMENT D’UN POSTE D’INFIRMIÈRE IMMATRICULÉE PREMIÈRE ASSISTANTE (IIPA)

De plus en plus, les hôpitaux voient dans le poste d’infirmière immatriculée première assistante une manière d’assurer la disponibilité d’une assistance rapide et qualifiée lors d’une intervention chirurgicale. Au Canada, le nombre d’IIPA augmente à chaque année. L’intérêt que suscite le poste accroît avec chaque individu qui se familiarise, soit par expérience directe, soit par les documents publiés, avec les avantages de ce rôle. Ce fait, de pair avec la réalité de la pénurie de médecins, mettent en relief l’importance du rôle de PIIPA dans plusieurs hôpitaux à travers le pays. Le financement du poste est un des plus grands défis auquels les hôpitaux, ainsi que les IIPA, font face lors de la transformation d’un besoin reconnu dans un poste d’IIPA salarié.

ABSTRACT

Increasingly hospitals are looking to the Registered Nurse First Assistant (RNFA) position as a means to ensure readily available, qualified assistance for a patient’s surgical intervention. Each year, in Canada, the number of RNFAs grows. As more individuals learn about the benefits of the position, through either direct experience or published reports, interest in the role increases. This, coupled with the reality of physician shortages, is bringing the RNFA role to the forefront in numerous hospitals across the country. Funding the position is one of the largest challenges that hospitals, and RNFAs, face in converting a recognized need into the reality of a paid RNFA position.

Increasingly hospitals are looking to the Registered Nurse First Assistant (RNFA) position as a means to ensure readily available, qualified assistance for a patient’s surgical intervention. Each year, in Canada, the number of RNFAs grows. As more individuals learn about the benefits of the position, through either direct experience or published reports, interest in the role increases. This, coupled with the reality of physician shortages, is bringing the RNFA role to the forefront in numerous hospitals across the country. Funding the position is one of the largest challenges that hospitals, and RNFAs, face in converting a recognized need into the reality of a paid RNFA position.

Why have hospitals with RNFA positions been successful? The reasons vary – not an answer that those struggling with the realities of implementing this position like to hear. Unfortunately it is not like a package of instant chicken soup – add hot water, stir, and voila! There are, however, common threads that should be considered by anyone investigating the RNFA position.

Firstly, the RNFA position is currently not a requirement in all hospitals. If surgical assistants (physicians or residents) are readily available the RNFA position has not been implemented. The RNFA has, however, had success in situations where physician/resident assistants are not available or where there is a shortage of available qualified assistants. The RNFA position is not intended as a replacement for all physician/resident assistants.

Secondly, hospital administration do not always appreciate that patient services and outcomes are being negatively impacted by a shortage of surgical assistants. It is not enough for operating room personnel to understand that additional surgical assistants are needed. Given that hospitals are generally the ones that finance the RNFA position it is of paramount importance that they understand the issues involved. Education is key to successfully implementing the RNFA position.

Beware of assumptions. Individuals working within the perioperative environment often assume that other healthcare workers understand what happens within the confines of the operating room environment. In the author’s experience those outside of the OR environment, including other nurses and physicians, often have very little understanding of what is involved in successfully completing a patient’s surgical experience.

Thus the challenges begin. Many healthcare providers do not understand that it takes a team of individuals to successfully complete an operation. The surgeon, in most cases, does not perform a procedure single-handedly. The team includes numerous personnel from nursing, anaesthesiology, and, in some specialty areas, registered respiratory therapy and perfusion. For the vast majority of operative procedures, the team includes a minimum of one surgical assistant. If a surgical assistant is unavailable procedures may be delayed or cancelled. Without a skilled surgical assistant, procedures can also take longer. It is well documented that a shorter operative procedure results in better patient outcomes.1’2 It is therefore imperative that everyone understands the significant role that a surgical assistant plays in a patient’s perioperative experience.

In Canada most surgical programs and hospitals do not pay directly for their surgical assistants traditionally surgical assistants are physicians (often family doctors) who bill the provincial healthcare plan for their assisting services. Some provincial health departments, like British Columbia’s, calculate precisely how much public money is paid out for surgical assistants.3 Most provinces, however, do not track this information.

Surgical residents also assist as part of their medical training, generally in teaching hospitals. Neither category of assistant, family physician or resident, is a hospital employee. Hospitals, therefore, do not have funds designated for surgical assistants. Being asked to fund a RNFA position is therefore something new – and something that there is no budget for.

It is relatively easy to do a side-by-side cost comparison between a full-time physician assistant and a RNFA. In unionized Ontario hospitals the bargaining unit for registered nurses (Ontario Nurses Association) has acknowledged the job classification of RNFA and RN/RNFA and a corresponding pay grid exists. For physician assistants access to the provincial fee schedule outlines remuneration for this position. A costeffective analysis4 demonstrates that RNFAs provide cost effective care based on monetary reward alone. Additional benefits that a RNFA brings to the environment have been described in a previous article (see CORN] – June 2003 ‘Why A RN First Assistant? A Look at the Benefits….’}. But for a hospital that has never had to budget for surgical assistants the $60,000 to $75,000, plus benefits, annual cost for each RNFA is significant. Ensuring that hospital administrators and finance personnel understand the importance of the assistant position, and the impact it has on delivery of care, is paramount to justifying this budget increase.

Thirdly, assumptions are often made about the quality of assistants available. Many individuals assume that the physician or resident assistant has the ability to complete surgery if something untoward should happen to the surgeon. In some rare instances a surgical assistant could complete the surgery. In most cases, however, this would not be true. The surgical assistant plays a complementary role to the surgeon – not an identical one. If something should happen to the surgeon intraoperatively then another surgeon would be called in.

Unbeknownst to most family physicians do not receive any special training to act as surgical assistants. Physicians may, or may not, have some experience depending on the electives they chose in medical school. Representatives of the Ontario Medical Association (OMA) and the Ontario College of Family Physicians acknowledge that most physician assistants do not have the ability to complete an operation should something happen to the operating surgeon.5 The role of a surgical assistant is, by definition, to assist. By virtue of their perioperative nursing background and formalized education RNFAs are well suited to act as surgical assistants.

Obtaining Funding:

There are ways for hospitals to fund RNFA positions. If the need is recognized, and patient care is being negatively impacted, hospitals, such as several in Ontario, are finding money within their budgets to fund RNFA positions. Both clinical (nursing and surgical) and administrative support are key to this method.

Some hospitals have chosen to assess the RNFA program via a pilot study. In this way funding is provided for a specific time period. Toward the conclusion of the study an evaluation determines the need for RNFA positions. Where there is a recognized need positions have often become permanent.

When a surgical program is implemented or expanded healthcare facilities submit funding proposals to the provincial government. At that time, the cost of RNFA positions can be factored into the cost of implementing/expanding the program. The case for including RNFAs must document a lack of surgical assistants or a quality initiative. In community hospitals this includes documentation that residents are not available and the difficulty of getting family physicians to assist, particularly during the day. The proposal should include the human resources aspect (i.e. number cases to be done, personnel required to do this, number of RNFAs to be utilized, outline of a job description) coupled with a financial impact statement. If the program/expansion is approved then the monies are available, and allotted, for RNFA positions. “Ask and ye shall receive!”

In an effort to retain experienced registered nurses some provincial nursing bodies are developing nursing initiatives that may be related to the RNFA position. For example, the Registered Nurses Association of Ontario is offering clinical fellowships that one hospital, and several RNFAs, are starting to take advantage of. This provides funding, for a short period of time, to evaluate the effectiveness of the RNFA position.

Thinking outside the box, coupled with a recognized need within the healthcare industry for surgical assistants, is the key to the financing of RNFA positions. By sharing their knowledge and resources employed RNFAs can help create additional RNFA positions. Information is key!

REFERENCES

1. Wysocki, Annete (1989). Surgical Wound Healing: A Review For PerioperativeNurses. AORN 49 (2) 508.

2. Mangram, A., Horan, T et al (1999). Guideline for Prevention of Surgical Site Infection, 1999. Infection Control and Hospital Epidemiology 20 (4), 256.

3. British Columbia Ministry of Health Services, Medical Services Plan.

4. Groetzsch, Grace. Cost Effective Analysis A RNFA working in cardiac surgery. Unpublished data, 1997/1998.

5. Ontario Medical Association. (January, 1998). Position Paper: Comments on Surgical First Assistant.

Additional Resources

Ontario Nurses Association, www.ona.org Registered Nurses Association of Ontario. www.rnao.org

Author: Grace Groetzsch RN, BScN, MEd, CPN(C), CRNFA, is a RNFA in the Cardiac Surgery department at Trillium Health Centre in Mississauga, Ontario, and a RNFA tutor for the British Columbia Institute of Technology.

Copyright Operating Room Nurses Association of Canada Dec 2004

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