My Specialty

Certified RN First Assistant, Bobbie Barraza, MemorialCare, Long Beach Medical Center

Performing surgical procedures independently

Bobbie Barraza, RN, BSN, BBA, CNOR, CRNFA
Cardiovascular Operating Room Certified Registered Nurse First Assistant and Resource Coordinator
MemorialCare Medical Group — Long Beach Medical Center

Tell us about your position and responsibilities.

As a certified registered nurse first assistant (CRNFA) in cardiovascular and thoracic surgery, I assist the surgeon during surgery by manipulating tissue, suturing, retracting, etc.

I also perform my own surgery, in which I endoscopically harvest the saphenous vein and prepare the vessel for bypass while the surgeon prepares the thoracic area for the procedure; we work in tandem.

How many hats do you wear during one workday?

On any given day, I serve in four distinct roles: CRNFA, resource coordinator, scrub nurse and circulating nurse. I basically provide whatever the patient, the case and the unit need at any given time. In my position, you honestly have to know everything about each of those roles and be able to step in at a moment’s notice.

Was this something you always wanted to do?

This was very much my dream. As a nursing student, I did an operating room rotation for just one day and knew right then that the OR was for me.

However, I never in a million years thought that I would actually have the opportunity because it’s so intense and such a competitive specialty to break into. I was an ICU nurse and I really enjoyed it, but I learned that if a chance to land a spot in a perioperative program comes along, I needed to seize the opportunity because it won’t come around very often.

So, it’s all about carpe diem and just going for it if you know you want it.

Yes, exactly, and that’s what I did.

Tell us about your career path.

After I graduated from nursing school, I wanted to be accepted into a high-quality perioperative program, so I waited until one was hiring. I worked first on a surgical stepdown unit, and then moved to ICU. In the meantime, I figured the experience of caring for post-surgical transplant patients would serve me well in the OR.

You broke some new ground at MemorialCare, didn’t you?

I did — I was the first cardiac RNFA hired on staff in the organization’s history. It’s been very exciting for me, since it’s helping to pioneer and pave the way for other RNFAs. This role is fairly unique to MemorialCare; many facilities don’t utilize RNFAs. I’m very proud that MemorialCare has us in the main operating room and the cardiovascular operating room (CVOR).

What I really like about my position in the CVOR is that my team is very supportive of one another. I have the resources I need to provide true patient-centered care. My team is highly specialized, and every single member can be counted on to know exactly what to do. We’re always one step ahead, and everyone always wants to pitch in and help.

What else do you find unique and exciting about this role?

Our team is very focused on the latest evidence, paying close attention to new developments and breakthroughs.

We’ve recently been building our expertise in performing hybrid procedures, which are cutting-edge approaches that allow us to perform minimally invasive surgery. (The “hybrid” aspect is that we have a super-high-tech room that fully integrates the cardiac OR and the cath lab.)

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We also serve as the aortic dissection center for all of our sister hospitals within the health system, providing what I see as the gold standard of care.

Not too long ago, cardiac cases were all big open-chest procedures, and now we do most of them in a minimally invasive manner. This decreases risk for the patient and the surgeon, reduces hospitalization time and hastens recovery.

Long Beach Memorial is also a center of excellence for robotic thoracic surgery. Surgeons and their teams from other states come to learn these robotic procedures from us. I am proud to say that I helped build this program, and I’m very excited that we are now building the robotic cardiac surgery program as well.

Can you describe a hybrid cardiac surgical procedure?

A good example would be for a patient who needs an aortic valve replacement, but is too high-risk to have an open-heart procedure.

In order to maximize the potential for a highly successful outcome, we would perform a transcatheter aortic valve replacement. This involves inserting a catheter percutaneously through a large vessel in the groin and then deploying the new valve through the catheter, whereupon it expands and pops into place.

With this procedure, the damaged valve doesn’t even have to be removed. Once the new valve is sitting in the proper orientation, it simply takes over the work of the damaged valve.

How scary was it to walk into the OR for the very first time and know you were responsible for such a key role?

I honestly felt very nervous and anxious because I knew that I had to perform under extreme pressure and I was afraid I would falter.

My mentors really helped reassure me; they stood by me to make sure I was always one step ahead. Because of their consistent support, my nervous anxiety faded away. Before I knew it, they were stepping back and I was doing things on my own. Even flying solo, I felt like they were with me because I felt so supported.

I really had the best experience as a perioperative nurse. I learned from the best and rotated through every single service line: general, pediatrics and everything else.

In the end, I didn’t choose to go into cardiac — that team actually chose me! They could see that I had the right personality and the right feel for the niche. They initially put me in vascular, then thoracic, and then I was ready for cardiac. It was very comforting that they could see something I didn’t even know was there.

What’s it like to perform surgery on your own?

It’s the most amazing feeling in the world to know that you’re helping to increase the quality of a patient’s life and decrease their hospital stay by performing endoscopic saphenous vein harvesting.

For decades, surgeons would dissect the leg to access the saphenous vein, which could cause significant postoperative pain. Now, we can simply harvest out of two or three tiny pea-sized incisions. This is much less painful for the patient, decreases infection risk and speeds healing.

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It’s equally amazing to be in the position of helping the surgeon in this capacity. It would take them an extra hour to do what I do, so surgical time is shortened significantly since we work simultaneously.

What qualifications are needed to perform such procedures as a nurse?

You need special training and credentials. First, you earn your BSN. Next, you obtain a position in a perioperative program in order to learn how to scrub and circulate in all service lines.

After two years, you’re eligible to become CNOR-certified, and then you can attend an accredited registered nurse first assistant (RNFA) school for didactic instruction and first assisting hours under the direct mentorship of a physician.

Once you complete 2,000 clinical hours as an RNFA, you are then allowed to sit for certification as a CRNFA and earn your full certification. To put this all into context, I began serving as an RNFA in 2013, and I just recently completed my hours and submitted my portfolio, receiving my certification in May 2021!

It almost seems like the same amount of time someone would spend in medical school and an internship.

Yes, it’s very similar in terms of how long it takes to earn full certification and do the amazing things I get to do every day.

Do you have any tips for nurses interested in following a similar professional path?

If you’re interested in this field, you should keep in mind that opportunities are currently very limited in California, since not many facilities utilize RNFAs. However, there’s a lot more demand for us in other states.

Should a new nurse who’s very certain about their interest in perioperative nursing go straight into a perioperative program out of school, or should they do a few years in med-surg first?

If I were a new graduate with that desire and I had the opportunity to get into a good perioperative program, I would take it without reservation. These programs provide an extensive education on all standards of care. It’s just like going to school, and you’re going to learn every single thing you need to know about the intraoperative process.

If a nurse goes directly into periop out of school and then decides it isn’t for them, will that harm their career prospects?

When I graduated, I was totally clear and knew exactly what I wanted. However, if you’re not confident in your skills or have any doubts, it might behoove you to begin on the floor and receive your clinical grounding there.

If you’re already in a perioperative program and truly aren’t sure, it’s better to speak to your instructor and make a decision right then and there. There are options to transfer out to other areas in perioperative care.

If someone does transfer out, where should they go?

Transitioning from perioperative to critical care is a possibility, but you might experience culture shock. It can be done, but you need to find a program that will mentor and support you.                          Alternatively, you might consider transferring from OR to preop or PACU, which would give you some critical care experience, if you still have your sights on critical care.

What do you foresee for yourself in the future?

I love to teach and mentor, so supporting new RNFAs and perioperative nurses who have just entered the field is something I would like to focus on more in the future. I’ve been asked to mentor main operating room RNFAs in harvesting veins, and I’m excited to have the opportunity to support my colleagues in that role.

During the COVID-19 surges, I did a great deal of safety education to help protect our patients and staff. Long-term, I can see myself in an educator role. I believe in supporting my teammates, and I’m here to help in any way I can.

Our surgical approach is definitely the wave of the future. We’re going to see more and more patients undergoing high-tech hybrid procedures and minimally invasive surgeries, which will shorten hospital stays; decrease infection risk; and significantly reduce morbidity, mortality and rehospitalization. I’m proud to be part of such a cutting-edge team, and I look forward to what we’ll see as the years go by.


Keith Carlson, RN, BSN, CPC, NC-BC, has worked as a nurse since 1996 and offers expert professional coaching at www.nursekeith.com. 


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