How to Become a Perioperative Nurse

Perioperative nurses help plan, carry out, and assess treatment for patients undergoing surgery. Working in hospital surgical departments, ambulatory surgery units, clinics, or physicians’ offices, these RNs are involved in the care of patients before, during, and after surgery.

Types of perioperative nurses include the following:

  • A scrub nurse is sterile and is responsible for choosing and handling instruments and supplies used during surgery. Duties include setting up a sterile area in preperation for surgery, helping the surgical team with gowns and gloves, and handing instruments to the surgeon.
  • The duties of a circulating nurse include developing a patient plan of care,  reviewing preoperative assessments with patients, and managing activities in the operating room. The circulating nurse is not sterile, but is there to serve everyone involved in a surgical procidure, not just the surgeon.
  • The RN first assistant (RNFA) assists during the operation by helping with surgical activities such as keeping bleeding under control, exposing wounds, and suturing, all under direction of the surgeon. Becoming an RNFA requires additional training beyond basic perioperative training.
  • A PACU (Post Anesthesia Care Unit) RN cares for patients immediately after surgical procedures and anesthesia.

Perioperative nurses may take on other roles, such as operating room business director, clinical educator, or researcher. Advanced practice registered nurses who have completed the appropriate graduate degree can work as certified registered nurse anesthetists (CRNAs) or surgical nurse practitioners.


Getting started in perioperative nursing typically requires at least one year of perioperative training. Although some nursing schools offer electives in perioperative nursing, most often nurses get their training through a post-bachelor’s non-degree granting perioperative certificate program or through on-the-job training programs at hospitals and surgery centers.

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Many programs are based on the standards set by the Association of periOperative Registered Nurses (AORN). Nurses can also take AORN’s online program, “Periop 101: A Core Curriculum.”

Nurses who want to become RN First Assistants need additional education through an RN First Assistant Program. Programs are available both through colleges and other continuing education organizations. Different programs are available for both experienced perioperative nurses and for nurse practitioners who have little perioperative experience.

With the exception of some perioperative clinical nurse specialist programs for military nurses, master’s degrees specific to perioperative nursing aren’t widely available. Becoming a surgical nurse practitioner requires a master’s degree or higher in a nurse practitioner program followed by perioperative subspecialty certification. NP programs don’t offer a surgical specialty, so students can choose any primary specialty patient population focus that supports their goals after graduation.

Nurses who want to become certified registered nurse anesthetists (CRNAs) need to complete a Master of Nurse Anesthesia program.

Perioperative Nurse Certification

The Competency and Credentialing Institute (CCI) is the only accredited credentialing program for perioperative RNs and offers the CNOR certification. The CNOR serves as documented validation that a nurse meets identified standards of practice in caring for patients before, during, and after surgery. The requirements to take the CNOR exam are as follows:

  • A current unrestricted RN license
  • Current full- or part-time employment in perioperative nursing in clinical practice, nursing education, administration, or research
  • Completion of at least two years and 2,400 hours of experience in perioperative nursing, with a minimum of 1,200 hours in the operating room

The 185-question exam covers the following topics (% of questions):

  • Intraoperative activities (31%)
  • Preoperative patient assessment and diagnosis (14%)
  • Cleaning, disinfecting, packaging, sterilizing, transporting, and storing instruments and tools (12%)
  • Developing individualized plans of care and identifying expected outcomes (9%)
  • Communication (9%)
  • Emergency situations (8%)
  • Managing personnel, services, and material (6%)
  • Professional accountability (6%)
  • Transfer of care (5%)

Recertification is every five years, with four recertification options available: completing continuing education contact hours, earning a minimum number of points in such ways as taking part in professional activities, passing a recertification exam, or maintaining a professional portfolio that documents continued perioperative competence.

CCI also offers the Certified Registered Nurse First Assistant (CRNFA) credential for registered nurse first assistants. To take the CRNFA exam, a nurse must meet the following requirements:

  • A current, unrestricted RN license
  • Either have CNOR certification or be an advanced registered nurse practitioner with a specialty certification
  • Have a bachelor’s degree in any field
  • Documented completion of a formal RNFA program that’s on CCI’s acceptable program list
  • Documented completion of a minimum of 2,000 hours of practice as an RNFA, including patient care before, during, and after surgery. At least 500 of hours must have been during the two years immediately before applying for the CRNFA exam.  Up to 600 of the hours may be in pre- and postoperative patient care, and at least 1,400 hours must be in intraoperative practice.

The questions on the CRNFA exam are 70% about intraoperative patient care and 30% about pre- and postoperative patient care. The questions cover:

  • Basic Sciences (18%)
  • Assessment Techniques (20%)
  • Intraoperative (55%)
  • Professional Practice  (9%)

Recertification of the CRNFA is every five years. Three routes to recertification are available: completing a specified number of continuing education contact hours, earning a minimum number of points in ways such as participating in various professional activities, or passing a recertification exam.

A nurse who has obtained both CNOR and CRNFA certifications needs only to meet the CRNFA requirements to be recertified for both credentials.

Specialty Certifications

Nurses who work in plastic surgery can become a Certified Plastic Surgical Nurse (CPSN) through the American Society of Plastic Surgical Nurses (ASPSN). To apply to take the exam, nurses must have a current RN license in the U.S. or Canada and at least two years of experience in plastic surgical nursing during the five year period prior to applying. Plus, they must have spent at least one-half of their practice hours in plastic surgical nursing during two of the five years prior to applying.

The American Association of Critical-Care Nurses Certification Corporation offers an Adult Cardiac Surgery Subspecialty Certification (CSC) for nurses who provide critical or acute care to adult patients in the first 48 hours after cardiac surgery. The American Society For Metabolic And Bariatric Surgery offers a Certified Bariatric Nurse (CBN) program for nurses involved in the care of bariatric surgery patients.

Registered Nurse First Assistants may want to pursue a credential as a Certified Surgical First Assistant (CSFA) through the National Board of Surgical Technology and Surgical Assisting.


The Association of periOperative Registered Nurses provides nursing education and clinical practice resources, such as the peer-reviewed AORN Journal. AORN has local chapters around the U.S.

Specialty associations include the American Society of Plastic Surgical Nurses and the American Pediatric Surgical Nurses Association. For nurse anesthetists, there’s the American Society of PeriAnesthesia Nurses and the American Association of Nurse Anesthetists.

Perioperative Nurse Salaries

The 2011 AORN Salary Survey found the following base annual salaries for full-time perioperative nurses.

Job Title
Small Facility (< 10 ORs)
Staff Nurse
Hospital/Facility Administrator
Vice President/Director/Assistant Director of Nursing
Nurse Manager/Supervisor/Coordinator/Team Leader/Business Manager
Educator/Staff Development
Clinical Nurse Specialist (Master’s Degree or Higher)
No Data
RN first assistant

The survey found that nurses with CNOR certification make about $1,400 more a year than nurses without CNOR certification. Nurses with a master’s degree in nursing make about $4,400 more in annual base salary than nurses without one. Nurses with a master’s degree in another field make about $6,100 more than nurses without a master’s.

The AORN survey broke down annual base salaries for staff nurses by facility type:

Facility type
Average Staff Nurse Base Salary
Acute Care Hospital/General/Community
Acute Care Hospital/Specialty
Acute Care Hospital/University/Academic
Ambulatory Surgery Center/General/Community
Ambulatory Surgery Center/University/Academic

In addition to base salary, 65 percent of nurses in the survey received additional pay from sources such as overtime, shift differential, on-call compensation, and bonuses.

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The salaries presented above represent all perioperative nurses. According to the National Salary Report 2011 from Advance for NPs and PAs, the average annual salary for nurse practitioners working in a surgery setting was $91,023.

According to the December 2010 Scrubs Magazine, certified registered nurse anesthetist is the highest paying nursing specialty. These advanced practice registered nurses, classified with perioperative nursing, earn an average annual salary of $135,000.

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