In August of 1984, I entered nursing school. It was kind of through the back door. My mother was the owner of the local day care center and had an affiliation with the school of nursing. The students would rotate through the center to see well children as part of their education pertaining to normal growth and development. I was certainly qualified but knew it helped that my family had ties to the school. After my three years there, I graduated and the world was my oyster. (1) I was offered positions in various specialties at every institution I applied. I chose to work at a prestigious teaching institution in the operating room. I want to work in an environment where nursing and medical advancements occurred. I share this with you because I chose another back door while I was working there. I was asked by one of the orthopeadic surgeon's to work as his private first assistant. Not having a BSN or even more of an advanced degree, it was unusual get a private position. I accepted the position which came without a job description and a “we'll just figure it out as we go” motto. I was lucky. We did figure it out as we went. My role turned into a combination of the permanent intern, sorcerer of medical and cardiac clearance and general girl friday. I was thrilled to be such a part of this process. I performed initial physical exams, coordinated testing, dressing changes, casting, patient teaching, first assisted in the OR, hospital rounds and much more. Suddenly, my circumstances changed when I decided to have a family and one hundred to one hundred twenty hour work weeks were no longer acceptable to me. My skills, that were never formally taught, were not transferable. I never took the time to complete my degree let alone attain my formal RNFA. The back door I choose had left me with limited options and I returned to a staff nurse position in the same operating room. Today, sixteen years later I seek the front door to my anticipated position as a first assistant. A great hospital where nurses are a vital part of the process. A place were our Magnet status is a revered way of life not just a banner on the lobby wall. The old adage “necessity is the mother of invention” holds true.(2) The need for the expanded role of the registered nurse and many people's versions of this expanded role has lead to the need for the standardization of the role of the registered nurse first assistant. I will discuss the evolution of the registered nurse first assistant as the needs of the surgeon, nurse and patient invented this expanding role. Through out history, the tragedies of war have lead to the great progress in patient care and outcomes. For example triage systems were developed during world war II and trauma systems during the Korean and Vietnam wars.(3) This holds true for the evolution of the nursing profession as well. At times of war, as most can only imagine, supplies as well as personnel are limited. Such shortages in surgeons rendered the need for operating room nurses to expand their role at the operative field especially close to the battle fields. During time of peace, in the traditional operating room setting similar circumstances arose. Surgeon's found them selves in need of “another set of hands” and found themselves with out another available surgeon. Another purpose for surgeon's employing a personal first assistant was to provide continuity of care for himself in the OR and the patient through out their care. Having an assistant familiar with the entire process of the patient's perioperative course was beneficial to the patient and surgeon a like. Thus, the onset of nurses being trained to assist the surgeon. The practice of physicians hand selecting nurses to assist them has been occurring as far back as the early 1900's. Their down sides to this method of attaining an assistant. Not all surgeons who need an assistant are able to compressively educate the