IN THE SUPREME COURT OF IOWA

No. 11–1977

Filed May 31, 2013

IOWA MEDICAL SOCIETY 

and IOWA SOCIETY OF ANESTHESIOLOGISTS,

Appellees,

vs.

IOWA BOARD OF NURSING,

Appellant,

and

IOWA ASSOCIATION OF NURSE ANESTHETISTS 

and IOWA NURSES ASSOCIATION,

Appellants,

and

IOWA OSTEOPATHIC MEDICAL ASSOCIATION,

Appellee.

Appeal from the Iowa District Court for Polk County, Artis I. Reis, 

Judge.

The Iowa Board of Nursing and intervenor nursing associations 

appeal from the district court’s decision invalidating two administrative 

rules permitting advanced registered nurse practitioners to supervise 

fluoroscopy. REVERSED AND REMANDED WITH INSTRUCTIONS.

Thomas J. Miller, Attorney General, and Chantelle C. Smith and 

Sara M. Scott, Assistant Attorneys General, for appellant Iowa Board of 

Nursing. 
2

James W. Carney and George W. Appleby of Carney & Appleby, 

P.L.C., Des Moines, for appellant Iowa Association of Nurse Anesthetists. 

Judith R. “Lynn” Boes and Jodie C. McDougal of Davis, Brown, 

Koehn, Shors & Roberts P.C., Des Moines, for appellant Iowa Nurses 

Association. 

Douglas A. Fulton and Paul A. Drey of Brick Gentry, P.C., 

West Des Moines, for appellee Iowa Medical Society.

Nicholas J. Mauro of Crawford Quilty & Mauro Law Firm, 

Des Moines, for appellee Iowa Society of Anesthesiologists. 

Kimberly Bartosh and Erik S. Fisk of Whitfield & Eddy P.L.C., 

Des Moines, for appellee Iowa Osteopathic Medical Association. 
3

WATERMAN, Justice.

In this appeal, we must decide whether the Iowa Board of Nursing

and Iowa Department of Public Health exceeded their regulatory 

authority by enacting rules allowing advanced registered nurse 

practitioners (ARNPs) to supervise radiologic technologists using 

fluoroscopy machines. Several physician associations brought this court 

action against the nursing board and the department of public health to 

invalidate the rules. Two nursing associations intervened to defend the 

rules. The district court, on cross-motions for summary judgment, 

invalidated the rules after concluding that ARNP supervision of 

fluoroscopy has not been “recognized by the medical and nursing

professions” within the meaning of Iowa Code section 152.1(6)(d) (2009), 

and the nursing board and the department of public health exceeded 

their authority in promulgating the rules. The nursing board and 

nursing associations appealed.

The Iowa legislature expressly granted the nursing board

interpretive authority as to chapter 152. See Iowa Code § 147.76. In 

Renda v. Iowa Civil Rights Commission, we recognized that such a grant 

of interpretive authority requires deferential review of the agency’s 

interpretation of the statute and its application of law to fact. 784 

N.W.2d 8, 11 (Iowa 2010). By contrast, without a legislative grant of 

interpretive authority to the agency, we interpret the statute de novo, as 

is exemplified in our opinion in Iowa Dental Ass’n v. Iowa Insurance 

Division, ___ N.W.2d ___, ___ (Iowa 2013). Applying Renda, we conclude

that the nursing board’s application of law to fact is not irrational, 

illogical, or wholly unjustifiable. We also conclude the rules fall within 

the authority of the nursing board and department of public health, and 

the other challenges to the rules fail. Accordingly, the rules at issue 
4

must be upheld. We therefore reverse the decision of the district court 

and remand for further proceedings consistent with this opinion. 

I. Background Facts and Proceedings.

We begin with an overview before a more detailed discussion of the 

record. The challenged rules are Iowa Administrative Code rules 655—

7.2(2), adopted by the nursing board, and 641—41.1(5)(n), adopted by 

the department of public health. The rulemaking process preceding 

adoption of these rules generated extensive public comments supporting 

and opposing the rules as proposed. Supporters advocated adoption of 

the rules to improve access to healthcare (particularly in rural areas), 

enhance the safety of certain procedures, lower costs, and clarify the 

authority for existing practices ongoing for many years in parts of Iowa, 

which had been approved by various hospital credentialing committees

staffed in part by physicians. Those opposed to the rules cited concerns 

with whether ARNPs were adequately educated and trained in radiation 

safety to supervise radiologic technologists, as well as other safety 

concerns, albeit without documenting a single injury attributable to an 

ARNP-supervised fluoroscopy procedure. The rules were adopted by the 

nursing board and the department of public health in June 2009 and 

April 2010, respectively. No objection to the rules was raised by the 

legislature’s Administrative Rules Review Committee (ARRC), the 

governor, or the attorney general. Proposed legislation to nullify the 

rules failed in 2010. The battle moved to the courtroom. 

On June 21, 2010, petitioners Iowa Medical Society and Iowa 

Society of Anesthesiologists filed petitions for judicial review against the 

nursing board and the department of public health. The district court 

granted motions to intervene by the Iowa Osteopathic Medical 

Association opposing the rules, and by the Iowa Nurses Association and 
5

Iowa Association of Nurse Anesthetists supporting the rules. The district 

court invalidated both rules by summary judgment. The nursing board, 

Iowa Nurses Association, and Iowa Association of Nurse Anesthetists 

appealed. The department of public health did not appeal. 

We will now undertake a more detailed review of the agency record 

upon which our decision is based. 

A. Rulemaking Proceedings. In December 2006, a radiologic 

technologist contacted the department of public health’s Bureau of 

Radiologic Health to inquire about who could supervise his operation of a 

fluoroscopy1 machine. The department of public health and the bureau

 

1The district court described fluoroscopy as a “real-time medical imaging 

technology that employs a beam of radiation to project a real-time visual image of the 

body onto a monitor screen.” According to the American College of Radiology:

Fluoroscopy is frequently used to assist in a wide variety of medical 

diagnostic and therapeutic procedures, both within and outside of 

radiology departments. Fluoroscopic equipment capabilities have 

changed dramatically in recent years. Modern fluoroscopic equipment is 

capable of delivering very high radiation doses during prolonged 

procedures. There have been reports of serious skin injuries in some 

patients undergoing certain fluoroscopically guided procedures. 

Therefore, the use of fluoroscopy in medical institutions must be 

proactively managed to reduce patient radiation exposures to levels that 

are as low as reasonably achievable consistent with the medical demands 

of the procedures for which fluoroscopy is used. Management of the use 

of radiation must also ensure adequate safety of medical personnel 

involved in these procedures.

ACR Technical Standard for Management of the Use of Radiation in Fluoroscopic 

Procedures Preamble 1 (Am. Coll. of Radiology) (rev. 2008), available at

http://www.acr.org/~/media/ACR/Documents/PGTS/standards/MgmtFluoroProcedur

es.pdf. 

ARNPs utilize fluoroscopy in numerous procedures they perform within the 

scope of their practice, including peripheral insertion of an extended length intravenous 

central catheter (PICC line), swallow studies, foreign body location, precise needle 

location for procedures such as breast biopsy, and interventional pain management. 

Use of fluoroscopy in these procedures allows the ARNP to see the precise spot to inject 

the medicine or to insert the vascular device. If ARNPs were not permitted to supervise 

fluoroscopy, the procedure would either need to be done blind or by a physician or 

under the supervision of a physician. 
6

began collaborating with the nursing board to address the inquiry and, 

ultimately, to develop rules permitting ARNPs2 to supervise fluoroscopic 

procedures performed by radiologic technologists. At that time both 

boards were aware that hospitals across the state had been 

credentialing3 ARNPs to supervise fluoroscopy and that several ARNPs

had reportedly been supervising fluoroscopy for over twenty years. 

The nursing board and the department of public health noted the

ARNPs who were currently supervising fluoroscopic procedures may have 

been acting within the scope of their practice under the then-existing 

rules, but recognized those rules were unclear. The rule existing at that 

time provided that “[t]he use of fluoroscopic X-ray systems by radiologic 

technologists and students shall be performed under the direct 

supervision of a licensed practitioner of the healing arts for the purpose 

 

2An advanced registered nurse practitioner is 

a nurse with current licensure as a registered nurse in Iowa or who is 

licensed in another state and recognized for licensure in this state . . . . 

The ARNP is prepared for an advanced role by virtue of additional 

knowledge and skills gained through a formal advanced practice 

education program of nursing in a specialty area approved by the board. 

In the advanced role, the nurse practices nursing assessment, 

intervention, and management within the boundaries of the nurse-client 

relationship. Advanced nursing practice occurs in a variety of settings, 

within an interdisciplinary health care team, which provide for 

consultation, collaborative management, or referral. The ARNP may 

perform selected medically delegated functions when a collaborative 

practice agreement exists.

Iowa Admin. Code r. 655—7.1. The board of nursing has recognized four different 

specialty areas of nursing practice for advanced registered nurse practitioners: certified 

clinical nurse specialists, certified nurse–midwifes, certified nurse practitioners, and 

certified registered nurse anesthetists. Id. r. 655—7.2(1). 

3Each hospital has a credentialing and privileging committee. Those committees 

are generally comprised of several physicians and other hospital administrators and 

medical staff members. ARNPs who wish to use fluoroscopy in their practice must first 

become credentialed and privileged to do so. The hospital committee considers 

numerous factors, including the ARNP’s specific educational background, actual 

experience in performing the procedure, and any identified problems they have had in 

practice. See id. r. 481—51.5(4). 
7

of localization to obtain images for diagnostic purposes.” Iowa Admin. 

Code r. 641—41.1(5)(l)(2) (2008). “Licensed practitioner of the healing 

arts” is not included in the definition section in chapter 41; however, 

individual definitions for “licensed practitioner” and “healing arts” appear 

in an earlier chapter’s definitions. See id. r. 641—38.2. Although found 

in a different chapter, these definitions apply to the rules found in 

several later chapters, including chapter 41. See id. (“As used in these 

rules, these terms have the definitions set forth below and are adopted 

by reference and included herein for 641—Chapters 39 to 45.”). 

“Healing arts” is broadly defined in chapter 38 as 

the occupational fields of diagnosing or treating disease, 

providing health care and improving health by the practice of 

medicine, osteopathy, chiropractic, podiatry, dentistry, 

nursing, veterinary medicine, and supporting professions, 

such as physician assistants, nurse practitioners, radiologic 

technologists, and dental hygienists.

Id. (emphasis added). The term “licensed practitioner” is more narrowly 

defined as 

a person licensed or otherwise authorized by law to practice 

medicine, osteopathy, chiropractic, podiatry, or dentistry in 

Iowa, or certified as a physician assistant as defined in Iowa 

Code section 148C.1, subsection 6, and is authorized to 

prescribe X-ray tests for the purpose of diagnosis or 

treatment.

Id. Nurse practitioners are not mentioned in this definition. Thus, 

supervision of fluoroscopy procedures performed by radiologic 

technologists was not within the scope of practice for ARNPs under the 

definitions contained in chapter 38 and applicable to the rule found in 

chapter 41. 

On December 15, the nursing board made a finding that the scope 

of practice for ARNPs includes the ability “to order, perform, supervise 

and interpret x-ray tests [including fluoroscopy] for the purpose of 
8

diagnosis or treatment.” The nursing board’s finding garnered support 

from the Iowa Hospital Association,

4 the Iowa Association of Nurse 

Anesthetists,

5 and the Iowa Nurses Association. The nursing board’s

finding, however, was opposed by physicians’ groups, including the Iowa 

 

4In a letter dated March 11, 2008, the Iowa Hospital Association confirmed that 

ARNPs working for rural hospitals were already supervising fluoroscopy:

To assess the current extent of this issue, the Iowa Hospital Association 

has recently verified with many rural hospitals across the state that the 

practice of ARNP’s performing procedures with the assistance of 

fluoroscopy is either currently being done or will be done in the near 

future. Coincidentally, this practice has been supported and even 

encouraged by medical providers within these communities.

5The Iowa Association of Nurse Anesthetists submitted a letter to the nursing 

board that focused on the absence of any injuries resulting from certified registered 

nurse anesthetist supervision and the importance of the access it provides to patients 

in rural communities:

No safety violations by CRNAs using fluoroscopy have been reported to 

the Board of Nursing, the IANA or the Bureau of Radiologic Health. The 

malpractice rates of CRNAs in Iowa have decreased, also indicating our 

continued safe practice. CRNAs are the sole providers of anesthesia 

services in over 90 of the 121 hospitals in Iowa. To limit the use of a tool 

that has the potential for enhancing the safety of our existing practices 

without any evidence of actual harm will impose severe limits on access 

to care for citizens who rely on CRNAs to provide these services 

presently. ARNPs have been able to order, perform, interpret and 

supervise X-ray tests for many years without adverse outcomes, and we 

should be allowed to continue to do so. The citizens of Iowa depend on 

our services, and restricting their access to high quality, safe care by 

limiting which tools we are able to use is not in the best interests of Iowa.
9

Medical Society,

6 the Iowa Society of Anesthesiologists, and the Iowa 

Board of Medicine.7 

The discussions and debate continued for another three years. The 

department of public health noticed a proposed amendment to its 

subrule 41.1(5) in early 2007, but rescinded the proposed rule after 

receiving considerable opposition from physicians’ groups.8 In June 

2008, the nursing board rescinded its finding and continued working 

with these groups. In the end, after three years of collaboration, the 

 

6The Iowa Medical Society argued that the rule was overly broad, that ARNPs do 

not receive sufficient education and training to supervise fluoroscopy, that permitting 

certified registered nurse anesthetists “to supervise fluoroscopy is in direct 

contradiction to national radiologic standards,” and that “supervision” as defined in 

Iowa Administrative Code chapter 42 

requires more oversight than telling a radiation technologist to “push a 

button.” In consideration of public safety and applying the minimum 

standard necessary to ensure public safety, for CRNAs to adequately 

supervise a student or radiologic technologist, a CRNA would have to 

obtain equal or greater training than the radiologic technologist.

7The Iowa Board of Medicine’s letter to the board of nursing stated as follows:

In addition to reviewing the current regulations, the Board considered 

CRNA education and found that it does not routinely and sufficiently 

cover radiology. Radiation exposure in fluoroscopy far exceeds that of a 

regular X-ray. With public safety in mind, the Board chose, at its 

November 7–8, 2007 meeting, not to write a new policy but to ask the 

Department of Public Health to enforce current policy that forbids a 

CRNA from supervising a radiologic technologist or student in the use of 

fluoroscopy. 

The Board understands the difficulties this may impose but finds the 

public health consequences warrant enforcement at least until other 

arrangements can be made for CRNAs to become more educated in 

radiology. The Board is willing to consider proposals in this regard.

8The board of nursing’s finding and the department of public health’s proposed 

rule, in addition to activities in other states, prompted a resolution from the American 

Medical Association stating that organization “encourage[s] and support[s] state medical 

boards and state medical societies in adopting advisory opinions and advancing 

legislation, respectively, that interventional pain management of patients suffering from 

chronic pain constitutes the practice of medicine.” Am. Med. Ass’n House of Delegates, 

Resolution: 903 (I-07), Interventional Pain Management: Advancing Advocacy to Protect 

Patients from Treatment by Unqualified Providers 2 (2007).
10

nursing board and department of public health were unable to reach a 

workable compromise with these groups. On September 11, the nursing 

board referred the issue to its ARNP Advisory Committee to begin the 

rulemaking procedure.

1. The nursing board’s rulemaking procedure. The nursing board

published its notice of intended action for its rule on April 22, 2009. The 

comment period for the rule was left open until June 3. Comments in 

support of the rule were received from several organizations, including 

the Iowa Association of Nurse Anesthetists, Iowa Nurse Practitioner 

Committee, the Iowa Hospital Association, and the Iowa Nurses 

Association. The nursing board also received comments in support of 

the rule from certified registered nurse anesthetists, hospitals, radiologic 

technologists, and physicians.

The Iowa Association of Nurse Anesthetists noted ways the rule will 

enhance patient safety and access to health care, and observed the 

absence of any reported injuries from ARNP-supervised fluoroscopy. The 

Iowa Hospital Association’s letter of support for the rule noted that “[t]he 

proposed amendment would assure that ARNPs receive initial training in 

radiation physics, radiobiology, radiological safety and radiation 

management and additional annual training on time, dose, shielding and 

the effects of radiation.” The nursing board also received supporting 

comments in letters from rural hospitals regarding their existing reliance 

on the supervision of fluoroscopy by a subspecialty of ARNPs. The Iowa 

Nurses Association observed the rule reflected existing practice.

The nursing board received comments in opposition from the board

of medicine and several physicians’ organizations, including the Polk 

County Medical Society, American Society of Radiologic Technologists, 

Iowa Society of Anesthesiologists, Iowa Medical Society, and the Iowa 
11

Radiologic Society. Individual comments opposing the proposed rule 

were received from radiologists, doctors, radiologic technologists, a 

dentist, and an associate professor for Trinity College of Nursing & 

Health Sciences’ radiology program. The opposition focused on whether 

it was appropriate and safe for ARNPs to supervise persons who had 

more knowledge and experience in radiology and on whether the 

educational requirements set forth in the rule would adequately resolve 

this knowledge gap. One commentator, a radiologist from Cedar Rapids, 

raised concerns about radiation risks and inadequate training.

The professor at Trinity College expressed her concern that ARNPs,

who “receive no education in radiation, radiation biology, or radiation 

protection,” would be supervising her students who “receive [hundreds] 

of hours of instruction solely on radiation protection and then many, 

many hours of practical application with skilled practitioners critiquing 

their radiation safety practices.” The American Society of Radiologic 

Technologists opposed the proposed rule on grounds that one who 

supervises a procedure should be able to perform it. The Iowa Board of 

Medicine formally objected to the proposed rule because it viewed the 

ARNPs’ training as insufficient. 

The Iowa Society of Anesthesiologists’ objection focused on “the 

proposed rule[’s] attempts to expand nursing practice into the area of 

chronic interventional pain medicine, a highly specialized field that 

constitutes the practice of medicine,” and which involves life-threatening 

risks because it requires “[p]lacement of needles in proximity to vital 

spinal and vascular structures under fluoroscopic guidance.” 

Accordingly, the Society contended that “[i]f complications do arise, the 

physician must know how to respond correctly and immediately in order 

to avoid a disastrous outcome. Failure to understand any of the above 
12

can ultimately lead to paralysis, stroke, or death.” The Society also 

disputed proponents’ contention that this expansion was necessary to 

ensure patients in rural areas had access to chronic-pain medicine: “No 

deprivation exists for any patient in Iowa with regard to access to chronic 

pain medicine, because no Iowan lives more than two hours from a 

physician board certified in pain medicine.” The Society further disputed

the proponents’ assertion that ARNPs have been supervising fluoroscopy 

for over twenty years, noting that “most procedures currently being 

taught within accredited pain medicine fellowships did not exist in their 

current forms prior to this decade.” A physician downplayed the safety 

record of fluoroscopy by warning that it may take years for cancer to 

manifest from radiation exposure. 

A public hearing for the rule was held on June 3. Twenty-two 

people attended the hearing, including representatives from the Iowa 

Nurses Association, the Iowa Association of Nurse Anesthetists, the Iowa 

Association of Nurse Practitioners, the Iowa Department of Public Health, 

the Iowa Radiological Society, the Iowa Medical Society, and the board of 

medicine. The nursing board’s notice of the adoption and filing of ARC 

7888B summarized the commentary from the public hearing as follows:

Comments opposing rules stated that education required 

was less than required of the radiological technologist or non 

radiological physician, did not require direct supervision by a 

radiologist, does not require the establishment of a 

collaborative practice agreement with a physician and is not 

recognized by the medical professions as being within the 

scope of practice. Comments also focused on radiological 

exposure of individuals involved. Comments supporting rule 

change were received from radiological technologists, 

physicians, hospital administrators, nurses, advanced 

practice nurse and associations. 
13

The nursing board adopted rule ARC 7888B on June 10 and 

published the rule on July 1, with an effective date of August 5. The rule 

as promulgated provides:

7.2(2) Supervision of fluoroscopy. An advanced 

registered nurse practitioner (ARNP) shall be permitted to 

provide direct supervision in the use of fluoroscopic X-ray 

equipment, pursuant to 641—subrule 42.1(2), definition of 

“supervision.” 

a. The ARNP shall provide direct supervision of 

fluoroscopy pursuant to the following provisions:

(1) Completion of an educational course including 

content in radiation physics, radiobiology, radiological safety 

and radiation management applicable to the use of 

fluoroscopy, and maintenance of documentation verifying 

successful completion. 

(2) Collaboration, as needed, as defined in rule 655—

7.1(152). 

(3) Compliance with facility policies and procedures. 

b. The ARNP shall complete an annual radiological 

safety course whose content includes, but is not limited to, 

time, dose, distance, shielding and the effects of radiation. 

c. The ARNP shall maintain documentation of the 

initial educational course and all annual radiological safety 

updates. 

d. The initial and annual education requirements are 

subject to audit by the board pursuant to 655—subrule 

5.2(5). 

Iowa Admin. Code r. 655—7.2(2) (2009). The following definition of 

“supervision” appeared in Iowa Administrative Code rule 641—42.1(2) at 

the time the nursing board adopted its rule:

“Supervision” means responsibility for and control of 

quality, radiation safety and protection, and technical 

aspects of the application of ionizing radiation to human 

beings for diagnostic or therapeutic purposes. Indirect 

supervision is being physically present in the immediate 

vicinity and able to assist if needed. Direct supervision is 

physically observing and critiquing the actual procedure and 

giving immediate assistance if required. 

Id. r. 641—42.1(2).
14

2. The department of public health’s rulemaking procedure. The 

department of public health published notice of ARC 8161B on

September 23, 2009. The proposed rule rescinded Iowa Administrative 

Code rule 641—41.1(5)(l)(2) and enacted rule 641—41.1(5)(n) in its place. 

The comment period for the rule was left open until December 7, during 

which time the department of public health received comments in 

support of the rule from organizations, including the Iowa Association of 

Nurse Anesthetists, the Iowa Hospital Association, rural clinics, and

individual health care practitioners such as certified registered nurse 

anesthetists, doctors of osteopathy, physicians, and radiologic 

technologists. In a letter dated May 4, 2010, setting forth a concise 

statement regarding its adoption of rule 641—41.1(5)(n), the department 

of public health summarized the comments it received in support of the 

proposed rule as follows:

1) Patient Safety. Fluoroscopy provides a visual image 

to make the procedures safer and more effective for patients. 

Fluoroscopy assists the practitioner in visualizing the precise 

location to inject a medication or place a device, which leads 

to better outcomes for patients than using a blind technique.

2) Sufficient Training Requirements. The training and 

education requirements promulgated by the Iowa Board of 

Nursing ensure the safe and competent supervision of 

radiologic technologists. 

3) Anesthesia Services. Hospitals and clinics rely on 

CRNAs for anesthesia services. Many rural hospitals rely on 

CRNAs to provide all of their anesthesia services and utilize 

fluoroscopy as an important component of patient care. 

4) Access to Care. ARNPs provide access to care in 

rural Iowa. If ARNPs are not authorized to supervise this 

procedure it would impede access to quality patient care for 

rural Iowans. 

5) Codifies Existing Practice. The rule codifies 

existing practice. ARNPs have been authorized to order and 

supervise radiologic procedures for over twenty years; they 

have ordered and supervised fluoroscopy when necessary. 

The Iowa Board of Nursing has confirmed that it is within 

the ARNP’s scope of practice to provide direct supervision in 
15

the use of fluoroscopic x-ray equipment and that ARNPs 

have utilized fluoroscopy for years for four primary purposes: 

(1) location of a foreign body; (2) needle localization for 

procedures such as breast biopsies and chronic pain 

treatments; (3) swallow studies; and (4) insertion of extended 

length IV lines (PICC lines).[9] 

6) History of Safe Use. ARNPs have a history of safe 

utilization of fluoroscopy while supervising radiologic 

technologists. There are no documented cases of 

misadministration or injuries resulting from ARNPs 

supervising fluoroscopic procedures.

7) Use by Other Health Care Providers. The rules 

currently authorize [physicians’ assistants] to directly 

supervise radiologic technologists using fluoroscopic 

equipment, which establishes a precedent for ARNPs to 

perform this function given their similar level of educational 

training and classification as independent practitioners. 

8) Standards from Other States. Several surrounding 

states authorize CRNAs to utilize and supervise fluoroscopy. 

The department of public health received comments in opposition 

to the rule from the board of medicine, the Iowa Medical Society, the

Iowa Society of Anesthesiologists, the Society of Interventional Radiology, 

the American College of Radiology, and the Iowa Radiologic Society, as 

well as from individual radiologic technologists, physicians, and 

professors. The department of public health summarized these 

comments in its concise statement:

 

9The nursing board submitted a supporting comment, which noted as follows: 

ARNPs currently perform a variety of procedures with the use of 

fluoroscopy. ARNPs have provided safe and prudent care to Iowans with 

the use of fluoroscopy for several years. 

Fluoroscopy is used by ARNPs for the following purposes: 

1. Location of a foreign body.

2. Needle localization, i.e., breast biopsy and chronic pain 

treatment.

3. Swallow studies.

4. Insertion of extended length IV lines (PICC).
16

1) Patient Safety. Patients can be harmed if 

fluoroscopic-guided procedures are performed incorrectly, 

including substantial increases in radiation doses to patients 

when the fluoroscopist does not use proper technique or 

when unnecessary procedures are performed. Conditions 

which require fluoroscopy are by their nature complex and 

this patient population is vulnerable to over-treatment, 

incorrect treatment, and complications. Only appropriately 

trained physician specialists should supervise these 

procedures. 

2) Education and Training Insufficient. The nursing 

curriculum for ARNPs does not include adequate training in 

fluoroscopy, radiography, radiation safety, radiation 

management, or radiation biology. In addition, the training 

and education rules adopted by the Board of Nursing are 

insufficient to ensure competency and safety. As a result, 

ARNPs lack the education, training, and experience to 

supervise fluoroscopy. Only appropriately qualified 

physicians have the skills, training, and experience to safely 

supervise this procedure.[10]

3) National Medical Standards. The rule contradicts 

national medical standards. The American College of 

Radiology Standards for Use of Radiation in Fluoroscopic 

Procedures provides guidelines on supervision of fluoroscopy 

which recommend supervision by a radiologist or other 

qualified physician. 

4) Inclusion of all ARNPs is Overly Broad. The 

inclusion of all areas of ARNPs, as opposed to solely 

including CRNAs, creates an overly broad rule. 

5) Scope of Practice. According to the Board of 

Medicine and various medical associations, it is outside the 

scope of practice of an ARNP to supervise fluoroscopy. 

6) Rule Inconsistent with Practice in Other States. 

Several states do not authorize ARNPs to perform or 

supervise fluoroscopy. 

 

10A letter dated October 23, 2009, from the American Society of Radiologic 

Technologists asserted as follows:

[A]n individual who supervises someone performing a procedure should 

have at least the same requirements. Under the current language, you 

will regularly have the supervisor knowing considerably less about the 

safe operation of medical imaging equipment than the technologist he or 

she supervises. Such a situation is not conducive to providing quality 

health care.
17

The department of public health held a public hearing for the rule 

on October 28, 2009. Representatives from professional organizations on 

both sides of the issue attended, as did representatives from the boards 

of nursing and medicine. Rule ARC 8161B was adopted at a hearing 

held on March 10, 2010. At that time, the nursing board described the 

results of its survey of the use of fluoroscopy by ARNPs in Iowa. The 

nursing board mailed 1459 letters to ARNPs and received 387 responses

from ARNPs practicing in Iowa; forty-three reported that they use 

fluoroscopy in their practice. These forty-three ARNPs who use 

fluoroscopy in their practice reported the length of their use as follows:

0–5 years 6–10 years 11–15 years 16-20 years >20 years

 33 4 3 0 3

The department of public health published its rule on April 7, with 

an effective date of May 12. This rule provides:

n. Supervision of fluoroscopy. The use of fluoroscopy 

by radiologic technologists and radiologic students shall be 

performed under the direct supervision of a licensed 

practitioner or an advanced registered nurse practitioner 

(ARNP), pursuant to 655–subrule 7.2(2), for the purpose of 

localization to obtain images for diagnostic or therapeutic 

purposes. The use of fluoroscopy by radiologist assistants 

shall be defined in 641—42.6(136C). 

Iowa Admin. Code r. 641—41.1(5)(n). 

According to its concise statement regarding the adoption of this 

rule, the department of public health identified the following as its 

principal reasons for overruling the opposition’s concerns with the rule:

1. The comments received from CRNAs, physicians, 

hospitals, and several associations support a finding that 

ARNPs are currently supervising fluoroscopic procedures in 

this state and that such practice has been longstanding. 

ARNPs are currently supervising fluoroscopic procedures in 

several areas of practice, including needle localization and 

insertion of PICC lines. 
18

2. The Iowa Department of Public Health and the 

State Board of Health were not provided with any 

documented evidence that the supervision of fluoroscopy by 

ARNPs has resulted in any misadministration or reportable 

injuries in this state. Rather, the preponderance of the 

comments and testimony support the position that the 

supervision of fluoroscopy enhances patient safety and 

patient access to care. The State Board of Health is 

cognizant of the needs of rural Iowans and recognizes that 

many areas of this state rely on ARNPs and [physicians’ 

assistants] to provide health care to Iowans. The State 

Board of Health is concerned that its failure to adopt this 

rule would impede access to care for Iowa’s rural patient 

population. 

3. The Iowa Department of Public Health and the 

State Board of Health have expressed to the Iowa Board of 

Nursing a need to address training and education for ARNPs 

that supervise fluoroscopy. In response, the Iowa Board of 

Nursing established rule 655 IAC 7.2(2) which outlines 

specific educational requirements for their licensees that 

supervise these procedures. The Iowa Department of Public 

Health and the State Board of Health find that these 

educational requirements are sufficient to ensure 

competency to supervise these procedures and that the rule 

provides an ARNP in a supervisory role adequate knowledge 

about the risks associated with the use of fluoroscopy. 

4. Arguments that these rules conflict with the 

national standard of care focus on the American College of 

Radiology (ACR) Technical Standard for Management of the 

Use of Radiation in Fluoroscopic Procedures (Revised 2008). 

In the Preamble of this document, ACR clearly articulates 

“These standards are an educational tool. . . . They are not 

inflexible rules or requirements of practice and are not 

intended, nor should they be used, to establish a legal 

standard of care.” In light of the purpose for these 

standards, the fact that ARNPs have a history of supervising 

fluoroscopic procedures in this state, and the fact that other 

states authorize ARNPs and CRNAs to supervise fluoroscopy, 

the Iowa Department of Public Health and the State Board of 

Health find that the adopted rule does not conflict with legal 

standards of care or the standard of practice in Iowa. 

3. Legislative and executive review. The legislature’s ARRC met on 

July 14, 2009, and reviewed the nursing board’s adopted rule ARC 

7888B. The ARRC made a “general referral” of the rule to the general 

assembly, which means the ARRC recommended the rule be considered 
19

by the entire general assembly. See Iowa Code § 17A.8(7). The “general 

referral” did not delay the effective date of the rule. 

Although permitted to do so pursuant to Iowa Code section 

17A.4(6)(a), neither the governor, attorney general, nor the ARRC filed an 

objection with the nursing board or the department of public health

alleging that either rule was “unreasonable, arbitrary, capricious, or 

otherwise beyond the authority delegated to the agency.” Similarly, the 

governor did not exercise his ability to “rescind [the] adopted rule[s] by 

executive order” as provided for in section 17A.4(8). 

Legislation was later proposed to overturn these rules. Senate 

Study Bill 3085 would have prevented ARNPs from using fluoroscopy in 

pain management. See S.S.B. 3085, 83rd G.A., 2d sess., explanation 

(Iowa 2010) (“This bill specifically defines the practice of chronic 

interventional pain medicine and the techniques used in that practice. 

The bill limits the practice of interventional pain medicine to licensed 

physicians, podiatrists, or dentists.”). House File 2136 would have 

prevented ARNPs from providing chronic pain management intervention 

to patients. H.F. 2136, 83rd G.A., 2d sess. (Iowa 2010). House Joint 

Resolution 2006 would have nullified the nursing board’s rule.11 The 

legislature ultimately declined to enact any measure to overturn or limit 

the rules at issue. 

 

11The explanation for House Joint Resolution 2006 provided as follows: 

This joint resolution nullifies an administrative rule adopted by 

the board of nursing that allows an advanced registered nurse 

practitioner to provide direct supervision in the use of fluoroscopic X-ray 

equipment. The joint resolution takes effect upon enactment. 

H.J. Res. 2006, 83rd G.A., 2d sess., explanation (Iowa 2010).
20

B. District Court Proceedings. On June 21, 2010, the Iowa 

Society of Anesthesiologists and the Iowa Medical Society petitioned for 

judicial review of the rules promulgated by the nursing board and the 

department of public health. The Iowa Society of Anesthesiologists is a 

statewide organization comprised of anesthesiologists practicing in the 

fields of anesthesiology and pain management. The Iowa Medical Society 

is a statewide nonprofit professional organization representing 

approximately 5200 medical and osteopathic physicians. Their petitions

urged the court to invalidate the rules as exceeding the regulators’ 

authority because the medical profession had not recognized supervision 

of fluoroscopy as being within the scope of practice of ARNPs, and the 

operation of radiation machines was within the exclusive purview of the 

department of public health. The district court consolidated the actions 

on August 11 and entered an order staying the rules on November 23. 

Meanwhile, the district court granted motions to intervene in 

support of the rules filed by the Iowa Association of Nurse Anesthetists 

and the Iowa Nurses Association, respectively, in the consolidated action. 

The Iowa Nurses Association is a statewide, nonprofit organization 

representing registered nurses licensed to practice in Iowa. The Iowa 

Association of Nurse Anesthetists is a statewide organization that 

represents certified registered nurse anesthetists licensed to practice in 

Iowa. The district court also granted a motion to intervene in opposition 

to the rules filed by the Iowa Osteopathic Medical Association, a 

statewide, nonprofit organization that represents osteopathic physicians 

licensed to practice in Iowa.

The parties filed cross-motions for summary judgment. The 

district court held a hearing on the motions for summary judgment on 

September 9, 2011. After finding that “none of the material facts at issue 
21

in this matter are in dispute,” the district court granted summary 

judgment on October 31. The district court concluded that the nursing 

board and department of public health’s rules were “invalid, illegal, void

and of no effect.” The order stated in part:

33. The Iowa Board of Nursing itself, both in its 

rulemaking process and in its support of the Iowa 

Department of Public Health rulemaking, could not set forth 

or point to any recognized standards showing that the 

medical or nursing professions have recognized ARNP 

supervision of fluoroscopy either in national training, 

education or curriculum standards. In fact, the Iowa 

Association of Nurse Anesthetists admitted during the 

rulemaking process that CRNAs—an even smaller 

subspecialty in the scope of nursing—do not receive 

sufficient training at the University of Iowa Nurse Anesthesia 

program to make CRNAs competent to utilize fluoroscopy in 

practice. 

34. The medical profession’s objections and [the 

nursing board’s] survey . . . demonstrate as a matter of law 

that ARNPs’ “direct supervision” of fluoroscopy as the term is 

defined within these rules is not a recognized practice by the 

medical profession. As such the [nursing board’s] rule 

exceeds its statutorily delegated authority and violates Iowa 

law. 

The district court also invalidated the department of public health’s rule 

as promulgated on “the mistaken impression that [the nursing board’s]

action in expanding the scope of practice for ARNPs was a legitimate 

exercise of its statutory authority.” 

Citing to Iowa Code section 136C.3, the district court also found 

that the department of public health could not delegate its duty to 

“establish minimum criteria and safety standards, including continuing 

education requirements, and administer examinations and disciplinary 

procedures for operators of radiation machines and users of radioactive 

materials,” to the nursing board. Accordingly, the district court 

concluded that ARNPs could only provide “ ‘direct supervision’ of 

fluoroscopy as the term is defined within the Iowa Administrative Code, 
22

[if] they . . . satisfy minimum education and safety standards, including 

continuing education requirements and an examination established by 

the Iowa Department of Public Health.” 

The nursing board and intervenors supporting the rule appealed. 

We retained the appeal. 

II. Scope of Review. 

Judicial review of agency rulemaking is governed by Iowa Code 

chapter 17A. Auen v. Alcoholic Beverages Div., 679 N.W.2d 586, 589 

(Iowa 2004). “[T]he district court acts in an appellate capacity.” City of 

Sioux City v. GME, Ltd., 584 N.W.2d 322, 324 (Iowa 1998). “We review 

the district court’s decision to determine whether it correctly applied the 

law.” Id. The agency decision is reviewed under section 17A.19(10). 

Auen, 679 N.W.2d at 589. We apply that section to determine whether 

we reach the same result as the district court. Id. The legislature has 

clearly vested the nursing board with rulemaking and interpretive 

authority for Iowa Code chapter 152 governing the practice of nursing. 

See Iowa Code § 147.76 (“The boards for the various professions shall 

adopt all necessary and proper rules to administer and interpret this 

chapter and chapters 148 through 158, except chapter 148D.”

(Emphasis added.)); Renda, 784 N.W.2d at 11 (“The question of whether 

interpretive discretion has clearly been vested in an agency is easily 

resolved when the agency’s enabling statute explicitly addresses the 

issue.”); Houck v. Iowa Bd. of Pharmacy Exam’rs, 752 N.W.2d 14, 17 

(Iowa 2008) (recognizing section 147.76 vests interpretive authority in 

the licensing boards).

Accordingly, the following standards in section 17A.19(10) for

judicial review of agency rulemaking are applicable here:
23

The court may affirm the agency action or remand to the 

agency for further proceedings. The court shall reverse, 

modify, or grant other appropriate relief from agency action 

. . . if it determines that substantial rights of the person 

seeking judicial relief have been prejudiced because the 

agency action is any of the following:

. . . .

b. Beyond the authority delegated to the agency by 

any provision of law or in violation of any provision of law. 

. . . . 

l. Based upon an irrational, illogical, or wholly 

unjustifiable interpretation of a provision of law whose 

interpretation has clearly been vested by a provision of law 

in the discretion of the agency. 

m. Based upon an irrational, illogical, or wholly 

unjustifiable application of law to fact that has clearly been 

vested by a provision of law in the discretion of the agency. 

Iowa Code § 17A.19(10). 

Because the issues decided are legal in nature, we will review the 

district court’s summary judgment as though it were a ruling on the 

merits in a judicial review action. See GME, 584 N.W.2d at 324–25. 

“ ‘An agency rule is presumed valid and the party challenging the rule 

has the burden to demonstrate that a “rational agency” could not 

conclude the rule was within its delegated authority.’ ” Id. at 325 

(quoting Overton v. State, 493 N.W.2d 857, 859 (Iowa 1992)); see also 

Iowa Code § 17A.19(8)(a) (“[I]n suits for judicial review of agency action 

. . . [t]he burden of demonstrating . . . the invalidity of agency action is 

on the party asserting invalidity.”).

III. Analysis. 

Our review is “controlled in large part by the deference we afford to 

decisions of administrative agencies.” Cedar Rapids Cmty. Sch. Dist. v. 

Pease, 807 N.W.2d 839, 844 (Iowa 2011). In this case, the legislature’s 

express grant of interpretive authority dictates a deferential standard of 

review that requires reversing the district court and upholding the rules 
24

promulgated by the nursing board and the department of public health. 

See Renda, 784 N.W.2d at 11.

A. Recognition by the Medical Profession. The central issue is 

whether the district court correctly reversed the nursing board’s 

determination that the supervision of fluoroscopy procedures by ARNPs

is “recognized by the medical and nursing professions” within the 

meaning of Iowa Code section 152.1(6)(d).12 That determination involves 

 

12Iowa Code section 152.1(6) sets forth the scope of practice for registered 

nurses as follows:

The “practice of the profession of a registered nurse” means the practice of 

a natural person who is licensed by the board to do all of the following: 

a. Formulate nursing diagnosis and conduct nursing treatment 

of human responses to actual or potential health problems through 

services, such as case finding, referral, health teaching, health 

counseling, and care provision which is supportive to or restorative of life 

and well-being. 

b. Execute regimen prescribed by a physician, an advanced 

registered nurse practitioner, or a physician assistant. 

c. Supervise and teach other personnel in the performance of 

activities relating to nursing care. 

d. Perform additional acts or nursing specialties which require 

education and training under emergency or other conditions which are 

recognized by the medical and nursing professions and are approved by 

the board as being proper to be performed by a registered nurse. 

e. Make the pronouncement of death for a patient whose death is 

anticipated if the death occurs in a licensed hospital, a licensed health 

care facility, a Medicare-certified home health agency, a Medicarecertified hospice program or facility, an assisted living facility, or a 

residential care facility, with notice of the death to a physician and in 

accordance with any directions of a physician. 

f. Apply to the abilities enumerated in paragraphs “a” through “e” 

of this subsection scientific principles, including the principles of nursing 

skills and of biological, physical, and psychosocial sciences. 

Iowa Code § 152.1(6) (emphasis added); see also id. § 152.1(5)(a) (excluding from the 

practice of nursing “[t]he practice of medicine and surgery and the practice of 

osteopathic medicine and surgery, as defined in chapter 148, . . . except practices which 

are recognized by the medical and nursing professions and approved by the board as 

proper to be performed by a registered nurse” (emphasis added)). The Missouri Supreme 

Court has recognized the “ ‘thin and elusive line that separates the practice of medicine 

and the practice of professional nursing in modern day delivery of health services.’ ” 
25

the application of law—section 152.1(6)(d)—to fact, specifically the 

agency record. We must defer to the board’s application of law to fact 

unless it is “irrational, illogical, or wholly unjustifiable.” See Iowa Code

§ 17A.19(10)(m). We are required to view the nursing board’s 

determination through the prism of our deferential standard of review. 

The parties challenging the rules argue, and the district court 

ruled, the “medical profession” has not “recognized” ARNP supervision of 

fluoroscopy. Who speaks for the medical profession as to such 

recognition? The Iowa Board of Medicine, Iowa Medical Society, Iowa 

Society of Anesthesiologists, and Iowa Osteopathic Medical Association

all deny the medical profession has recognized ARNP supervision of 

fluoroscopy. Do they effectively have a veto over such a determination by 

the Board charged under Iowa law with the regulation of nursing?

Intervenor Iowa Nurses Association argues no such veto should be 

allowed:

[I]f the District Court’s ruling were to be upheld, it would 

fundamentally alter the nursing profession, as well as 

healthcare within Iowa, by allowing physician associations to 

have absolute veto power over any proposed new nursing 

rule, regardless of the actual opinions of Iowa physicians 

and of the actions of Iowa physicians in their privileging of 

nurses to perform various practices. 

Our court has not interpreted section 152.1(6)(d). But, the Office 

of the Iowa Attorney General addressed a related question in an opinion 

issued shortly after the enactment of this statute. In 1976, the executive 

director of the nursing board asked the Iowa Attorney General to give an 

____________________

Mo. Ass’n of Nurse Anesthetists, Inc. v. State Bd. of Registration for the Healing Arts, 343 

S.W.3d 348, 360 (Mo. 2011) (quoting Sermchief v. Gonzales, 660 S.W.2d 683, 688 (Mo. 

1983)). The court noted that at least forty state legislatures, including Iowa’s, have 

authorized “the broadening of the field of practice of the nursing profession.” Sermchief, 

660 S.W.2d at 690 & n.6. 
26

opinion as to “whether [the] board may define by rule those groups who 

are to define nursing practice for submission to the board.” 1976 Op. 

Iowa Att’y Gen. 727. The attorney general provided the following opinion 

regarding the interpretation of the nursing board’s authority under 

section 152.1(6)(d):

There is nothing in that section or in any other provision of 

the Act which makes [reference] to any specific medical or 

nursing groups. Your board has the ultimate authority to 

further define nursing, and the Legislature apparently wants 

you to receive input from the medical and nursing 

professions. However, there is nothing mandatory that you 

specifically name those organizations from which you will 

allow input. Since you have the duty to define nursing 

based upon input from others, it is entirely possible that the 

Legislature was intending to allow you to pick certain 

organizations, although it certainly did not so state. 

However, we deem such a move unwise, not in a purely legal 

sense, but because the greatest amount and variety of input 

should give you a better base from which to define nursing. 

Also, by specifically limiting such information to certain 

groups, the board may be binding itself for the future and 

may only be able to receive additional information by 

amendment of the rules. Your board also appears to be 

under the impression that medical or nursing organizations 

must define the practice of nursing and submit such 

definition to you for approval. We do not see anything in the 

Act which will lead to that conclusion. Again, the Legislature 

is giving you the opportunity to receive a great amount of 

input from the medical and nursing associations that will 

enable you to define nursing. 

Id. at 728–29 (emphasis added). 

We agree with the attorney general’s reasoning. The plain 

language of section 152.1(6)(d) allows the nursing board to decide 

whether the medical and nursing professions have recognized a 

particular practice of nurses. If the legislature had intended to give 

another agency or organization the power to determine recognition by the 

medical profession, it would have said so in this provision. See Auen, 

679 N.W.2d at 589 (“We determine legislative intent from the words 
27

chosen by the legislature, not what it should or might have said.”). We 

conclude the nursing board could apply section 152.1(6)(d) to determine 

that ARNP supervision of fluoroscopy is “recognized by the medical and

nursing professions” despite the opposition of the board of medicine and 

physician organizations. In light of the legislature’s express grant of 

interpretive authority to the nursing board, we are to uphold the board’s 

application of law to fact in this determination unless it is “irrational, 

illogical, or wholly unjustifiable.” Iowa Code § 17A.19(1)(l); see Auen, 679 

N.W.2d at 590; see also Renda, 784 N.W.2d at 11 (“The amendments to 

chapter 17A clarified when the court should give deference to an agency’s 

interpretation of law.” (citing Arthur Earl Bonfield, Amendments to Iowa 

Administrative Procedure Act, Report on Selected Provisions to Iowa State 

Bar Association and Iowa State Government 62 (1998))). Applying this 

deferential standard of review, we conclude the district court erred by 

reversing the nursing board’s determination. 

The agency record shows that the credentialing committees, which 

include physicians, at sixteen or more Iowa hospitals had granted 

privileges to ARNPs to supervise fluoroscopy. See Iowa Code § 135B.7(3)

(setting forth the criteria that must be included in the hospital’s rules 

governing the granting of clinical privileges to practitioners including 

ARNPs). Moreover, forty Iowa medical doctors wrote comments 

supporting the nursing board’s proposed rule. And, the board of 

medicine had never sought to enjoin any ARNP from supervising 

fluoroscopy as practicing medicine without a license, even though ARNPs 

had been doing so openly in Iowa for up to twenty years. We hold it was 

not irrational, illogical, or wholly unjustifiable for the nursing board to 

determine that ARNP supervision of fluoroscopy is recognized by the 

medical and nursing professions. 
28

A different standard of review explains the result in Spine 

Diagnostics Center of Baton Rouge, Inc. v. Louisiana State Board of 

Nursing. 4 So. 3d 854, 867–68 (La. Ct. App. 2008) (affirming declaratory 

judgment enjoining nursing board from allowing certified registered 

nurse anesthetists to practice interventional pain management). There, 

the appellate court reviewed the trial court’s declaratory ruling for abuse 

of discretion and the factual findings of the trial court (not the nursing 

board) under a “manifest error or clearly wrong standard.” Id. at 863. 

B. Supervision Versus Operation and Training Requirements. 

We next must decide whether the district court erred in invalidating the 

rules based on Iowa Code section 136C.3, which grants the department 

of public health control over the use of radiation machines, including the 

training requirements for operators. The district court invalidated the 

rules on grounds that the department improperly delegated to the 

nursing board the responsibility to specify the training required. The 

issue turns on the difference between “supervision” and “operation.” It is 

undisputed that ARNPs are not licensed to operate fluoroscopy 

machines. The parties challenging the rules contend an ARNP

responsible for supervising the use of fluoroscopy must be personally 

able to operate the equipment. The rules’ supporters disagree. No party 

cites any caselaw deciding this specific issue. 

The dispositive question is whether an ARNP who “directly 

supervises” the use of fluoroscopy is an “operator” of a radiation 

machine. The nursing board’s rule permits ARNPs “to provide direct 

supervision in the use of fluoroscopic X-ray equipment, pursuant to 

641—subrule 42.1(2), definition of ‘supervision.’ ” Iowa Admin. Code r. 

655—7.2(2). That rule defines “supervision” as follows:
29

“Supervision” means responsibility for and control of 

quality, radiation safety and protection, and technical 

aspects of the application of ionizing radiation to human 

beings for diagnostic or therapeutic purposes. Indirect 

supervision is being physically present in the immediate 

vicinity and able to assist if needed. Direct supervision is 

physically observing and critiquing the actual procedure and 

giving immediate assistance if required.

Id. r. 641—42.1(2) (2008) (emphasis added).

13 We see nothing in the 

plain language of the rules or statute that requires the ARNP supervising 

fluoroscopy to have the legal or technical ability to operate the 

equipment. Many professionals supervise work done by others without 

the license or ability to do the work themselves. For example, an 

architect or general contractor who is not a licensed electrician may

nevertheless supervise electrical wiring by licensed electricians in a 

construction project. We affirm the agency determination that a qualified

ARNP may directly supervise fluoroscopy without acting as an operator of 

the radiation machine within the meaning of chapter 136C. 

The department of public health considered and rejected the 

position by the physician groups opposed to the rules. The department’s 

concise statement regarding adoption of its rule specifically determined 

that the training for ARNPs was adequate for their supervisory role:

3. The Iowa Department of Public Health and the 

State Board of Health have expressed to the Iowa Board of 

Nursing a need to address training and education for ARNPs 

 

13The department of public health subsequently removed the definition of 

“supervision” contained in chapter 42, effective March 13, 2013. See Iowa Admin. Code 

r. 641—42.2 (Feb. 6, 2013). As with statutes, we continue to use the contemporaneous 

definition cross-referenced in the nursing board’s rule. See 2B Norman J. Singer & J.D. 

Shambie Singer, Statutes and Statutory Construction § 51:8, at 315 (7th ed. rev. 2012) 

(“Repeal of a referred statute has no effect on the reference statute unless the reference 

statute is repealed by implication with the referred statute.”); 73 Am. Jur. 2d Statutes

§ 16, at 256 (2012) (“The repeal of a statute cross-referenced in another statute does 

not render the descriptive reference inapplicable; instead, the court must look to the 

language of that section of the cross-referenced statute in effect at the time the specific 

cross-reference was enacted.”). 
30

that supervise fluoroscopy. In response, the Iowa Board of 

Nursing established rule 655 IAC 7.2(2) which outlines 

specific educational requirements for their licensees that 

supervise these procedures. The Iowa Department of Public 

Health and the State Board of Health find that these 

educational requirements are sufficient to ensure 

competency to supervise these procedures and that the rule 

provides an ARNP in a supervisory role adequate knowledge 

about the risks associated with the use of fluoroscopy. 

We believe the district court erred in second-guessing the 

department of public health and nursing board on the adequacy of ARNP 

training to supervise fluoroscopy. Significantly, nowhere in the 

voluminous record is there any report of an injury resulting from ARNPsupervised fluoroscopy, although the practice has been ongoing in parts 

of Iowa for many years. The record affirmatively shows ARNPs have been 

safely supervising fluoroscopy and are adequately trained to do so. The 

equipment at all times is operated by a licensed radiologic technician. 

The visual images provided by the fluoroscopy improve patient safety by 

guiding the precise placement of needles, insertion of PICC lines, location 

of foreign objects, and other procedures. Importantly, allowing ARNP 

supervision of fluoroscopy improves access to health care for rural 

Iowans and helps lower costs. We cannot conclude the agency 

rulemaking was irrational, illogical, or wholly unjustifiable. 

These regulatory judgments fall within the scope of the authority 

and expertise of the nursing board and department of public health. The 

challengers failed to meet their “burden to demonstrate that a ‘rational 

agency’ could not conclude the rule was within its delegated authority.” 

GME, 584 N.W.2d at 325 (citation and internal quotation marks omitted). 

IV. Conclusion. 

For the foregoing reasons, we hold the district court erred in 

invalidating the agency rules that allow qualified ARNPs to supervise 

fluoroscopy. Accordingly, we reverse the summary judgment of the 
31

district court and remand for entry of an order lifting the stay and

upholding Iowa Administrative Code rule 655—7.2(2) and rule 641—

41.1(5)(n). 

REVERSED AND REMANDED WITH INSTRUCTIONS. 

All justices concur except Cady, C.J., who dissents, and Zager, J., 

who takes no part.
32

#11–1977, Iowa Med. Soc’y v. Iowa Bd. of Nursing

CADY, Chief Justice (dissenting). 

I respectfully dissent. I would affirm the decision of the district 

court. 

Our legislature authorized the Iowa Board of Nursing (Board) to 

enact rules governing the nursing profession, including rules that 

address what constitutes the practice of the profession of a registered 

nurse. In addition to other acts, the Board may authorize registered 

nurses to perform acts “which are recognized by the medical and nursing 

professions . . . as being proper to be performed by a registered nurse.” 

Iowa Code § 152.1(6)(d) (2009). Our legislature directed that both 

professions must recognize the act as proper for registered nurses to 

perform. 

The question in this case is whether the nursing board properly 

found that the supervision of fluoroscopy by registered nurses is 

recognized by the medical profession as being proper for registered 

nurses to perform. The question is not whether the Board disagrees or 

agrees with the medical profession, but whether the medical profession 

approves the procedure as proper for registered nurses. 

The medical profession clearly does not approve the procedure at 

issue. Every Iowa medical professional society, board, or association 

that has weighed in on the question in this case has concluded the 

procedure should not be approved for registered nurses. The evidence to 

the contrary is merely anecdotal and basically limited to some opinions 

from individual doctors, and evidence that numerous hospital 

credentialing committees in Iowa have credentialed individual registered 

nurses to supervise fluoroscopy. See Iowa Admin. Code r. 481—51.5(4). 
33

There can be no doubt that the evidence in support of the Board 

action falls far short by any standard as a voice of the medical 

profession. Credentialing committees are not only comprised of 

physicians, but also include hospital administrators and medical staff 

personnel. Their collective voice is not the voice of the medical 

profession. Additionally, credentialing committees only address 

questions of the qualifications of individuals to perform particular 

procedures. A credentialing committee does not address the larger 

issues identified by the legislature in section 152.1(6) of whether the 

medical profession as a whole has approved a procedure as being 

properly performed by registered nurses. 

Registered nurses may be qualified to supervise fluoroscopy. Yet, 

the legislature has left it for the medical profession to make this decision, 

in partnership with the nursing profession. The legislature, however, did 

not leave it to the nursing board to decide. The Board clearly acted well 

beyond its authority, contrary to a clear legislative directive.