Court Opinion

ID: 4249478
Source: CourtListenerOpinion
Date Created: 2018-02-28 21:18:55.173057+00
Date Added: 2024-06-11T14:44:03.259992
License: Public Domain

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 Medicare-
       certified 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 ARNP-
supervised 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.