Evaluation and Program Planning 49 (2015) 117–123

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Evaluation and Program Planning

journal homepage: www.elsevier.com/locate/evalprogplan

Progress in centralised ethics review processes: Implications

for multi-site health evaluations
Brenton Prosser a,*, Rachel Davey a, Diane Gibson b
a
Centre for Research and Action in Public Health, University of Canberra, Bruce, ACT 2617, Australia
b
Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Increasingly, public sector programmes respond to complex social problems that intersect specific fields
Received 2 April 2014 and individual disciplines. Such responses result in multi-site initiatives that can span nations,
Received in revised form 30 September 2014 jurisdictions, sectors and organisations. The rigorous evaluation of public sector programmes is now a
Accepted 8 December 2014
baseline expectation. For evaluations of large and complex multi-site programme initiatives, the
Available online 14 January 2015
processes of ethics review can present a significant challenge. However in recent years, there have been
new developments in centralised ethics review processes in many nations. This paper provides the case
Keywords:
study of an evaluation of a national, inter-jurisdictional, cross-sector, aged care health initiative and its
Ethics
encounters with Australian centralised ethics review processes. Specifically, the paper considers
Centralisation
Multi-site progress against the key themes of a previous five-year, five nation study (Fitzgerald and Phillips, 2006),
Evaluation which found that centralised ethics review processes would save time, money and effort, as well as
Aged care contribute to more equitable workloads for researchers and evaluators. The paper concludes with
Nurse Practitioners insights for those charged with refining centralised ethics review processes, as well as recommendations
for future evaluators of complex multi-site programme initiatives.
ß 2015 Elsevier Ltd. All rights reserved.

1. Introduction
Historically in western nations, ethics approval processes for
medical and health studies have been localised, unregulated and
not conducive to large projects (Gold and Dewa, 2012; Snooks
et al., 2012). The recent growth in multi-site studies within health
research and evaluation has reinforced that previous arrangements
were inadequate (Hicks, James, Wong, Tebbutt, & Wilson, 2009;
Nowak et al., 2006; Studdert et al., 2010). As Gold and Dewa (2012)
explain, local ethics review mechanisms, when used with multi-
site studies, can jeopardise the integrity of methodological
approaches. Meanwhile, requests for the ethics review of non-
medical studies also grew dramatically throughout the 1990s. This
was due to both the expansion of evidence-based practices and an
explosion in applications from the humanities and the social
sciences (Fitzgerald & Phillips, 2006). Hence, a growing awareness
of the inadequacy of ethics review processes led to greater
* Corresponding author at: Centre for Research and Action in Public Health,
Building 22, University of Canberra, Bruce, ACT 2606, Australia.
Tel.: +61 2 62012914.
E-mail addresses: Brenton.Prosser@canberra.edu.au (B. Prosser),
Davey@canberra.edu.au (R. Davey), Davey@canberra.edu.au (D. Gibson).
advocacy for the streamlining of ethics approval for all research,
including evaluations of health initiatives.
International studies point to the significant advantages from
centralised ethics review processes. For instance, Canadian
research in the field of oncology found that centralised processes
sped up approvals, reduced duplication and resulted in higher
quality reviews (Chaddah, 2008). Meanwhile, research from the
United States highlighted the potential for centralised systems to
result in faster approvals for multi-site projects (Wagner, Murray,
Goldberg, Adler, & Abrams, 2010), and better targeting of expertise
in the context of increasingly complex proposals (McWilliams,
Hebden, & Gilpin, 2006). Tellingly, Fitzgerald and Phillip’s (2006)
five-year study of multi-site projects in Australia, Canada, New
Zealand, the USA and the UK, found that centralised ethics review
would save time, money and effort, as well as contribute to more
equitable workload and a stronger focus on issues of ethics (rather
than administration). The idea of a coordinated and centralised
ethics approval system soon took hold in the United States (Nowak
et al., 2006), the United Kingdom (Snooks et al., 2012) and Australia
(Studdert et al., 2010).
The case study that is considered in this paper is located within
the Australian context. The Australian Health Ministers’ Advisory
Council agreed in October 2006 to implement a national system

http://dx.doi.org/10.1016/j.evalprogplan.2014.12.021
0149-7189/ß 2015 Elsevier Ltd. All rights reserved.
118 B. Prosser et al. / Evaluation and Program Planning 49 (2015) 117–123
facilitating the recognition of a single ethical review process within
and across all Australian jurisdictions (National Health and
Medical Research Council [NH&MRC], 2013), it was named the
Harmonisation of Multi-centre Ethical Review (HoMER). It is now
over seven years since the establishment of this agreement and the
publication of the findings of the Fitzgerald and Phillip’s study.
Hence, we contend that it is timely to consider the progress that
has been made in centralised ethics review processes in Australia,
particularly in relation to the challenges faced by multi-site health
evaluations. Specifically, this paper provides a case study of
experiences with the HoMER process between 2011 and 2012 for a
national evaluation of diverse Nurse Practitioner models of aged
care that spanned Australian jurisdictions, sectors and organisa-
tions. As one case it is constrained in its scope, however, it is
indicative of potential areas for further examination, it provides
insights on which those charged with the process might reflect,
and where its insights aligns with existing literature (see Section
4), it reaffirms the need for continued effort in these areas.
2. Context: nurse practitioner aged care services in Australia
Australia, like many other industrialised countries, faces
unprecedented challenges in the provision of health care and
the prevention of disease for an ageing population. Attempts to
respond to these challenges have resulted in changing models of
health care and shifting professional role boundaries, including the
development of advanced practice roles for nursing. One such
advance practice role is that of nurse practitioners, which are now
well established in the United States and the United Kingdom. In
Australia, a Nurse Practitioner (NP) is a registered nurse who has
additional training, expertise and endorsement to provide
specialised health care services (Australian Nursing and Midwifery
Council 2012). This training enables them to take on roles that
support healthier communities, including the management of
medication and disease symptoms. This provides the potential for
them to play a valuable role with aged care in a range of health care
Box 1. Methodological flowchart.
settings. In recognition of these developments, the Australian
Government provided $18 m (between 2011 and 2014) to support
the Nurse Practitioner – Aged Care Models of Practice Program (the
NP Program).
The NP Program aims to establish the role of NP as a key provider
of aged care services across Australia. Thirty-two models were
selected by the Australian Government to provide a diverse
representation of jurisdictions, locations, service delivery settings,
aged care service needs and different cultural groups. The Australian
Government also provided funding for an independent evaluation of
the effectiveness, efficiency and financial sustainability of each of
the models. The evaluation of the NP Program was selected as a case
for this paper because the authors were chief investigators within
this evaluation and, hence, had first-hand access to all information
relating to the centralised ethics approval process.
The specific objectives and methods of the national evaluation of
the NP Program have been documented previously in this journal
(Prosser, Clark, Davey & Parker, 2013). However, they can be briefly
summarised as a mixed method evaluation approach (see Box 1),
which includes quantitative data on access to health services and the
economic viability of delivery models, as well as qualitative data on
the critical factors in the effectiveness of these models and different
accounts of stakeholder experiences. The final evaluation report is
due to be submitted to the Australian Government in early 2015.
3. Case study: centralised ethics review of the nurse
practitioner evaluation
Since 2006, the centralised ethics approval process in Australia
has been similar to that of the United Kingdom, where global
approval is gained prior to seeking local governance approval
(Snooks et al., 2012). The NP Evaluation applied for global ethics
approval from the University of Canberra Human Research Ethics
Committee (the global HREC) in late November 2011. This
application consisted of a covering letter, a National Ethics
Application Form (NEAF), and copies of data collection tools,
 B. Prosser et al. / Evaluation and Program Planning 49 (2015) 117–123
questionnaires and personal information and consent forms
(PICFs). Provisional approval was granted on the 9 December
2011 with a request for minor changes (as listed later in this
paper). The response of the global HREC noted that ‘‘all areas have
been thoroughly detailed and ethical issues have been very well
considered in this proposal’’. It also instructed the NP Evaluation
team to access the HoMER process to streamline local governance
approval for the thirty-two NP models which spanned several
jurisdictions. National ethics approval was granted on 18 January
2012.
In line with the instructions of the global HREC, the NP
Evaluation team accessed the HoMER process. In theory, this
involves contacting one centralised body in each of the eight
Australian states and territories, a process that was relevant in this
case for all jurisdictions other than one (due to it only having one
model in the NP Program). While information endorsing the
HoMER process was found on all jurisdictional websites, most did
not provide a single point of contact for ethics approval. However,
one jurisdiction had a centralised service to allocate multiple-site
applications to one local HREC. What follows is a short description
of the approval process for this jurisdiction.
3.1. Systematically centralised review processes
The central coordinating system (CCS) for ethics approval
allocation was contacted in early February 2012. A questionnaire
was completed over the phone and the application was automati-
cally allocated to a local HREC, with its next meeting on 6 March.
Subsequent to this meeting, a letter was received which stated that
approval could not be given without the provision of a research
protocol and PICF for Nurse Practitioners. In response, the
evaluation team explained that the application had already
provided a national research protocol (in the form of the NEAF)
and all consent forms (including one that combined NPs and allied
health professionals). The HREC replied that an appropriately
formatted protocol and PICF had not been supplied, without which
the application would not be progressed. In response, the research
team created a new protocol document (reformatted from the
Box 2. Ethics approval overview.
119
existing global NEAF), as well as a separate NP PICF (edited down
from the existing PICF). This administrative requirement resulted
in a further eight-week delay in approval of the evaluation.
The approval of this HREC was provisional on the successful
completion of Site Specific Assessments (SSA) for each site under
its jurisdiction. Site Specific Assessments are a form of assess-
ment that support centralised processes by considering local
impact. Their purpose is to ensure that each site has the
resources and governance structures necessary to support the
research. The SSAs were completed and sent to the relevant sites
for comment and signatures before sending to the jurisdictional
HREC for approval. For one site, the approval of SSAs was
straightforward. However in another, the local site requested
that an individual legal agreement between the universities
conducting the evaluation and the state government site. The
research team explained that legal agreements already existed
between the Australian Government (the funding body) and the
site, and between the Australian Government and the universi-
ties (the NP Evaluation team). Further, no other site in the project
had required a third legal agreement between the site and
evaluation team (due to there being no exchange of financial
resources between these bodies). The site insisted on its
conditions and the evaluation team then took legal counsel to
produce a legal agreement. This requirement delayed the
approval of the evaluation by a further five months, which
meant that the particular site was unable to participate in the
first of two national data collection periods and a planned site
visit was delayed. This highlights the significance of administra-
tive delays in the ethics review process.
3.2. Informally centralised review processes
Of the remaining six jurisdictions, three expressed support for
the centralisation of ethics review processes (see Box 2), but had no
formal processes in place. It should also be noted that at the time
none of these jurisdictions accepted the global NEAF document.
Rather, each jurisdiction had their own unique requirements and
NEAF forms. This involved transferring information across from the
120 B. Prosser et al. / Evaluation and Program Planning 49 (2015) 117–123
global NEAF to jurisdictional NEAF documents, and while a
national website has been developed to facilitate this administra-
tive task, it was still detailed and time consuming.
Of the three jurisdictions that expressed support for centralisa-
tion, informal arrangements were swiftly put in place for two. In
the third jurisdiction, the evaluation team was advised by the
central ethics contact in the health department to send an
individual ethics application to each of the six local HRECs.
However, an administration officer at one of the regional HRECs
intervened in February 2012 and made arrangements with
colleagues at the other relevant HRECs to bundle the applications
for consideration by one local HREC. This highlights the importance
of administrative support and individual initiative in the applica-
tion of HoMER principles.
However, securing local approval in the third jurisdiction was
complex due to the SSA requirements imposed by this HREC. The
evaluation team was instructed to provide details in relation to
governance arrangements and the resources available for individ-
ual models. This request created some difficulty as the university-
based evaluation team were not privy to the confidential funding
agreements between the Australian Government and the models,
which worked in both private and public sector context. Nor was it
able to access information about other matters (including
insurance, funding sources, and staffing allocations) prior to ethics
clearance being granted. Completing the SSA thus required an
additional effort by model representatives to obtain approval to
release governance and funding arrangements, to provide finan-
cially confidential information and to secure multiple signatures of
approval. In particular, this process of securing multiple signatures
from various levels of authority (for whom an ethics process is of
varying levels of priority), was extremely time consuming. This
process resulted in a further four-month period before ethics
approval was granted.
3.3. Non-centralised review processes
The remaining three jurisdictions provided no support for
centralisation of ethics approval for the NP Evaluation. That said, in
one of these jurisdictions, an administrative officer to a
Box 3. Identifying ethics affiliation flowchart.
departmental HREC agreed to accept all applications for that
state. However, once the application was considered by the HREC it
was returned stating it did not have the authority to consider non-
departmental models and the evaluation team was instructed to
make other arrangements. This points to a key challenge for
complex evaluations that include private business, community and
sole practitioner provided health services, in this case, the
difficulty was in identifying a HREC that would accept responsi-
bility for NP models. Of the thirty-two models in the project, fifteen
did not have existing HREC affiliations or established institutional
arrangements for ethical approval. In many cases, when the
evaluation team contacted potential ethics committees, they
responded that they could not, or would not affiliate with the
particular NP model. This process again resulted in significant
delays. Representatives of the NP models had been asked to
nominate a potential local HREC for affiliation, and for four sites,
approval was negotiated. If not recognised by an established HREC,
a request would then be sent to the governing body for the model
to request a letter accepting an affiliation with the global HREC and
acceptance of its approval (see Box 3). The period after global
approval to secure the local approval for these non-affiliated sites
was five months.
4. Discussion: progress in centralised ethics review in Australia
Although these changes are relatively recent and there is (as
yet) limited literature within the Australian context, the introduc-
tion of centralised ethics review processes in Australia has not
been without some criticism. Researchers using the HoMER system
initially found little change in approval times (Hicks et al., 2009),
with any time gained in centralised ethics approval absorbed by
expanded local approval processes. Olver, Falleiro, Marson, &
Bishop (2011) reported that while centralised ethics approval may
be faster, the associated administration procedures still need
serious reform. Meanwhile, Shelby James and colleagues (2010)
concluded that the new arrangements added cost and time (but
not value), to the ethics review process. The specific case of the NP
Evaluation provides little evidence to contradict these broad
criticisms.
 B. Prosser et al. / Evaluation and Program Planning 49 (2015) 117–123
However, we argue that more case studies and a more detailed
assessment of the progress of centralised ethics review processes
in Australia are warranted. Further, it is our view that the case of
the NP Evaluation (as a thirty-two site, inter-jurisdictional,
programme evaluation in an area of national health priority), is
an example of the sort of study that Fitzgerald and Phillips (2006)
had in mind when they conducted their detailed analysis of issues
for greater centralisation. In that paper, a five-nation study of
multi-site ethics review processes was presented and an argument
was made for improvement of both ethics and administrative
review procedures. Fitzgerald and Phillips made the distinction by
defining administrative processes as providing documentation,
managing applications, reviewing the format of documents,
ensuring that all forms had been completed, and providing a
conduit between the applicant and the committee. In contrast,
ethical processes were defined as the assessment of substantive
ethical issues related to the proposed research as considered
through a full committee process. Building on this distinction, we
will examine the challenges for centralised review according to
their ethical and administrative aspects.
Before doing so, it is important to place the following critique in
context. In their review, Fitzgerald and Phillips reported that
multi-site approvals take a minimum of two months, but on
average between six and twelve months. That the above case
included thirty-two sites and that full ethics clearance for the NP
Evaluation was secured in eleven months demonstrates that the
above case is not unique, but is broadly representative of other
complex, multi-site evaluations.
4.1. Insights into ethical approval processes
The global ethics approval request resulted in three requests for
amendments. These were that the language of PICFs be simplified
(given the inclusion of aged care participants), that it be made
clearer that the choice not to participate by elderly clients would
not impact on their care, and that more guidance be provided to
NPs around the appropriate collection of client consent forms. Each
of these requests were addressed to the satisfaction of the HREC
without problem. Meanwhile, the local governance ethics approval
identified resulted in seven requests in relation to ethical matters.
These were:
1. the dependence of elderly clients on NPs and preventing their
coercion to participate (4 HRECs);
2. the freedom of NPs to participate in the national evaluation,
when funding requirements made involvement in NP Program
compulsory (2 HRECs);
3. the protection of identity, confidentiality and privacy for
participants included in low unit or unique context data (2
HRECs);
4. the simplification of documentation to make it more accessible
to aged care clients (1 HREC);
5. the dependence of elderly clients on NPs and any preventing
change in care if clients decline to participate or withdraw (1
HREC);
6. the adverse time impact associated with NP participation (1
HREC); and
7. the clarification of provisions for indigenous Australian parti-
cipants (1 HREC).
Again, each of these requests were addressed to the satisfaction
of the particular HREC without problem.
However, the process of accessing centralised ethics approval
processes identified a number of other specific ethical challenges
for evaluations of health practitioner-based aged care policy
121
programmes. As Australians live longer than previous generations,
more people require care for the complex and chronic conditions
associated with greater longevity (Australian Productivity Com-
mission, 2011). These health trends present specific challenges for
centralised ethics review processes. For instance, early stage
dementia affects concentration and short-term memory, which
has implications for the informed consent of participants. While
standardised documentation can support centralised processes, it
can also result in the production of complex and lengthy
documentation which can be less accessible to elderly cohorts.
In this case study, nurse practitioners expressed concern on
numerous occasions that the required format of the PICFs
(including legal terms and complex language) made them
inaccessible to their aged care service clients (which had an
impact on rates of participation). Meanwhile, later stage dementia
also presents challenges for the NP Evaluation in relation to
securing consent from guardians with enduring power-of-attor-
ney. Australian jurisdictions have different legal arrangements, use
different terminology and require different documentation as
evidence of such arrangements. Having to address these complex-
ities within standardised ethics documentation as well as provide
additional documentary evidence to substantiate a dependent
relationship, resulted in additional layers of complexity and
administration for the nurse practitioners (and again had an
impact on rates of participation).
Another ethical consideration for evaluations of health service
provision to aged cohorts was the complex and rapidly changing
nature of illness trajectories. The requirement to pre-identify the
number of participants and the full nature of their needs proved
exceedingly difficult in this case study as it has with studies of
other vulnerable groups (Studdert et al., 2010). This difficulty was
not limited to mobile or community clinic contexts, where ‘who’
will present with ‘what’ was unknown on a daily basis, but also
included ensuring consent continued when health conditions
changed rapidly or after a client died. Further, a tension emerged
between the need to put in place processes that were sensitive to
the changing needs of palliative clients and the requirement to
produce standard protocols for all participants (Cadell et al., 2009).
Together, these examples point to issues of justice in relation to
recruitment and inclusion of aged care research participants, as
well as fair distribution of, and participation in, the benefits of
evaluations by significant groups within aged care client cohorts
(NH&MRC, 2007).
4.2. Insights into administrative approval processes
While matters related to gaining ethical approval were not
substantial in our case, there were notable challenges associated
with the administrative aspects of centralised ethics review
processes. For instance, Shelby James and colleagues (2010)
propose that the introduction of a ‘standardised’ NEAF has
increased (rather than reduced) paperwork, while Fitzpatrick,
Boult, & Fitridge (2010) have argued that the failure of jurisdictions
to uniformly accept the NEAF has meant that there has been little
positive impact for large inter-jurisdictional, multi-site studies.
The experience of the NP Evaluation reaffirms past findings that
unless all HRECs consistently adopt standardised administrative
procedures, then the practical result will be increased time,
replication of tasks and, consequently, greater costs.
Issues also emerged that were linked specifically to an
evaluation involving non-government health practitioners. One
of these limitations was their lack of recognition within existing
centralised ethics review organisational structures. Another was
the lack of recognition of the unique contribution of these
practitioners within administrative procedures. For instance,
completing current NEAFs encouraged an ‘either/or’ assessment
122 B. Prosser et al. / Evaluation and Program Planning 49 (2015) 117–123
for researcher and participant. However, documenting nurse
practitioners as ‘associate researcher’ was misleading as it
suggested a role for the nurse practitioner in evaluations that is
not appropriate, while it also implied that the independent
evaluation team had a degree of authority over the actions of
nurse practitioners that we did not have. Meanwhile, document-
ing nurse practitioners as solely ‘participants’ overlooked their
contribution to participant recruitment and consent, as well as
support for data collection within the evaluation. Further, the
complexity of standard recruitment procedures across diverse
aged care services models resulted in time consuming adminis-
trative processes for nurse practitioners. A key insights was that
centralised processes should take into account the contribution of
practitioners in evaluations of health service delivery and raises
questions of unfair administrative burdens being placed on them
(NH&MRC, 2007).
Adding further complexity, the national evaluation is being
conducted while the various models are in the process of
establishment. Hence, it was difficult to pre-determine the full
scope of potential ethics issues for models as they are emerging
and developing – yet this is an administrative requirement of
current ethics processes. Further, the requirement to consult all
stakeholder communities (even before all could be fully identified),
was a requirement that ran the risk of making the ethics review
reductionist and artificial (Studdert et al., 2010). While some might
argue that evaluation should wait until needs are fully identified,
models are established, stakeholders are known and policy cycles
have gone full turn, this creates an un-reconcilable tension for
health programme evaluations whose benefit, merit and integrity
(NH&MRC, 2007) include making formative contributions to
current and future policy development (Pawson, 2006). In
response, we would stress that a key insight from this case is
that should centralised systems make it even more difficult, time-
consuming and costly to gain ethics approval for studies that
explore areas of national health priority, then this may have the
perverse consequence of presenting an ‘unethical barrier’ (Gold
and Dewa, 2012) to future evaluations.
5. Recommendations for improving centralised ethics review
processes
While the case of the NP Evaluation confirms the finding of
Fitzgerald and Phillips that centralised ethics approval processes
result in a stronger and more efficient focus on ethical issues, it also
aligns with existing literature on key challenges to be addressed.
Most notably, the referral to local level or organisational governing
bodies for around half of the sites in this case echoes findings in the
UK (Snooks et al., 2012) that one of the challenges for medical and
health studies is local site committees working in isolation as
pseudo ethics committees. Hence, we would suggest more
attention be given to how centralised ethics review processes
might more effectively and efficiently cover evaluations of those
involved with health services across private and public sectors.
Meanwhile, there appears to be much more work ahead to
prevent administrative demands resulting in more time, money
and effort, as well as inequitable workloads for researchers and
evaluators. Important improvements to address these demands
could include:
1. The introduction of a formal procedure that results in the
approval by global ethics review bodies triggering access to
centralised local governance approval processes;
2. The introduction of formal coordinating systems to streamline
the centralisation of local governance applications with one
HREC in all jurisdictions;
3. The production of standardised administrative processes for the
handling of applications to local HRECs;
4. The acceptance and endorsement of standardised national ethics
document templates by global and local governance HRECs;
5. The introduction of mechanisms to enable mediation with
HRECs to reduce time delays and the need for appeals against
decisions (which can act as coercive forces for applicants);
6. The need to foreground the educative role of all HRECs, both in
providing detail to ethics applicants and guidance to local SSAs;
7. Greater recognition within centralised ethics processes of the
workload demands placed on health practitioners that are
required to participate in evaluations of health programmes; and
8. Greater recognition within centralised ethics processes that
programme evaluations (as different from traditional research
projects) are required to report on emerging models of practice and
inform future programme development, hence, exact parameters
cannot always be pre-identified for ethics applications.
Based on our case study of the NP Evaluation experience with
the HoMER centralised ethics approval process, we suggest that
the above refinements would benefit national health evaluations
within the Australian context, but are also worthy of consideration
for the evaluation of complex, multi-site, programmes interna-
tionally.
6. Lessons learned
The encounter of the NP Evaluation with centralised ethics
approval processes in Australia points to a number of insights that
might guide those planning similar evaluations in the future.
1. We suggest that evaluation planners should allow for up to one
year to be devoted to securing ethics approval, even when
accessing centralised processes. We also note that this is a
significant time and cost commitment in the context of three-
year health programme evaluations.
2. We concur with the NH&MRC (2013b), that researchers and
evaluators seeking to conduct multi-site projects in the future
should identify and approach the relevant local HREC organisa-
tions well prior to application. Doing so cannot only streamline
the administrative process, but in cases where the correct
affiliation is unclear, it can save time once global approval has
been granted.
3. When designing PICF and other documentation, identify and
consult all relevant HRECs about their requirements prior to
submitting an application to the global HREC. This will minimise
later difficulties in maintaining consistency between documents
approved at global and local governance levels.
4. In projects that include private health service providers,
planning should include provisions for when individual models
are not accepted by a certified HREC.
5. Although public health service providers are usually affiliated
with a certified HREC, specific consideration should be given to
potential requirements at the local level to prevent lengthy
delays.
6. In evaluations involving community-based or private health
practitioners, planning should take into account any potential
administrative burdens associated with centralised ethics
approval and provide for appropriate compensation for their
involvement.
7. When working with elderly or vulnerable groups, consideration
should be given to reconciling any tensions between the specific
ethical requirements of the group and the broader ethical and
administrative requirements of centralised approval processes
(Table 1).
 B. Prosser et al. / Evaluation and Program Planning 49 (2015) 117–123
Table 1
Insights into centralised ethics review processes in Australia.
Key barriers
Slow administrative approval procedures
Complex language in standard PICF documents (particularly for elderly participants)
Ensuring informed consent (particularly for participants with dementia)
Different requirements for guardian consent in different jurisdictions
Predicting participant numbers, health need and all relevant stakeholders
(when models were still in ‘set up’ and some models provided ‘walk in’ services)
Predicting participant vulnerabilities (when the health of elderly participants can
decline rapidly)
Lack of affiliated HRECs for privately provided service models
Lack of provision within standard documentation for professional partners
(as both participants and co-researchers)
Local site assessment bodies operating in isolation as pseudo HRECs
7. Conclusion
Seven years after the establishment of HoMER, what is the
progress against the claims of Fitzgerald and Phillips (2006) about
the benefits of centralised procesess? In terms of ethical aspects,
the case of the NP Evaluation suggests that some progress has been
made. Notably, however, in relation to their call for administrative
processes to be centralised (to save time, money and effort), then
achievements against this goal would seem limited. While this
paper only presents one case in one nation (and hence general-
isations must be made cautiously), the multi-site and inter-
jurisdictional nature of the NP Evaluation aligns well with
Fitzgerald and Phillip’s five nation study. It is also representative
of the growing body of complex evaluations that intersect specific
fields and individual disciplines, as well as spans sectors and
organisations. Further, this case study points to the need for more
consideration of similar cases, both in Australia and overseas, to
see if the relatively limited progress found in this case is shared.
That said, this case remains indicative of potential areas for further
examination, offer insights on potential refinements to the current
process, and aligns with existing literature to reaffirms the need for
continued effort to improve centralised ethics review processes.
Competing interests
The authors declare that they have no competing interests.
Acknowledgements
This paper is a contract material developed within the ‘Nurse
Practitioner Aged Care Models of Practice National Evaluation’
project, which has been funded by the Australian Government
Department of Health and Ageing. The authors also wish to
acknowledge the contribution of the following University of
Canberra and Australian National University researchers to the
conceptual development and implementation of this project: Dr
Shannon Clark; Adjunct Assoc. Professor John Goss; Dr Catherine
Hungerford; Dr Carmel McQuellin; Assoc. Professor Rhian Parker.
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Dr. Brenton Prosser is a senior research fellow to the Nurse Practitioners Aged Care
Models of Practice Evaluation within the Centre for Research and Action in Public
Health, University of Canberra. He is an adjunct in the School of Sociology at the
Australian National University and in the School of Education at the University of South
Australia.
Professor Rachel Davey is Director of the Centre for Research and Action in Public
Health, University of Canberra. Her research focuses on the primary and secondary
prevention of chronic disease and in evaluating public health interventions and
innovative models of health service delivery.
Professor Diane Gibson is Dean of Health at the University of Canberra. Professor
Gibson is nationally and internationally recognised for her research on ageing and aged
care.