Running the Aspen project where you work — dual roles, and what the board asks about them
Most Aspen projects happen where the person doing them already works, and the university plans for that. What the board reads, though, is not one file but two: a design, and a set of relationships. The second is where workplace projects draw findings, because Aspen’s handbook counts people who report to you among those needing protection.
Charlotte Devereux, MSN, RN · 2026-08-23
In short. Yes, your workplace can be the venue. Aspen’s guidance says to be off the clock and outside your usual duties; the handbook lists subordinates of the researcher among vulnerable populations, so the file must name the safeguards that keep participation freely refusable.
Does Aspen allow the project to run where you work?
It does, and its published guidance draws the line rather than pretending the question never arises. Aspen’s capstone guidance states it plainly: you can use your workplace as a venue, but you must be off the clock and perform tasks outside your usual job description. That boundary is about your role rather than geography — it separates what your employer pays you for from what the board approved.
Hold that line and much of the rest follows. Recruiting on paid time, inviting people you supervise from a work account, running a session that doubles as a shift duty — each collapses the separation, and every safeguard downstream then gets harder to argue.
What does the board see when your name is on both sides?
Aspen’s handbook opens its list of vulnerable populations with subordinates of the researcher, employees among them, before reaching any clinical category. That single line is why workplace files get read so closely: anyone who could be pressured or unduly swayed is owed additional safeguards, and where you hold authority over a potential participant the board begins from the assumption that refusing you costs them more than refusing a stranger.
| The role you also hold | What the board is reading for | What the file should name |
|---|---|---|
| You supervise, appraise, or schedule potential participants | Whether declining is genuinely costless for them | Recruitment routed outside the line of authority; someone other than you handling responses; an assurance that neither taking part nor declining reaches your management role |
| You teach, precept, or assess them | Whether the invitation reads as an assignment | Distance between the teaching relationship and the invitation; no participation during instruction time |
| You obtain the consent yourself | Whether consent was sought under conditions that minimise coercion or undue influence | Who asks, where, when, and how long people get to consider it privately — the rule wants a real chance to weigh it, not a form passed across at handover |
| You have job access to the records you want to use | Whether access is authorised for this purpose, or only for your job | Explicit permission in the site letter, and a de-identified route where one exists |
| You will also implement the change being studied | Whether the project can report an outcome it did not manufacture | How outcomes are measured and by whom; what stops the project supplying its own evidence |
| You are offering an incentive | Whether the incentive is large enough to be undue influence in your setting | The remuneration plan, set out in the consent, and not made contingent on completing |
| Colleagues will recognise each other in the results | Whether confidentiality is achievable in a small unit | Reporting that leaves a small group unidentifiable; what is never reported at all |
Notice what none of these safeguards is: a sentence promising participation is voluntary. Every consent says that. The board is testing whether anything in the arrangements makes it true.
Who signs the site permission letter — and what must it say?
Not your manager by default, and never you. Aspen’s Appendix C sets the terms: printed on the organisation’s letterhead, with the handbook stating outright that email will not suffice. It names you and the project, gives a short lay purpose, confirms the protocol has been reviewed, and spells out exactly what is permitted at the site along with any restrictions — then carries the signatory’s title, email and phone. The signature belongs to someone attesting they hold authority to grant it; for nursing projects the handbook points to a Chief Medical Officer or a Director.
Two traps belong to working where you already work. An immersion agreement signed earlier is a different instrument entirely; the handbook treats this as its own permission, sought for this project, so a standing arrangement with your employer will not stand in for it. And the letter must state what is permitted rather than that the organisation thinks well of you — an endorsement naming neither activities nor data leaves the board unable to approve any access, however senior the signature.
Where the signatory has no template, the handbook expects you to draft it for them from Aspen’s, tailored and proofed, returned on letterhead. It moves at another person’s pace, so start it first. The application checklist puts it in sequence with the rest.
Does your employer’s own review board come first?
Usually, yes. Where the entity hosting your project runs its own IRB, Aspen’s handbook says you typically seek that approval first, and puts the duty of finding out squarely on you: establishing whether oversight exists at your site is your responsibility. That board’s approval then travels with the Aspen application as a conditional attachment.
The reverse case is handled too. Should the organisation want something conditional from Aspen before it will look at your submission, the handbook directs you to write in for guidance, copying your chair. Two boards waiting on each other is a solvable problem, but only early.
Is a workplace initiative quality improvement, or research?
The answer shapes the whole file, and Aspen settles it by intent rather than by label. Working from the regulatory definition — a systematic investigation intended to develop, or add to, knowledge that generalises — the handbook gives a practical test: where the data is collected to contribute to generalizable knowledge, or the results apply beyond this setting or population, the activity is usually research. Where they stay in-house for administrative use, many organisations do not treat it so.
Two corrections come with it. Publication is not the deciding factor — the handbook calls it an indicator used incorrectly, and says intent is what counts. And Aspen expects doctoral work to exceed a simple in-house improvement initiative, which is why an application is required whatever the project is called.
One nuance is worth reading twice, because it travels half-remembered. The handbook notes that unless the site requires one, a consent form is often unnecessary for a quality improvement project — its example is assessing staff understanding of an established evidence-based protocol, then reviewing charts for the effect. The same passage adds that site permission is still needed to implement it. No consent form is not the same as no permission, and neither call is yours alone: the review path belongs to the IRB Chair or designee, and the handbook says to write in when in doubt.
What about the records you can already open?
Job access is not project access. Being able to open a chart because of your role says nothing about whether you may use it as data, and boards read that boundary closely. Aspen ties HIPAA to any use of medical records — electronic, archival or paper — and expects a HIPAA authorization form with the file where it applies.
The handbook’s own site-letter examples point at the cleaner route: working through the quality department or a designated specialist to gather de-identified data on the outcome being measured. Where identifiers are unavoidable, it asks for data coded so only you can link it to individuals, the cross-reference log held apart from the data — a separate system entirely where the data is electronic — and a plan naming authentication, encryption and secure storage.
One duty belongs in a workplace file and is regularly left out: the ending. Aspen’s nursing handbook expects participants to receive a copy of the completed project, with the chance to accept or reject how their data is applied, and preserves their right to retract it up to formal publication. Where you will still be working alongside those people, design for that rather than discover it. Its place in the sequence is covered in continuing review and closure.
What to do next
Send the project as it stands, and describe your position at the site — who reports to you, what you can already open, and who would put a signature on a permission letter. It gets read against Aspen’s current handbook and portal, and the findings come back in writing at no charge: a candid reading of whether the design behaves like research, and where the dual-role questions are going to land. Ask for the free application review. Want it carried instead? The category is settled with you, the permission letter drafted for signature, every document built, and each reply the board writes answered in turn. The route is on the how it works page and the FAQ takes the remainder. What you make here belongs to you; the determination belongs to the board.
Sources
- Aspen University, IRB Handbook 2025–2026 — vulnerable populations including subordinates of the researcher, safeguards, site permission approval and its distinction from an immersion agreement, external IRB sequencing, QI versus research and the intent test, consent for QI projects, HIPAA, data coding and storage, review level determined by the IRB: aspen.smartcatalogiq.com/…/IRB-Handbook.pdf
- Aspen University, IRB Handbook — Appendix C, the site permission letter’s required contents and signatory: aspen.smartcatalogiq.com/…/irb-forms/appendices/
- Aspen University, IRB Handbook (current edition landing page): aspen.smartcatalogiq.com/en/academic-year-2026-2027/irb-handbook/
- Aspen University, MSN Capstone FAQs — using your workplace as a venue, off the clock and outside your usual job description: aspen.edu/altitude/faqs-msn-capstone/
- Aspen University, DNP Handbook — participants receive a copy of the project and may retract data up to formal publication: aspen.smartcatalogiq.com/…/DNP-Handbook.pdf
- Common Rule, section 46.111 — fair selection, and extra protection for participants who could be pressured or unduly swayed: Cornell LII, 45 CFR 46.111
- Common Rule, section 46.116 — consent asked for in conditions that leave real room to think, and real room to say no: Cornell LII, 45 CFR 46.116