The Cochrane Collaboration Twenty Years On

In the early 1990s, health care costs were spiraling, and new challenges, such as HIV and AIDs, as well as the old faithfuls of infection control, patient safety, and health care quality, were consuming our thoughts. Meanwhile, in Oxford, England, Iain Chalmers, David Sackett, and Muir Gray were starting to think about setting up the Cochrane Collaboration.

Privileged to be in Oxford at the time, I went to see Iain Chalmers about my literature review on post-operative pain management in surgical patients (Kitson, 1994). In the relatively brief encounter, I realized that there was a vast difference between my general sweeping and pulling together of the literature on post-operative pain management and his developing views about what now are universally accepted as systematic reviews (Chalmers & Altman, 1985). Needless to say, I embarked upon a significant journey to understand the methodology informing reviews of the literature and systematic reviews in general. This conversation led to an invitation to several nursing colleagues to work with Dave, Iain, and Muir in developing the first masters degree in Evidence-Based Health Care at the University of Oxford, UK (Dawes et al., 1999).

We did not know it then, but as a relatively young team of researchers and clinical practice developers, we were in the vortex of a great social movement. As time went on, we began to realize how potent and transformational this activity would become. The developments were not without challenges. Some of the early debates revolved around what to do when there is a paucity of research (of any quality) to inform practice (Kitson, 1997) and what constitutes evidence (Rycroft-Malone et al., 2004). This seemed to be a particular challenge for relatively young disciplines such as nursing. In most nations, nursing research was in its infancy, with little funding and less experience in conducting large-scale studies of effects, such as randomized controlled trials (RCTs).

In those early days, the Cochrane Collaboration was certainly evangelical. Like all social movements, there was a strict code of conduct, a set of rules to be followed, and an emergent “priesthood” (Tilly, 1978). The Collaboration used explicit methods to prepare systematic reviews of controlled trials, using statistical synthesis (meta-analysis) when appropriate and possible. This has led to the Collaboration's wide recognition as the gold standard in assessing and reporting research to determine the effectiveness of different health care treatments and interventions.

Importantly, as with all strongly articulated paradigms, the Cochrane Collaboration stimulated other responses to the way we analyze and see the world and inspired the Campbell Collaboration and the Joanna Briggs Institute. This debate is in the true spirit of scholarship and vitally important to the ongoing refinement and improvement of ideas. It has been reassuring to observe how the Cochrane Collaboration has grown and matured over the past 20 years to embrace a broader set of methodologies and a more eclectic set of approaches, to insure that evidence can move into practice.

Most commentators recognize the need for rigor and ongoing refinement of evidence synthesis approaches. There is also a growing recognition of the need to close the evidence-to-practice gap (Kitson & Strauss, 2010) with systematic review and research on the actual mechanisms that enable successful translation of research into practice. The Cochrane Effective Practice and Organization of Care (EPOC) work, led by Jeremy Grimshaw, has had a significant impact on our conceptualization of this part of the knowledge-to-practice cycle (Kitson, Wiechula, Salmond, & Jordan, 2012). Here, too, we can see the maturation of ideas over time, with the linear rigidity of cause-and-effect reductionist approaches making way for complexity and other psychological theories that go some way to explain (and eventually) predict what it takes to get evidence into practice.

Research in Nursing & Health has played a significant role in advancing the methodological pluralism required to inform the evidence-based practice movement and the Cochrane Collaboration. A look at the most-cited papers in 2012 reveals methodological papers on topics such as levels and applications of qualitative research evidence (Kearney, 2001) and mixed methods and sample size in qualitative research (Sandelowski, 1995, 2000). Sandelowski's work in particular (e.g., Sandelowski & Barroso, 2007) has been profoundly influential in bridging the gap between qualitative research approaches and qualitative synthesis.

In addition to Cochrane's traditional systematic review activity and the refinement and honing of methodologies for synthesizing qualitative research, I have seen ongoing acknowledgement of the need to engage volunteers to undertake the reviews and to apply the results. As the largest health care profession in the world, it is essential that nurses feel connected to this great social movement. The Cochrane Nursing Care Field (CNCF), established in 2009, is one very positive example of creating networks of volunteers to interrogate the Cochrane database, searching for relevant reviews to inform nursing practice.

One part of the CNCF is the Review Tagging Group. This group both identifies the content of reviews relevant to an element of nursing practice (such as managing a patient's elimination or nutritional needs) and considers the potential effects of the intervention. For example, in a recent review of the use of zinc to manage the common cold in children, authors identified a number of digestive side effects of the preferred intervention (Singh & Das, 2011). These were tagged as important considerations for nursing care and should prompt the nursing team to consider how these symptoms ought to be managed (Kitson, Robertson-Malt, & Conroy, 2013).

The Cochrane Collaboration has probably done more to improve the quality of health care research than any other single initiative. Fueled by volunteers, its philosophy is based on promoting excellence, and it enriches and educates people who want to learn and work together to improve health care. It is an exceptional example of how generosity and openness can overcome the competitive spirit, with space for contributions of all shapes and sizes. It is reassuring that nursing, through many champions and through structures such as CNCF, can continue to utilize this vast resource to support better patient care. In the pages of this esteemed journal, nurses involved in the Cochrane Collaboration are delighted to celebrate its 20 years' success and look forward to the next 20 years with equal excitement.