In his Letters of Advice to his Son, Britain’s Lord Chesterfield wrote:

The world can doubtless never be well known by theory: practice is absolutely necessary; but surely it is of great use to a young man, before he sets out for that country, full of mazes, windings, and turnings, to have at least a general map of it, made by some experienced traveler.11 (197)

The Earl of Chesterfield saw the world as being analogous to a confusing maze, and sought to offer some direction to his son on how best to deal with the twists and turns of London’s politics and high society. The analogy of the maze can just as aptly be applied to critical care research and practice.

Although the terms maze and labyrinth are often used interchangeably, they refer to very different items.22,33 Mazes are multicursal; they contain multiple potential paths, including dead ends. Labyrinths are unicursal, with a single path that leads to the center. Mazes and labyrinths both have ancient origins and both have become popular activities in contemporary culture. However, their objectives and strategies are different. In a maze, the goal is to find one’s way through the confusion of multiple paths to an exit, often with the added objective of finding the shortest or quickest route. In a labyrinth, the goal is to calmly follow the path that has been prescribed to reach the center.

The walls of a maze are usually high enough to prevent visualization of the paths and exit. It is easy to feel lost in a maze, but a maze also offers challenges and thrills that the labyrinth does not. Alternately, with a bit of faith in the labyrinth’s design, a participant can find it a calming and thought provoking experience. Interestingly, in colloquial terms, mazes are “run,” whereas labyrinths are “walked.”

Running the Maze

Mazes have a long history as important model systems for studies of cognition, stress, and anxiety.44,55 The idea of “a rat in a maze” is ingrained in our culture, and serves as a metaphor for seeking one’s way out of a difficult problem.

On some days providing care to a critically ill patient can seem like the most complex maze, filled with wrong turns, dead ends, and frustration. On such days even the most insightful and experienced nurse can feel like a lab rat blindly trying to find the way out—trying to reach the best outcome for the patient. Sometimes the correct path becomes clear only after the outcome has been analyzed.

“Evidence-based practice distills research from many sources to a unicursal path that leads to a center of the best outcomes for patients.”

Although clinical research is often portrayed as a deliberate, methodical process that proceeds linearly and logically, researchers, too, have unanticipated twists, wrong turns, and moments of intense anxiety. “What if the hypothesis is wrong?” we ask. The implementation of a research project can hold many unanticipated twists and turns. Careful planning may reduce some of the false paths, but because research inherently involves the discovery of something unknown rather than the retreading of a path that has been carefully laid, false starts and dead ends cannot be avoided. Sometimes a research project ends in a very different place from what the investigators imagined at the inception of the process, and the final conclusions differ from the original hypotheses. The path to the goal becomes clear only in retrospect.

Walking the Labyrinth

Labyrinth walls serve to define the path, but are low and do not obscure the view of one’s destination. In the middle ages, labyrinths were inlaid on the floors of cathedrals; a flat stone labyrinth installed during construction of the Chartres Cathedral in France around the year 1200 is still walked by visitors to the cathedral. Recently, labyrinths have been incorporated in healing gardens and have become popular landscape elements in cancer treatment centers.33,66 

More recently, the therapeutic effects of labyrinths on human well-being have been the focus of nursing research investigations.77,88 In addition to being the focus of research designs, mazes and labyrinths can serve as metaphors for broader activities in research and clinical practice.

The labyrinth can serve as a pattern for well-written research reports. Such reports are written after the completion of the research project, and are created to lead others to an understanding of what was accomplished. The author has a responsibility to clearly lay out the research question (the labyrinth entrance) and to provide a single path that encompasses the background, citations of literature, presentation of data, and discussion of results that will lead readers to the report’s conclusions (the center of the labyrinth). As the report is prepared for publication, it is the responsibility of journal editors and reviewers to assist the author in making the path from research question to conclusions clear and unambiguous for the reader. Like a well-designed labyrinth, a good research report will lead the reader to contemplation and reflection. The unicursal aspect of research reports may not fully reflect the nature of the research process, which often is more like a maze than a labyrinth.

Evidence-Based Practice

If individual research projects are like mazes, programs of research are even more so. Individual investigations may move the science forward, or they may turn out to be enticing dead ends that looked promising but fail to solve the problem of finding a way out. Researchers can easily become convinced that the path they are on is the right one, only to find after substantial investment of time that it is neither productive nor true. However, as multiple investigators target the same problem, understanding of that problem grows, and what works—or what doesn’t—eventually emerges. Even the unproductive paths may provide valuable information for clinicians. As a result of time spent in the maze of research, a labyrinth of evidence-based practice can be constructed.

Evidence-based practice distills research from many sources to a unicursal path that leads to a center of the best outcomes for patients. A guideline for best practice provides clear direction for clinicians, but it can be developed only as a result of research that precedes it. Evidence-based practice is the “general map … made by some experienced traveler.”11 Previous research directs the development of the guideline not only by identifying the shortest or best path to the desired outcome, but also by informing us about interventions that seemed to hold promise but were found to be less effective. Knowledge gained in the exciting mazes of research permits us to tread the more orderly path of evidence-based practice.

“Knowledge gained in the exciting mazes of research permits us to tread the more orderly path of evidence-based practice. ”

World Labyrinth Day is held annually on the first Saturday in May; this year it’s on May 1. If you wish to celebrate by walking a labyrinth, the Web site of the Labyrinth Society has a labyrith locator.99 If a maze is more to your liking, the Purdue University Department of Agronomy has compiled links to corn maze locations throughout the United States.1010 Whatever the path you walk or run, enjoy both the challenge of research and the confidence afforded by evidence-based practice.

REFERENCES

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Footnotes

The statements and opinions contained in this editorial are solely those of the coeditor.

FINANCIAL DISCLOSURES
 None reported.

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