Edifices of Evidence: The Proliferation of Pyramids

By Levin, Rona F. | Research and Theory for Nursing Practice, April 1, 2011 | Go to article overview

Edifices of Evidence: The Proliferation of Pyramids


Levin, Rona F., Research and Theory for Nursing Practice


Once, history books told us that the great Egyptian pyramids were built by slaves. More recently, however, according to National Geographic (National Geographic Society, 2010), the builders of the pyramids were Egyptians who lived in villages overseen by the pharaohs. Some were employed as builders and others were compelled to serve for a limited time. Pyramids served as burial chambers. Nevertheless, more than that, they were tombs built to safeguard the soul of the Pharaoh or King. "Ancient Egyptians believed that when the pharaoh died, he became Osiris, king of the dead" (National Geographic Society, 2010, Kings of the Dead section, para. 1).

I have been thinking a lot these days about how the notion of levels of evidence (LOE) has developed and gained almost a religious sanctity in some circles. The evidence-based practice (EBP) movement has led to a proliferation of evidence pyramids (see Figure 1 for an example). Are we building these edifices to deify the evidence of research, particularly systematic reviews of quantitative evidence? Are some researchers, particularly in the fields of medicine, nursing, and, more recently, other health professions searching for a "God of Evidence" to put their unquestioning faith in? Others in these professions, particularly medicine, still believe that the randomized controlled trial (RCT) is the top level of evidence on the pyramid-the almighty vehicle of truth.

Currently, I am in throes of writing a chapter on EBP for a major, medical- surgical textbook for undergraduate nursing students. The editors are attempting admirable not only to include a chapter on EBP but also to carry the theme of LOE throughout the textbook, citing the LOE for various types of evidence that authors' use to support practice recommendations. When I first sent the editors the quantitative pyramid I had been using to identify LOE to use throughout the book, one of them raised a very good question: Where do multicenter RCTs fit into the pyramidal hierarchy? Why would these not be considered top-level evidence for an appropriate quantitative question in addition to systematic reviews of RCTs? I gave that question a lot of thought and concluded (my own opinion and so, a very low LOE) that multicenter RCTs should definitely be considered in the top tier of evidence. …

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