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0 (zero) is the first ending theme of the anime adaptation of Jun Mochizuki 's The Case Study of Vanitas , composed and sung by LMYK .

Two versions were released, in both English and Japanese. [1]

1.1 TV Version
1.2 Full Version
3 Characters
4.2 Screenshots
5 References
6 Navigation

TV Version [ ]

English (official)
English (translation)

始まった途端に　終わりが見える崩れて溶け出す Horizon みたいにもっともう遠くに優しく響くため息が立てるさざ波みたいに When I lose myself, I become you 一から十生み出すしがみつくベール外して明日の名札も解かれるよ Was it you I’ve been searching for Spent my life alone and waited for So tenderly and endlessly You make me whole You make me whole 涙に沈んでくさようならの先へと巡り巡る時の中 You make me whole You make me whole Was it you who I heard through the door When I cried and had no place to go 巡り巡る時の中もう一人じゃない巡り合えた腕の中 You make me whole You made me whole I lose myself I lose myself もう一人じゃない

Hashimatta tokan ni owari ga mieru Kuzurete tokedasu Horizon mitai ni Motto mou tooku ni yasashiku hibiku Tameiki ga tateru sazanami mitai ni When I lose myself, I become you Ichi kara juu umidasu Shigamitsuku beeru hazushite Ashita no nafuda mo hodokaeru yo Was it you I’ve been searching for Spent my life alone and waited for So tenderly and endlessly You make me whole You make me whole Namida ni shizundeku Sayounara no saki e to Megurimeguru toki no naka You make me whole You make me whole Was it you who I heard through the door When I cried and had no place to go Megurimeguru toki no naka Mou hitori janai Meguri aeta ude no naka You make me whole You made me whole I lose myself I lose myself Mou hitori janai

Ahead in the empty distance Fading away unanswered I turn off the lights to see All the colors in the shadow Travels across an instant Far beyond tomorrow I'm watching a faint breath Send a ripple through the water When I lose myself, I become you 一から十 leads me back to Here inside your veil, finer than a grand view We'll take a dive, not even lies can come between us Was it you who I've been searching for Spent my life alone and waited for So tenderly and endlessly You make me whole You make me whole And the walls I built, they melt away With every touch and your embrace Every day, every night, every note I play You make me whole You make me whole Was it you who I heard through the door When I cried and had no place to go 巡り巡る時の中 You'll never believe I'm alone In the end we begin 'till we meet again You made me whole You made me whole I lose myself I lose myself I know I'm never alone

Full Version [ ]

始まった途端に終わりが見える崩れて溶け出すアイスみたいに最も遠くに優しく響くため息が立てるさざ波みたいに When I lose myself I become you 一から十を満たすしがみつくベール外して明日も名札も解かれる Was it you who I’ve been searching for Spent my life alone and waited for? So tenderly and endlessly You made me whole, you made me whole 涙に沈んでいくさよならの先へと巡り巡る時の中 You made me whole, you made me whole 重なった記憶に迷いが消える鏡を抜けて触れ合うたびに最も深くに鋭く沁みる真夜中震わす稲妻みたいに When I lose myself I become you 体中を伝うありふれる恋と違って台詞も形も奪われる Was it you who I’ve been searching for Spent my life alone and waited for? So tenderly and endlessly You made me whole, you made me whole 暗闇を彩るあなたしか見えないさらに深く連れていって You made me whole, you made me whole なぞり続ける夕日何度もゼロに戻り思い出す　孤独な私はいない回り続けるメロディー痛み分け合う二人身を任す　無我夢中に Was it you who I’ve been searching for Spent my life alone and waited for? So tenderly and endlessly You made me whole, you made me whole 涙に沈んでいくさよならの先へと巡り巡る時の中 You made me whole, you made me whole Was it you who I heard through the door When I cried and had no place to go? 巡り巡る時の中　もうひとりじゃないめぐり逢えた腕の中 You made me whole, you made me whole もうひとりじゃない

Hajimatta totan ni owari ga mieru Kuzurete tokedasu aisu mitai ni Mottomo tooku ni yasashiku hibiku Tameiki ga tateru sazanami mitai ni When I lose myself I become you Ichi kara juu wo mitasu Shigamitsuku beiru hazushite Ashita mo nafuda mo tokareru Was it you who I’ve been searching for Spent my life alone and waited for? So tenderly and endlessly You made me whole, you made me whole Namida ni shizunde iku sayonara no saki e to Meguri meguru toki no naka You made me whole, you made me whole Kasanatta kioku ni mayoi ga kieru Kagami wo nukete fureau tabi ni Mottomo fukaku ni surudoku shimiru Mayonaka furuwasu inazuma mitai ni When I lose myself I become you Karadajuu wo tsutau Arifureru koi to chigatte Serifu mo katachi mo ubawareru Was it you who I’ve been searching for Spent my life alone and waited for? So tenderly and endlessly You made me whole, you made me whole Kurayami wo irodoru anata shika mienai Sara ni fukaku tsurete itte You made me whole, you made me whole Nazori tsuzukeru yuuhi Nando mo zero ni modori Omoidasu kodoku na watashi wa inai Mawari tsuzukeru merodii Itamiwake au futari Mi wo makasu muga muchuu ni Was it you who I’ve been searching for Spent my life alone and waited for? So tenderly and endlessly You made me whole, you made me whole Namida ni shizunde iku sayonara no saki e to Meguri meguru toki no naka You made me whole, you made me whole Was it you who I heard through the door When I cried and had no place to go? Meguri meguru toki no naka mou hitori janai Meguriaeta ude no naka You made me whole, you made me whole Mou hitori janai

Ahead in the empty distance Fading away unanswered I turn off the lights to see All the colors in the shadow Travels across an instant Far beyond tomorrow I'm watching a fake breath Send a ripple through the water When I lose myself, I become you 一から十 leads me back to Here inside your veil, finer than a grand view We'll take a dive, not even lies can come between us Was it you who I've been searching for Spent my life alone and waited for So tenderly and endlessly You make me whole You make me whole And the walls I built, they melt away With every touch and your embrace Every day, every night, every note I play You make me whole You make me whole How could I have been so blinded Running away in circles I hear my doubts drop when I see you in the mirror Right beneath the surface Washed away my sorrows I feel your heart beat as it echoes through the hour When I lose myself, I become you You are the moment I belong to Here without our names, we're back to being brand new There's no need to hide Just you and I, until forever Was it you who I've been searching for Spent my life alone and waited for So tenderly and endlessly You make me whole You make me whole Was it you who I heard through the door When I cried and had no place to go Every day, every night, every note I play You make me whole You make me whole Tracing and tracing the sunset Appearing a zero and finally Now I remember I have never lived a day without you Untie the layer of memories Louder we spin with the melody You are the only, only one for me (You make me whole, You make me whole) Was it you who I've been searching for Spent my life alone and waited for So tenderly and endlessly You make me whole You make me whole And the walls I built, they melt away With every touch and your embrace Every day, every night, every note I play You make me whole You make me whole Was it you who I heard through the door When I cried and had no place to go 巡り巡る時の中 You'll never believe I'm alone In the end we begin 'till we meet again You made me whole You made me whole I lose myself I lose myself I lose myself I lose myself I know I'm never alone

The moment that it begins, you can see the ending, Collapsing and dissolving, like the horizon Yet, further in the distance, gently resounding, Sighs start, like ripples When I lose myself, I become you Reproduced from one to ten, Take off the veil you're clinging to, The nameplate of tomorrow, too, will be dissolved Was it you I’ve been searching for Spent my life alone and waited for So tenderly and endlessly You make me whole You make me whole Sinking into a sea of tears beyond the farewells Spinning and swirling amidst time You make me whole You make me whole My doubts disappear in overlapping memories Every time we touch through the mirror Piercing through me sharply as deep as possible, This quivering sensation hits me like lightning in the middle of the night When I lose myself I become you Travelling through your body Unlike ordinary love My words and shapes are stolen away Was it you I’ve been searching for Spent my life alone and waited for So tenderly and endlessly You make me whole You make me whole You're the only one I can see, Coloring the deepest darkness So take me deeper into the unknown You make me whole You make me whole The sunset I keep on tracing Always coming back to zero I remember that my lonely self isn't here anymore This melody that keeps on turning The two that share the pain with each other I entrust by body to you, losing control of myself Was it you I’ve been searching for Spent my life alone and waited for So tenderly and endlessly You make me whole You make me whole Sinking into a sea of tears beyond the farewells Spinning and swirling amidst time You make me whole You make me whole Was it you who I heard through the door When I cried and had no place to go While I'm spinning and swirling amidst time, I'm no longer alone In your arms I'd luckily met You make me whole You made me whole I lose myself I lose myself I'm no longer alone

Characters [ ]

Noé Archiviste

Gallery [ ]

Vanitas no Carte Ending 1 - 0 (Zero) (Full)

Screenshots [ ]

References [ ]

↑ LMYK website

Navigation [ ]

3 List of Characters (The Case Study of Vanitas)

0 (zero) English version

LMYK – 0 (zero) English Version [The Case Study of Vanitas / Vanitas no Carte Ending]

Ahead in the empty distance Fading away unanswered I turn off the lights To see all the colors in the shadow Travels across an instant Far beyond tomorrow I’m watching a faint breath Send a ripple through the water

When I lose myself I become you Ichi kara juu leads me back to Here inside your veil Finer than a grand view We’ll take a dive Not even tides can come between us

Was it you who I’ve been searching for Spent my life alone and waited for? So tenderly and endlessly You made me whole, you made me whole And the walls I built they melt away With every touch in your embrace Every day, every night, every note I play You made me whole, you made me whole

How could I have been so blinded Running away in circles I hear my doubts drop When I see you in the mirror Right beneath the surface Washed away my sorrows I feel your heartbeat As it echoes through the hour

When I lose myself I become you You are the moment I belong to Here without our names We’re back to being brand new There’s no need to hide Just you and I until forever

Was it you who I’ve been searching for Spent my life alone and waited for? So tenderly and endlessly You made me whole, you made me whole Was it you who I heard through the door When I cried and had no place to go? Every day, every night, every note I play You made me whole, you made me whole

Tracing and tracing the sunset Appearing a zero and finally Now I remember I have never lived a day without you Untie the layer of memories Louder we spin with the melody You are the only, only one for me

Was it you who I heard through the door When I cried and had no place to go? Meguri meguru toki no naka I’ll never believe I’m alone In the end we begin ‘til we meet again You made me whole, you made me whole

I know I’m never alone

Case study definition

Case study, a term which some of you may know from the "Case Study of Vanitas" anime and manga, is a thorough examination of a particular subject, such as a person, group, location, occasion, establishment, phenomena, etc. They are most frequently utilized in research of business, medicine, education and social behaviour. There are a different types of case studies that researchers might use:

• Collective case studies

• Descriptive case studies

• Explanatory case studies

• Exploratory case studies

• Instrumental case studies

• Intrinsic case studies

Case studies are usually much more sophisticated and professional than regular essays and courseworks, as they require a lot of verified data, are research-oriented and not necessarily designed to be read by the general public.

How to write a case study?

It very much depends on the topic of your case study, as a medical case study and a coffee business case study have completely different sources, outlines, target demographics, etc. But just for this example, let's outline a coffee roaster case study. Firstly, it's likely going to be a problem-solving case study, like most in the business and economics field are. Here are some tips for these types of case studies:

• Your case scenario should be precisely defined in terms of your unique assessment criteria.

• Determine the primary issues by analyzing the scenario. Think about how they connect to the main ideas and theories in your piece.

• Find and investigate any theories or methods that might be relevant to your case.

• Keep your audience in mind. Exactly who are your stakeholder(s)? If writing a case study on coffee roasters, it's probably gonna be suppliers, landlords, investors, customers, etc.

• Indicate the best solution(s) and how they should be implemented. Make sure your suggestions are grounded in pertinent theories and useful resources, as well as being realistic, practical, and attainable.

• Carefully proofread your case study. Keep in mind these four principles when editing: clarity, honesty, reality and relevance.

Are there any online services that could write a case study for me?

Luckily, there are!

We completely understand and have been ourselves in a position, where we couldn't wrap our head around how to write an effective and useful case study, but don't fear - our service is here.

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• Select your payment type, sit back and relax!

With lots of experience on the market, professionally degreed writers, online 24/7 customer support and incredibly low prices, you won't find a service offering a better deal than ours.

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The Case Study of Vanitas

A human wields a magic book that can cure vampires of their bloodlust, and sets out to find vampires to cure with the book. A human wields a magic book that can cure vampires of their bloodlust, and sets out to find vampires to cure with the book. A human wields a magic book that can cure vampires of their bloodlust, and sets out to find vampires to cure with the book.

Zeno Robinson
Alexis Tipton
10 User reviews
3 Critic reviews
3 wins & 18 nominations

Episodes 24

Noe Archiviste …

Dominique de Sade

Noé Archiviste

Roland Fortis …
Veronica de Sade

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Production, box office & more at IMDbPro

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Did you know

Trivia "Vanitas" is a term that refers to a work of art associated with the transience of life; the trademark of such a work is to contrast symbols of wealth and prosperity with symbols of death. A fitting title for a vampire story protagonist.

User reviews 10

MissSimonetta
Aug 12, 2021
How many seasons does The Case Study of Vanitas have? Powered by Alexa
July 2, 2021 (Japan)
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Runtime 23 minutes

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Vanitas no Karte Part 2

The Case Study of Vanitas Part 2

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Opening theme, ending theme.

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The Case Study of Vanitas (Official)

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Strongest Characters in The Case Study of Vanitas: Vanitas, Noe, & More

By Archak Mitra

The Case Study of Vanitas is a story based in a fictional 19th-century Paris where humans and vampires share the city. The story revolves around Vanitas and his companion, Noe Archiviste. They are on a quest to heal cursed vampires through the Book of Vanitas. It goes into detail about the Vampire born under the Blue Moon. He was isolated because of their fear, and thus, he swore vengeance against the vampires born under the Red Moon. His name was none other than Vanitas. The narrative is a memoir from the eyes of Noe Archiviste. He delves into how he came to meet Vanitas, their journey together, and how it eventually ends.

While he derives his name from an old vampire and uses his grimoire The Book of Vanitas. One wouldn’t be harshly criticized if they had mistaken Vanitas for a vampire. And that speaks for Vanitas himself, who is a human first and foremost. While he isn’t physically weak, he compensates for his lack of strength with his intelligence and grimoire. A combination of these two allows him to manipulate the actual names of vampires, making him a formidable presence within the series.

Noe Archiviste

The sole survivor of the Archiviste clan, Noe is the narrator of the series and accompanies Vanitas on his journey of curing Vampires. While one may argue that Noe has been defeated several times within the series. It might be accurate, but his compassion and kindness prevent him from having a severe physical altercation.

Despite being a vampire himself, Noe treats vampires and humans as equally good creatures. It’s this good virtue that pulls him down from time to time. But make no mistake, with his ability to relive memories just by drinking the respective person’s blood. It is safe to say one wouldn’t want to get on his wrong side.

Lucius Oriflamme

He is one of the most powerful and influential characters in The Case Study of Vanitas. Despite his young age, he serves as the Grand Duke to the Vampire Queen herself. He’s an aristocrat through and through.

Despite his childlike demeanor, he’s quite skilled at manipulating others with his strategic ploys and engagement in political scenarios to further his motive and maintain his clan’s position of power. To top it off, he holds Jeanne as his Chevalier.

Prolific, Revered, and the guardian of Lucius Oriflamme, Ruthven is often considered one of the most essential characters in The Case Study of Vanitas. Playing a pivotal role in ending the war between humans and vampires, he now finds himself as a member of the Senate and is well-known amongst humans as well.

He sought peace between humans and vampires during the war, even acting as a peacemaker. Having been betrayed by his students, he no longer shares the same passion and is ready to use any means to seek his desires. Cold, ruthless, and feared by vampire society, with his powers yet to be showcased, he’s just a testament to the man that is Ruthven.

Jean-Jacques Chastel

Chastel is the protector and longtime companion of Chloe d’Apchier and the last surviving member of the d’Apchiers. His loyalty knows no bounds, as he goes on to sign a contract with the devil itself just to realize Chloe’s wish. He turns himself into the very beast the village feared in exchange for his actual name. He wreaks havoc on anyone who tries to hurt Chloe, a symbol of his genuine and sincere feelings towards her.

Despite holding a degree in Chemistry Majors, Archak found himself as a Journalist. His love for anime and choccy milk is unmatched! When not writing, Archak can be found indulging with motorcycles. After all, four wheels move the body but two wheels move the soul!

The Case Study of Vanitas Manga Online

The case study of vanitas.

There once lived a vampire known as Vanitas, hated by his own kind for being born under a full blue moon, as most arise on the night of a crimson one. Afraid and alone, he created the “Book of Vanitas,” a cursed grimoire that would one day take his vengeance on all vampires; this is how the story goes, at least.

Vanitas no Karte follows Noé Archiviste, a young man who is traveling aboard an airship in 19th century Paris with one goal in mind: to find the Book of Vanitas. A sudden vampire attack leads him to meet the enigmatic Vanitas, a doctor who specializes in vampires and, much to Noé’s surprise, an entirely ordinary human. The mysterious doctor has inherited both the name and the infamous text from the Vanitas of legend, using the grimoire to heal his patients. But behind his kind demeanor lies something a bit more sinister…

All Chapters

The Case Study of Vanitas, Chapter 63
The Case Study of Vanitas, Chapter 62.2
The Case Study of Vanitas, Chapter 62.1
The Case Study of Vanitas, Chapter 62
The Case Study of Vanitas, Chapter 61
The Case Study of Vanitas, Chapter 60
The Case Study of Vanitas, Chapter 59
The Case Study of Vanitas, Chapter 58
The Case Study of Vanitas, Chapter 57
The Case Study of Vanitas, Chapter 56
The Case Study of Vanitas, Chapter 55.5
The Case Study of Vanitas, Chapter 55
The Case Study of Vanitas, Chapter 54.5
The Case Study of Vanitas, Chapter 54
The Case Study of Vanitas, Chapter 53
The Case Study of Vanitas, Chapter 52
The Case Study of Vanitas, Chapter 51.5
The Case Study of Vanitas, Chapter 51
The Case Study of Vanitas, Chapter 50
The Case Study of Vanitas, Chapter 49
The Case Study of Vanitas, Chapter 48
The Case Study of Vanitas, Chapter 47
The Case Study of Vanitas, Chapter 46
The Case Study of Vanitas, Chapter 45
The Case Study of Vanitas, Chapter 44
The Case Study of Vanitas, Chapter 43
The Case Study of Vanitas, Chapter 42
The Case Study of Vanitas, Chapter 41
The Case Study of Vanitas, Chapter 40
The Case Study of Vanitas, Chapter 39
The Case Study of Vanitas, Chapter 38
The Case Study of Vanitas, Chapter 37
The Case Study of Vanitas, Chapter 36
The Case Study of Vanitas, Chapter 35
The Case Study of Vanitas, Chapter 34
The Case Study of Vanitas, Chapter 33
The Case Study of Vanitas, Chapter 32
The Case Study of Vanitas, Chapter 31
The Case Study of Vanitas, Chapter 30
The Case Study of Vanitas, Chapter 29
The Case Study of Vanitas, Chapter 28
The Case Study of Vanitas, Chapter 27
The Case Study of Vanitas, Chapter 26
The Case Study of Vanitas, Chapter 25
The Case Study of Vanitas, Chapter 24
The Case Study of Vanitas, Chapter 23
The Case Study of Vanitas, Chapter 22
The Case Study of Vanitas, Chapter 21
The Case Study of Vanitas, Chapter 20
The Case Study of Vanitas, Chapter 19
The Case Study of Vanitas, Chapter 18
The Case Study of Vanitas, Chapter 17
The Case Study of Vanitas, Chapter 16
The Case Study of Vanitas, Chapter 15
The Case Study of Vanitas, Chapter 14
The Case Study of Vanitas, Chapter 13
The Case Study of Vanitas, Chapter 12
The Case Study of Vanitas, Chapter 11
The Case Study of Vanitas, Chapter 10
The Case Study of Vanitas, Chapter 9
The Case Study of Vanitas, Chapter 8
The Case Study of Vanitas, Chapter 7
The Case Study of Vanitas, Chapter 6
The Case Study of Vanitas, Chapter 5
The Case Study of Vanitas, Chapter 4
The Case Study of Vanitas, Chapter 3
The Case Study of Vanitas, Chapter 2
The Case Study of Vanitas, Chapter 1

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Strongest Characters in The Case Study of Vanitas: Vanitas, Noe, & More

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Noe Archiviste

Lucius Oriflamme

Jean-Jacques Chastel

The post Strongest Characters in The Case Study of Vanitas: Vanitas, Noe, & More appeared first on ComingSoon.net - Movie Trailers, TV & Streaming News, and More .

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Open access
Published: 14 May 2024

Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

Jocelyn Schroeder 1 ,
Barbara Pesut 1 , 2 ,
Lise Olsen 2 ,
Nelly D. Oelke 2 &
Helen Sharp 2

BMC Nursing volume 23 , Article number: 326 ( 2024 ) Cite this article

150 Accesses

Metrics details

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Peer Review reports

Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2 for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables 1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig. 1 for an overview of the results from each phase.

Fig. 1 Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table 3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure 2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table 4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

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Acknowledgements

We would like to acknowledge the faculty and students who generously contributed their time to this work.

JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

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JS made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. JS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. BP made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. BP has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. LO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. LO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. NDO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. NDO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. HS made substantial contributions to drafting and substantively revising the work. HS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

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JS conducted this study as part of their graduate requirements in the School of Nursing, University of British Columbia Okanagan.

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Correspondence to Barbara Pesut .

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Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

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Developing a survey to measure nursing students' knowledge, attitudes
The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice. ... The final survey consists of 45 items including 4 case studies. Systematic evaluation of knowledge-to-date coupled with stakeholder ...

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Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

Aim, design, and setting

Participants

Phase I. Item generation through literature review

Phase 2. Item refinement through expert panel review

Phase 3. Face validity through cognitive interviews with nursing students

Phase 1: survey item generation

Phase 2: faculty expert panel review

Phase 3. Outcomes of cognitive interview focus group

Availability of data and materials

Abbreviations

Acknowledgements

Author information

Contributions

Authors’ information

Corresponding author

Ethics declarations

Consent for publication

Competing interests

Additional information

Supplementary Information