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Article
Transforming Students’
Attitudes and Anxieties
Toward Death and
Loss: The Role of Prior
Death Experiences
Cara L. Wallace
1
, Harriet L. Cohen
2
, and
David A. Jenkins
3
Abstract
This study examines the impact of a death and dying course on 39 undergraduate
students’ attitudes and anxieties about death. Authors outline key aspects of the
curriculum used in the course and discuss how the approach lends itself to a trans-
formative learning experience related to death and loss, preparing students who will
face clients with a variety of needs in these areas across practice settings. The
majority of students (n¼34) experienced a decrease in death avoidance, fear of
death, and overall death anxiety. Students with a history of multiple violent, trau-
matic, or unexpected deaths (n¼5) did not experience any significant changes but
demonstrated increased scores of death anxiety suggesting that they may be in need
of greater support while engaging in death education.
Keywords
undergraduate students, death education, transformative learning theory, death
anxiety, death attitudes
OMEGA—Journal of Death and
Dying
2019, Vol. 79(1) 52–71
!The Author(s) 2017
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0030222817710140
journals.sagepub.com/home/ome
1
School of Social Work, Saint Louis University, MO, USA
2
Department of Social Work, Texas Christian University, TX, USA
3
Kent School of Social Work, University of Louisville, KY, USA
Corresponding Author:
Cara L. Wallace, School of Social Work, Saint Louis University, Tegeler Hall, 3550 Lindell Blvd., Saint
Louis, MO 63103, USA.
Email: wallacecl@slu.edu
When working with clients surrounding loss, practitioners must have the ability
to cope with their own experiences of loss (Ho Chan & Tin, 2012) and have an
understanding of their own personal death attitudes (Black, 2007). However,
practitioners often do not have the knowledge necessary to feel competent in
their role with clients facing loss (Black, 2007; Kramer, Pacourek, & Hovland-
Scafe, 2003; Stewart, Lord, & Mercer, 2000), and knowledge and skill develop-
ment in providing these services have been inadequate (Christ & Sormanti,
2000). Yet knowledge about death and dying is a main competency needed
for graduates working in gerontology (Council on Social Work Education,
2009), a growing field within health care in need of new clinicians (Bureau of
Labor Statistics, 2015). This study examines the impact of a Death and Dying
course on undergraduate students’ attitudes and anxieties about death with
consideration for the type and amount of prior death experiences. Authors out-
line key elements of the curriculum used in the course and discuss how the
approach lends itself to a transformative learning experience in relation to
death and loss, preparing students who will face clients with a variety of needs
in these areas across practice settings.
Literature Review
In response to death being recognized as a taboo topic not fit for research or
education (Feifel, 1963), death education developed when professionals began
calling attention to the need for exploring death as a key aspect of living.
Popularity in educating about death, also known as thanatology, grew alongside
the movement for hospice care in the 1960s (Pine, 1986) and peaked in popu-
larity in the 1970s (Durlak, 1994). Many professional groups recognize the need
for death education to be taught within educational curriculum. Increasing the
amount of information taught on palliative and end-of-life care has been called
for across multiple disciplines (Supiano & Vaughn-Cole, 2011; Wass, 2004), in
medical schools (Bickel-Swenson, 2007; Sullivan, Lakoma, & Block, 2003), nur-
sing schools (Khader, Jarrah, & Alasad, 2010; Mallory, 2003), and within
schools of social work (Csikai & Raymer, 2005; Kramer et al., 2003).
Teaching About Death and Dying
Although there is a vast literature on death education programs, objectives and
curriculum are often not discussed in depth within publications (Durlak, 1994).
However, important elements of death education can be drawn out across stu-
dies. A number of educational programs address death anxiety (Chow, 2013;
Maglio & Robinson, 1994) and attitudes toward death (Mallory, 2003; Wass,
2004; Watts, 2007; Wessel & Rutledge, 2005) as central components, or specific
outcomes, to teaching about death and dying. A summary across key studies
highlighted the following prominent features: arousing death-related attitudes
Wallace et al. 53
through readings, media, field trips, and experiential exercises; reducing negative
feelings about death (or death anxiety); and group discussion and activities
(Durlak, 1994, p. 252). With the growth in focus on the use of interdisciplinary
teams in health care, including information about the team and roles of various
members is also an important element. Many educators have adopted an inter-
disciplinary approach in death education by including students from across
disciplines in one class taught by multiple instructors from various professional
backgrounds (Fineberg, 2005; Howe, Hyer, Mellor, Lindeman, & Luptak, 2001;
McIlwaine, Scarlett, Venters, & Ker, 2007; Supiano, 2013; Supiano & Berry,
2013).
Importance of emotional learning. Multiple studies have considered the impact of
emotional learning versus didactic methods alone. In a meta-analysis of 47 death
education outcome studies through the 1980s, Durlak and Reisenberg (1991)
found that education including experiential components produced a change in
death anxiety and fear of death, while those that lacked this element did not. In a
more recent review of death education literature, Wass (2004) highlights the need
for ‘‘attending to the personal dimension’’ (p. 298) in order for students to
explore their own understanding and attitudes, become comfortable working
with others in crisis, and to develop empathy. Supiano and Vaughn-Cole
(2011) studied the impact of personal grief and loss on the personal and
professional development of individuals across health professions. Their findings
suggest that personal loss mediates the development as a professional helper.
Real-life exposure, self-disclosure, and emotional guidance are all supported
strategies for providing an impactful educational experience preparing profes-
sionals for work with dying and grieving clients.
Outcomes of Death Education
Overall, research suggests that death attitudes are positively impacted through
death education. After a 6-week death education course within a nursing school,
students’ attitudes about caring for dying patients were more positive (Mallory,
2003); and after a palliative care training for nursing professionals in hospice
and home care, attitudes toward death were also improved (Wessel & Rutledge,
2005). Changes in attitude through death education courses have been replicated
across a number of studies with nurses (Khader et al., 2010), with emergency
medical technicians (Smith-Cumberland & Feldman, 2006), and other health
professionals (Durlak & Reisenberg, 1991).
Studies examining the impact of death education on death anxiety have had
more mixed results. One meta-analysis across 47 studies showed a slight decrease
in death anxiety for programs with an experiential component and no effect in
didactic programs (Durlak & Reisenberg, 1991). A second meta-analysis several
years later indicated that death education leads to increased death anxiety, but
54 OMEGA—Journal of Death and Dying 79(1)
that the effect was larger for didactic interventions than experiential ones
(Maglio & Robinson, 1994). This may be due to the hyper focus on death
during the course when students were previously not thinking about death at
all. In a more recent study, McClatchey and King (2015) examined the impact of
death, dying, and bereavement education on death anxiety for students within
human services and found that students who received the education had signifi-
cantly lower fear of death and death anxiety than a comparison class of students
who did not. Additional outcomes of death education include changing beliefs
about mortality and increasing knowledge about ethical dilemmas in caring for
dying clients (Watt, 2007); enhancing personal, professional, and interpersonal
learning (McIlwaine et al., 2007); and increasing competence and confidence in
interdisciplinary practice (Supiano & Berry, 2013). The impact of death educa-
tion for practitioners is an important consideration in order to properly prepare
clinicians for their likely encounter with dying or grieving patients across the
practice spectrum.
Transformative Learning Theory
The theoretical framework chosen for this study is transformational learning
theory, the process of making meaning of one’s experience (Mezirow, 1978).
Transformative learning focuses on ‘‘how we learn to negotiate and act upon
our own purposes, values, feelings and meanings rather than those we have
uncritically assimilated from others—to gain greater control over ourselves as
socially responsible, clear thinking decision makers’’ (Mezirow, 2000, p. 8).
Transformative learning is about how the learner experiences growth and
change. Cranton (2006) describes transformative learning as the way we inter-
pret our experiences or perspectives about the world as critically reflective lear-
ners. We learn to reconstruct our frame of reference making it more visible and
permeable. Students engage in this process of deconstructing and reconstructing
their frame of reference differently, depending on their previous life experiences
and learning styles (Cranton, 2000, 2006). Both Mezirow (1978, 2000) and
Cranton (2000, 2006) emphasize the importance of self-reflection as a critical
condition for transformative learning.
Transformative learning can engage our meaning schemes or meaning per-
spectives, resulting in a change in either one or both (Mezirow, 2000). Meaning
schemes are specific values, feelings, judgments, and beliefs. Meaning perspec-
tives, our frame of reference or worldview, represent the influence of culture,
family, and other institutions and are often difficult to change. When our
meaning perspective shifts, a perspective transformation occurs.
Kegan (2000) differentiates between transformational kinds of learning and
informational kinds of learning. Transformative learning does not result in a
change in behavior or in adding new information. Rather, it encompasses an
epistemological change, altering our way of knowing. Transformative learning
Wallace et al. 55
involves changing our way of knowing, that is, we change the form or paradigm
by which we make meaning in our lives (Kuhn, 1996). Kegan’s (2000) influence
assists us by narrowing our definition of transformative learning to focus on our
epistemologies, that is, our cognitive structures, to distinguish them from other
forms of learning, and to expand our definition to include transformative learn-
ing as a developmental process throughout the life span.
Adult learning pedagogies, including transformative learning, used in this
course, challenge students to understand how their frame of reference constrains
the way they have come to understand and perceive the world, including their
attitudes and beliefs about death and dying. Social work educators can facilitate
a perspective transformation by planning assignments in which students encoun-
ter learning which confronts their old beliefs and helps them incorporate new
learning into their belief system.
Course Information
Course Development
This undergraduate, elective course is offered each fall through a Department of
Social Work housed in a private university in a major metropolitan area.
Undergraduate students from a variety of majors and minors often enroll
within this course. During course development for the class, the instructor
reviewed a range of death and dying syllabi (Csikai & Jones, 2007) along with
other literature on death education. This review along with the use of transfor-
mative learning theory led the instructor to include experiential aspects to
enhance emotional learning in addition to cognitive learning. Recognizing that
students arrive in the classroom with their own experiences of loss (Balk, 2001),
the instructor included experiential activities and assignments to provide oppor-
tunities for students to explore their own feelings, attitudes, and beliefs about
death and dying.
Class Activities and Exercises
In-class participation is an important component within this course and con-
tributes to a portion of students’ final grade. Participation includes active
engagement during class exercises, or for example, attending the class field
trip to a funeral home. Class time is spent using several different teaching meth-
ods, including interactive lectures with student-active breaks and experiential
learning activities. These methods keep students engaged during course time
in addition to pushing them to consider or apply the material at higher cognitive
levels (Nilson, 2010). Examples of in-class activities include a small-group com-
petition creating a list of euphemisms for the words ‘‘dead’’ or ‘‘dying,’’ small
group or in-class discussions on a given topic, participation in a life-expectancy
56 OMEGA—Journal of Death and Dying 79(1)
quiz, and students working together to create imagined case studies to apply
course concepts on developmental perspectives across the life span. A simulation
activity is also used to guide students through an experience of loss. Simulations
allow students to connect to the material through ‘‘intense emotional, cognitive,
and behavioral experiences’’ that they have never had in their real life
(Nilson, 2010, p. 149).
Taking into account various styles of learning, the instructor also uses media,
such as short video clips, news stories or current events, and personal accounts
of death, grief, or loss, as an additional way to enhance student understanding.
Relating media and current events to course materials makes the information
much more relevant to students and assists them in connecting and applying
concepts to their own lives and the lives of those around them (Grise-Owens,
Cambron, & Valade, 2010).
Course Assignments
One of the major assignments for the course consists of reflective essays that are
due periodically throughout the semester. Students are given 10 prompts that
correspond with topics discussed during class and within course materials. Many
of these prompts ask that students examine their own experiences, beliefs, or
feelings surrounding course topics. For example, one prompt asks that students
describe experiences from their past that have most significantly influenced their
current attitudes and feelings about death or loss. They are also asked to con-
sider how these experiences might affect how they would relate to others who are
grieving. Other essays require that students complete a specific behavior or
action or that they imagine a scenario and how it might impact them. In one
essay, students complete a living will and discuss barriers or resistance they
encountered in considering these documents. They also reflect upon how class
discussion or materials either changed or confirmed their feelings surrounding
their wishes at the end of life. Throughout the reflections, students are asked to
make connections to course materials either by applying course content within
their discussion or in considering how course materials have influenced their
thinking on each of the topics. Additional assignments include a presentation
on a culture or belief system different from their own (which includes interview-
ing someone within that culture), an assignment depicting wishes of their own
funeral and writing their own obituary, quizzes/exams, and overall participation.
Methods
Procedure
As a case study, authors collected data for this project using purposive sampling
from all undergraduate students enrolled in a death and dying course during
Wallace et al. 57
2012–2013 (N¼39). Although case studies have traditionally been thought of as
a qualitative approach (Creswell, 2013), case study research is complimentary to
quantitative data collection and is useful in approaching how or why something
occurs within a particular case or context (Yin, 2012). Within this framework,
the purpose for this study was to explore how this class and course design
impacted students’ death anxiety and death attitudes while taking prior loss
experiences into consideration. Using a pre- and posttest design, students were
asked to complete a Death Anxiety Scale (DAS) and a Death Attitude Scale on
the first day of class. The instructor also used this as a learning exercise by
asking students to reflect on completion of these scales and to discuss their
perception of their own death anxiety and attitudes. Completion of the scales
helped students recognize their own areas of discomfort and to consider which
course topics might cause some discomfort or challenges for them.
At the end of the semester, the instructor administered the scales a second
time for the posttest. All 39 enrolled students across both semesters (100%)
completed the pre- and posttests for death attitudes. However, three of the
death anxiety posttests were only partially completed (students only completed
the front side of the survey) resulting in a total completion rate for that scale of
92.3%. Only one student did not complete the journal entry describing prior loss
experiences (97.4% completed). Permission to use information from students’
course participation was obtained from the governing university’s institutional
review board.
Measurement Instruments
The survey instruments used within this study were Templer’s Death Anxiety
Scale–Extended (DAS-E; Templer et al., 2006) and the Death Attitudes Profile–
Revised (DAP-R; Wong, Reker, & Gesser, 1994). Both have been validated
among student populations (Templer et al., 2006; Kumar, Chris, Pais, Sisodia,
& Kumar, 2014), and Templer’s DAS has been used worldwide more than any
other death-attitude related instrument.
The DAS-E is a 51-question scale consisting only of true–false questions.
The extended questionnaire was created in order to address a more culturally
diverse range of anxiety. The added questions related to various religions,
were existential in nature, or were related to common fears of types of death,
including terrorism, drugs, or natural disasters (Templer et al., 2006). A
diverse panel of raters assessed the content validity and ranked the statements
based upon relevancy to death anxiety. The scale was then administered to
four groups of university students across four countries (two groups were
within the United States) and had an internal consistency Kuder–
Richardson coefficient of .73. The scale is scored by adding up all of the
‘‘true’’ responses, except in the case of six questions which are scored in the
reverse direction.
58 OMEGA—Journal of Death and Dying 79(1)
The DAP-R is a 32-item questionnaire with a 7-point Likert-type scale
response for each question ranging from strongly disagree (1) to strongly agree
(7), with an option in the middle for undecided (Wong et al., 1994). The scale has
five dimensions, or subscales, and is scored within each dimension: fear of death
(which contains 7 items measuring negative thoughts and feelings about death),
death avoidance (5 items measuring attempts to avoid thinking about death),
neutral acceptance (5 items measuring the extent to which a person is neutral
toward death, neither accepting nor fearing), approach acceptance (10 items
measuring the extent a person sees death as an entrance to a happy afterlife),
and escape acceptance (5 items measuring the extent a person sees death as an
escape from a painful existence). Neutral, approach, and escape acceptance are
described as aspects of overall death acceptance, or avenues for coming to terms
with personal death. Each subscale was scored by adding up each of the items
and dividing it by the total number of items within that dimension.
Students’ experiences of death were pulled from one of students’ initial reflec-
tive essay assignments asking students to describe experiences that ‘‘have most
significantly influenced [their] current attitudes and feelings about death and
loss,’’ though these methods were described in depth elsewhere (Felderhoff &
Wallace, 2015). Essentially, students’ experiences were categorized and counted
by a team of independent coders, then checked for consistency across coders.
Resulting categories in the initial analysis included expected deaths (due to nat-
ural causes, cancer, and other illness), violent, traumatic, or accidental deaths
(VTADs), other unexpected deaths, other death of unknown causes, and pet loss.
Data Analysis
Authors used descriptive statistics to consider the demographics and character-
istics of students within the course. A ttest was used to determine any significant
changes between the baseline (first class of the semester) and the end of the
course on the various aspects of death attitudes or on death anxiety. Pre- and
posttest scores were also compared across semesters and by experiences of death
(by type and amount). All data analysis was conducted using the Statistical
Packages for Social Sciences software, version 23.0.
Results
Sample
All participants for this study were undergraduate students enrolled in the Death
and Dying course during Fall 2012 and 2013 semesters (N¼39). Students
enrolled in both classes were primarily female, although around one in five
were male (n¼8, 20.5%). The age of students ranged across classes from 19
to 58, but the mean age was 22.4 years and the majority of participants were
Wallace et al. 59
between the ages of 19 and 24 (92.3%). Overall, both semesters were filled with
mostly upperclassmen (juniors and seniors, 89.7%). One notable between seme-
sters was related to the number of social work students versus those from other
disciplines. During the Fall 2012 semester, 55.6% of students were outside of the
Department of Social Work (defined as not seeking social work as a major or a
minor); while in the Fall 2013 semester, only 28.6% came from outside of the
social work department. Across semesters just over half (n¼22, 56.4%) were
social work students. Other students came from a wide range of disciplines,
including psychology, sociology, business, criminal justice, speech pathology,
communication, child development, English, and religion.
Students reported similar numbers in total deaths experienced (just less than
half each semester reported three or more losses), but those in the Fall 2013
semester reported higher rates of VTADs across most categories and had 23.8%
of students report multiple experiences within this category (compared to zero
students in Fall 2012). Table 1 shows the full demographics of the sample.
Death Attitudes
A paired samples ttest was conducted to compare students’ anxiety and atti-
tudes about death from the beginning and end of a death and dying course. t
Tests were also run separately among groups by semester, experiences of
VTADs, and total number of deaths. Table 2 shows the mean scores across
all pre- and posttest results. During the first semester, Fall 2012, there was a
significant difference in Death Avoidance, one of the subscales within the DAP-
R, from pretest (M¼3.51, SD ¼1.22) to posttest (M¼2.6, SD ¼0.91);
t(17) ¼3.48, p¼.003. Using Cohen’s d, the effect size for this change was .82,
suggesting a large effect on the level of death avoidance among these students.
Students’ fear of death scores were also impacted from pretest (M¼3.64,
SD ¼1.29) to posttest (M¼3.17, SD ¼1.28); t(17) ¼1.96, p¼.067, d¼.46.
Interestingly, in Fall 2013, no significant changes were noted across any of the
subscales of the DAP-R. However, in the total sample, there were significant
differences for both fear of death (pretest M¼3.69, SD ¼1.05; posttest
M¼3.28, SD ¼1.31) and death avoidance (pretest M¼3.27, SD ¼1.24; posttest
M¼2.89, SD ¼1.04); t(38) ¼2.24, p¼.03, d¼.36, and t(38) ¼2.01, p¼.05,
d¼.32, respectively. Cohen’s deffect sizes were smaller than those noted
during the Fall 2012 semester but remain meaningful. Table 3 shows the results
of the paired sample ttests by year.
In addition to looking at differences by year, differences by both experiences
of VTA deaths and by total number of deaths reported (of any kind) were
explored. Students with fewer experiences of VTA death (0–1) and fewer experi-
ences of death overall (0–2) both had significant differences in fear of death at
the end of the course, pretest M¼3.82, SD ¼0.98; posttest M¼3.23, SD ¼1.16;
t(32) ¼3.36, p¼.002, d¼.58 and pretest M¼4.08, SD ¼0.91; posttest M¼3.43,
60 OMEGA—Journal of Death and Dying 79(1)
Table 1. Demographics of the Sample.
Category
Fall 2012,
n(%)
n¼18
Fall 2013,
n(%)
n¼21
Total, n
(%)
N¼39
Gender
Male 4 (22.2%) 4 (19%) 8 (20.5%)
Female 14 (77.8%) 17 (81%) 31 (79.5%)
Age (19–58)
19–20 3 (16.7%) 9 (42.9%) 12 (30.8%)
21–22 12 (66.7%) 10 (47.6%) 22 (56.4%)
23–24 2 (11.1%) 0 2 (5.1%)
25–29 0 0 0
30þ1 (5.6%) 2 (9.5%) 3 (7.7%)
Classification
Sophomore 0 4 (19%) 4 (10.3%)
Junior 4 (22.2%) 8 (38.1%) 12 (30.8%)
Senior 14 (77.8%) 9 (42.9%) 23 (59%)
Field of Study
Social work major 2 (11.1%) 12 (57.1%) 14 (35.9%)
Social work minor 5 (27.8%) 3 (14.3%) 8 (20.5%)
Other 10 (55.6%) 6 (28.6%) 16 (41%)
Unknown 1 (5.6%) 0 1 (2.6%)
Students’ reporting experiences of violent, traumatic, or accidental deaths (VTADs)
Terrorism/war 2 (11.1%) 1 (4.8%) 3 (7.7%)
Gang violence 0 2 (9.5%) 2 (5.1%)
Accidental gun 1 (5.6%) 0 1 (2.6%)
Murder 1 (5.6%) 4 (19.1%) 5 (12.8%)
Suicide 2 (11.1%) 5 (23.8%) 7 (17.9%)
Car accident 1 (5.6%) 3 (14.3%) 4 (10.3%)
Drug overdose 0 2 (9.5%) 2 (5.1%)
Other 2 (11.1%) 3 (14.3%) 5 (12.8%)
Multiple VTADs 0 5 (23.8%) 5 (12.8%)
Total # of reported death experiences
Missing 1 (5.6%) 0 1 (2.6%)
0–2 9 (50%) 11 (52.4%) 20 (51.3%)
3þ8 (44.4%) 10 (47.6%) 18 (46.2%)
Wallace et al. 61
Table 2. Mean Scores of DAP-R and DAS-E.
By Semester By experiences of VTA deaths By total # of deaths
Fall 2012 Fall 2013 0–1 Multiple 0–2 3þTotal
Scales n¼18 n¼21 n¼33 n¼5n¼20 n¼18 N¼39
DAP-R M SD M SD M SD M SD M SD M SD M SD
Fear of Death Pre 3.65 1.29 3.73 0.83 3.82 0.98 3.34 0.97 4.08 0.91 3.4 0.95 3.69 1.05
Fear of Death Post 3.17 1.28 3.38 1.37 3.23 1.16 3.83 2.2 3.43 0.91 3.18 1.68 3.28 1.32
Death Avoid Pre 3.51 1.22 3.06 1.25 3.54 1.11 1.92 0.86 3.32 1.12 3.33 1.32 3.27 1.24
Death Avoid Post 2.6 0.91 3.13 1.09 2.87 0.99 3.2 1.39 2.84 1.02 3.0 1.07 2.89 1.04
Neutral Accept Pre 5.82 0.56 5.98 0.57 5.89 0.58 6.0 0.53 5.87 0.61 5.95 0.53 5.9 0.56
Neutral Accept Post 5.72 1.11 5.75 0.77 5.67 0.97 6.08 0.58 5.82 0.66 5.61 1.18 5.74 0.93
Approach Accept Pre 5.53 1.19 5.57 0.95 5.59 1.01 5.0 1.18 5.4 1.12 5.65 0.95 5.55 1.05
Approach Accept Post 5.76 1.49 5.37 1.18 5.6 1.33 5.08 1.46 5.35 1.44 5.73 1.22 5.55 1.33
Escape Accept Pre 3.98 1.65 4.34 1.58 4.22 1.6 4.0 1.87 3.99 1.65 4.42 1.59 4.17 1.6
Escape Accept Post 4.44 1.86 4.44 1.49 4.31 1.69 5.04 1.37 4.04 1.86 4.81 1.32 4.44 1.65
DASE n¼17 n¼20 n¼30 n¼5n¼18 n¼17 N¼36
Pre 13.77 4.76 15.0 7.62 14.2 6.44 17 5.96 14.61 7.06 14.59 5.76 14.42 6.37
Post 10.94 6.12 15.42 9.46 11.83 6.73 23.8 9.88 12.17 7.88 15 8.64 13.31 8.26
Note. DAP-R ¼Death Attitudes Profile–Revised; DAS-E ¼Death Anxiety Scale–Extended.
62
SD ¼0.91; t(19) ¼3.68, p¼.002, d¼.82, respectively. Similarly, these groups
also experienced differences in death avoidance, pretest M¼3.54, SD ¼1.11;
posttest M¼2.87, SD ¼0.99; t(32) ¼3.98, p¼.000, d¼.69 and pretest
M¼3.32, SD ¼1.12; posttest M¼2.84, SD ¼1.02; t(19) ¼2.4, p¼.027,
d¼.55, respectively. Students with multiple VTA deaths or a total of three or
more reported deaths did not experience any statistically significant differences.
Tables 4 and 5 show these results in full.
Death Anxiety
Following the same procedures as above, a paired samples ttest was conducted
to compare death anxiety, using the DAS-E, between the beginning and end of
the semester for students enrolled in a death and dying course. tTests were also
run by year (Fall 2012 and 2013), by VTA deaths (0–1 and multiple), and by
overall number of deaths reported (0–2 and 3 or more). For the students enrolled
in the course in 2012, there was a significant difference in the pretest (M¼13.77,
SD ¼4.76) and the posttest (M¼10.94, SD ¼6.12) of the DAS-E; t(17) ¼2.184,
Table 3. Results of Paired Sample tTests by Year.
Variable Mdiff SD t df p
Fear of death 2012 0.48 1.05 1.96 17 .067
2013 0.35 1.24 1.29 20 .21
All 0.41 1.14 2.24 38 .03
Death avoidance 2012 0.91 1.11 3.48 17 .003
2013 0.08 1.06 0.33 20 .75
All 0.38 1.18 2.01 38 .05
Neutral accept 2012 0.1 0.97 0.44 17 .67
2013 0.22 0.91 1.11 20 .28
All 0.17 0.93 1.12 38 .27
Approach accept 2012 0.23 0.69 1.42 17 .17
2013 0.2 0.77 1.19 20 .25
All 0.001 0.76 0.01 38 .99
Escape accept 2012 0.47 1.35 1.46 17 .16
2013 0.1 1.15 0.38 20 .71
All 0.27 1.25 1.34 38 .19
DAS-E 2012 2.82 5.33 2.18 16 .04
2013 0.42 8.58 0.21 18 .83
All 1.11 7.32 0.91 35 .08
Note. DAS-E ¼Death Anxiety Scale–Extended.
The values that are bolded are the significance values; the non-bolded items are not significant.
Wallace et al. 63
p¼.044, d¼.53. In other words, students enrolled during the course in 2012
were significantly less anxious about death following the course than when they
entered it. Yet similar to the death attitude results above, no significant changes
in death anxiety were noted in the 2013 class.
Table 4. Results of Paired Sample tTests by Experiences of Violent, Traumatic, or
Accidental Deaths.
Variable M diff SD t df p
Fear of death 0–1 0.59 1.0 3.36 32 .002
Multiple 0.49 1.58 0.69 4 .53
Death avoidance 0–1 0.67 0.96 3.98 32 .000
Multiple 1.28 1.15 2.48 4 .068
Neutral accept 0–1 0.23 0.97 1.35 32 .188
Multiple 0.08 0.69 0.26 4 .807
Approach accept 0–1 0.005 0.80 0.03 32 .974
Multiple 0.08 0.42 0.43 4 .693
Escape accept 0–1 0.08 1.22 0.4 32 .691
Multiple 1.04 0.88 2.65 4 .057
DAS-E 0–1 2.37 6.46 2.01 29 .05
Multiple 6.8 8.67 1.75 4 .206
Note. DAS-E ¼Death Anxiety Scale–Extended.
Table 5. Results of Paired Sample tTests by Total Number of Reported Deaths.
Variable M diff SD t df p
Fear of death 0–2 0.67 0.8 3.68 19 .002
3þ0.21 1.4 0.65 17 .525
Death avoidance 0–2 0.48 0.9 2.4 19 .027
3þ0.33 1.45 0.97 17 .344
Neutral accept 0–2 0.05 0.66 0.34 19 .74
3þ0.34 1.16 1.23 17 .235
Approach accept 0–2 0.04 0.73 0.26 19 .797
3þ0.08 0.81 0.41 17 .688
Escape accept 0–2 0.05 1.07 0.21 19 .837
3þ0.39 1.36 1.21 17 .242
DAS-E 0–2 2.44 7.11 1.46 17 .163
3þ0.41 7.66 0.22 16 .827
Note. DAS-E ¼Death Anxiety Scale–Extended.
64 OMEGA—Journal of Death and Dying 79(1)
When looking at students with low numbers of VTA deaths (0–1), death
anxiety scores were significantly lower at the end of the semester, pretest
M¼14.2, SD ¼6.44; posttest M¼11.83, SD ¼6.73; t(29) ¼2.01, p¼.05,
d¼.37. There were no significant changes in anxiety when looking at the total
number of reported deaths or within the sample as a whole. Although there was
also not a statistically significant change reported in students with multiple
VTADs, the change in mean score for these five students is noteworthy as
mean scores went up by 6 points on the scale (pretest M¼17, SD ¼5.96; posttest
M¼23.8, SD ¼9.88). Using an independent samples ttest, death anxiety scores
at posttest were significantly higher for students with multiple VTADs
(M¼23.8, SD ¼9.88) than those reporting 0 or 1 VTADs (M¼11.83,
SD ¼6.73), t(33) ¼3.45, p¼.002, d¼.6. There was not a statistically significant
difference among these groups at pretest.
Discussion
Since results varied across semesters, even though course materials remained the
same, some discussion is warranted about these differences. All five students
experiencing multiple VTA deaths were in the 2013 class, causing greater varia-
tion in both the death attitudes and the death anxiety scores within that group of
students. Although nine students in 2012 reported experiencing a VTA death,
zero reported experiencing more than one. The total number of losses reported
per student in 2012 ranged from 0 to 4, but in 2013 5 of the 21 students reported
five or more losses, and two of those were students who did not fall within the
multiple VTA deaths group. So essentially one third of the students during the
2013 semester (n¼7) experienced either a greater number of violent or traumatic
deaths (e.g., incidences of loss by suicide, drug overdose, gun violence, and gang
violence) or a greater number of successive losses, with three students experien-
cing both of these. This difference across semesters may also be reflected by
looking at the mean anxiety pretest scores, 13.75 in 2012 compared to 15.0 in
2013. Although not a statistically significant difference using an independent
samples ttest, it provides additional context for this discussion. The differences
in posttests were even more striking, as the mean score in 2012 was 10.94
compared to 15.42 in 2013.
Death anxiety and death attitudes therefore may be mediated by types and
number of loss experiences or through healthy bereavement of those losses.
Comparing results by these variables demonstrated that students with fewer
overall deaths (0–2) and fewer VTA deaths (0–1) experienced decreased fear
of death and death avoidance. Those with one or less VTA deaths also experi-
enced a decrease in death anxiety. Students with multiple VTA deaths and larger
numbers of reported experienced deaths (3þ) did not experience statistically
significant changes in these areas. Although there is some research that indicates
that 22–30% of undergraduate students have experienced a death within the past
Wallace et al. 65
year and 35–48% have experienced a loss within the past 2 years (Balk, 2001),
these data do not take into account the type or number of losses experienced and
how these losses may impact students’ readiness to learn about death, dying,
grief, and loss.
Findings here support Supiano and Vaughn-Cole’s (2011) findings that stu-
dents with prior history of loss can benefit from death education. Although
their study described several students with at least one VTA death (4 of 35
students experienced six total unexpected traumatic or accidental deaths), dif-
ferences of these students compared to others without experiences of VTA
deaths was not considered. It also was not reported whether the two students
who did not report ‘‘increased readiness to care for suffering persons’’ were
those with this history of traumatic loss (Supiano & Vaughn-Cole). The cur-
rent study provides further context to the relationship of prior losses and the
impact of death education, suggesting that students with a history of multiple
VTA deaths may not experience the same decrease in death anxiety, fear of
death, and death avoidance as other students without a history of multiple
traumatic deaths.
Furthermore, students with a history of multiple VTA deaths may actually
experience an increase in death anxiety and require additional support during
the educational process. This corresponds with older research in this area that
suggests students may experience an increase in anxiety directly following edu-
cation due to overexposure to the subject and to reliving painful connections to
death and dying (Maglio & Robinson, 1994). Prior research has not considered
the experience of VTA deaths as an indicator for why this occurs in some
students and not others. Multiple prior experiences of VTA deaths may predict
students who have increased anxiety when exposed to specialized death educa-
tion. Further research in this area should include an evaluation of the timing of
prior losses and on any ongoing grief needs at the start of a death education
curriculum. Future studies might also include a posttest further in the future
after completion of the course to see how changes may differ over time.
Additionally, it is important to understand the overall lived experience of stu-
dents enrolled in a course, as this study suggests that transformative changes in
attitudes and anxiety can occur, corresponding with other recent research with
students in human services (McClatchey & King, 2015).
Limitations
This research does however present with several limitations. As a course open to
students across disciplines, a cross-discipline analysis might have considered dis-
cipline-specific differences in student learning related to death education.
However, due to the inconsistent distribution across disciplines and the overre-
presentation within social work, this was not possible. The context of teaching an
interdisciplinary group versus a group of only social work students might also be
66 OMEGA—Journal of Death and Dying 79(1)
considered in future research. Another limitation was that students’ attitudes and
anxieties about death may have been influenced by factors outside of the course,
which was not controlled for within this research design. Since the scales were
initially introduced as part of a learning exercise and not for purposes of research,
adding a control group for comparison purposes was not initially discussed.
Another limitation was that the experiences of deaths were captured from
students’ reflective essays, so it is possible that some of the deaths previously
experienced by students were not reported. There was also no reference or
measurement for the timing of the deaths experienced by students. Finally, the
small number of students in this sample who experienced multiple VTA deaths
(n¼5) was a limitation in this study. However, ttests remain useful even with
extremely small samples of five or less (de Winter, 2013). The comparisons in this
study were particularly meaningful since no other studies have considered the
relationship between VTA deaths and death anxiety and attitudes of undergrad-
uate students.
Summary and Implications for Education
Overall, the findings of this study provide promising results for transforming
students’ fear of death, death avoidance, and anxiety about death, although
more attention is needed on past experiences of loss, the timing of losses, and
ongoing experiences of grief. Results also suggest that students with a history of
multiple VTADs may experience an increase in anxiety during death education.
The potential for personal struggle related to course materials is not a reason to
stop providing important education, rather there a number of practices that can
be built in to curriculum to support students who may struggle with the difficult
material (Carter, 2015). Instructors should familiarize themselves with support
systems across the university, including disability services, student academic
support services, and available counseling services (Nilson, 2010). Faculty can
create space within the classroom for students to explore their discomfort with
material, initially engaging them with the possibility that this may occur, so that
students can adequately prepare themselves to participate meaningfully across
various topics.
As an instructor continuing to provide death education to college students
post completion of this study, the first author now incorporates a number of
new practices based on the results and ongoing student feedback. At the begin-
ning of each semester, professor and students engage in a discussion about
potential discomfort that may occur in relation to death-related material
across the semester. Students are asked to examine the syllabus and consider
which topics they are most looking forward to studying as well as those they are
most anxious about. The important roles of self-reflection and self-care within
professional work are explored both initially and during a more in-depth lecture
on self-care early in the course. This lecture is inclusive of tools for self-care and
Wallace et al. 67
the role of professional mental health support for health-care workers. Other
activities across the semester include completion of a personal death awareness
worksheet to assist students in identifying areas of sensitivity, various check-ins
about how students are coping with course material, and ongoing self-reflection
and critical thinking about how personal aspects impact the professional self.
Although the ongoing need for death education has been well-documented
(Bickel-Swenson, 2007; Black, 2007; Csikai & Raymer, 2005; Khader et al.,
2010; Kramer et al. 2003; Mallory, 2003; Supiano & Vaughn-Cole, 2011;
Sullivan et al., 2003; Wass, 2004), the additional context of challenges for stu-
dents with a history of traumatic losses emphasizes the importance of exposing
students to this material prior to engaging with clients independently in profes-
sional practice.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publica-
tion of this article.
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Author Biographies
Cara L. Wallace, PhD, LMSW, is an assistant professor in the School of Social
Work at Saint Louis University. Her research is related to overcoming barriers
to end-of-life care, transitions to care, and the role of family in healthcare
decision making. Her primary practice experience is in hospice and hospital
social work. Dr. Wallace teaches values and ethics as well as courses related
to direct practice in health, end-of-life, or with older adults.
Harriet L. Cohen, PhD, LCSW, retired in May 2016 from the Department of
Social Work at Texas Christian University. Her teaching responsibilities
included social work practice, ethics, death and dying, and healthy aging
courses. Her research examined resiliency in older marginalized populations,
specifically LGBT older adults and Holocaust survivors; and spirituality and
religiosity with midlife and older adults. In April 2017, Dr. Cohen returned to
social work practice, and is employed full-time as a clinical social worker in the
Older Adult Service department at Jewish Family Service of Greater Dallas.
David A. Jenkins, PhD, LCSW, is professor and dean at the University of
Louisville. He previously served as associate dean of Research and Graduate
Studies, Social Work Department chair, and MSW Program director at Texas
Christian University. Dr. Jenkins most recent scholarship focuses primarily on
marginalization, with specific interests in LGBT populations, substance abuse,
and intergenerational families.
Wallace et al. 71
