Psychological and attitudinal responses to death-related education: a sequential explanatory mixed-methods study informed by terror management theory

Abstract

Background

Undergraduates in geriatric service management must be prepared to engage with death-related issues in practice. This study aimed to understand geriatric service management undergraduates’ psychological and attitudinal responses to structured death-related learning by examining changes in death attitudes, self-esteem and purpose in life and exploring students’ subjective experiences of the learning process.

Methods

A nine-week sequential explanatory mixed-methods study informed by Terror Management Theory was conducted with 25 geriatric service management undergraduates. The quantitative component used a repeated-measures observational design, assessing death attitudes, self-esteem, and purpose in life at three time points using the Death Attitude Profile-Revised, Rosenberg Self-Esteem Scale, and Purpose in Life Test. Quantitative data were analysed using Friedman tests with Bonferroni-adjusted Wilcoxon signed-rank post-hoc comparisons. Semi-structured interviews were subsequently conducted and analysed using content analysis. Quantitative and qualitative findings were integrated during interpretation to explain and contextualise students’ responses to death-related learning.

Results

No significant change was observed in the overall death attitude score (p = .399), although several death-attitude subscales showed significant temporal changes. Fear of death increased during the early learning phase before declining significantly by study completion (pc = .004), whereas neutral acceptance increased over time (pa < .001; pb < .001). Approach acceptance declined during the early phase (pa < .001), with no significant overall change across the study period (pb = .074). Self-esteem showed the strongest and most consistent improvement, with significant gains across all time-point comparisons (pa < .001; pb < .001; pc < .001). Purpose in life increased significantly over time (pa < .001; pb < .001). An exploratory subgroup analysis indicated that early changes in death-attitude profiles differed according to prior formal death education. Qualitative analysis identified three themes: conceptualising life and death as interconnected, perceiving constructive meanings in mortality, and engaging with death through anticipation and learning. These themes provided explanatory context for the quantitative findings by illuminating how students integrated death into their understanding of life, developed greater openness toward mortality, and strengthened their sense of purpose and professional identity. Qualitative accounts also revealed heterogeneous responses to mortality, helping explain the non-significant change in the overall death-attitude score.

Conclusion

Structured exposure to death-related learning was associated with subscale-specific changes in death attitudes and consistent improvements in self-esteem and purpose in life among geriatric service management undergraduates. The observed trajectory of an initial increase and subsequent decline in fear of death, together with gains in self-esteem and purpose in life, was broadly consistent with Terror Management Theory and may inform the design of end-of-life care education.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09816-1.

Short abstract

Structured death-related education was associated with subscale-specific shifts in death attitudes and consistent improvements in self-esteem and purpose in life. The observed pattern of change was broadly consistent with Terror Management Theory and suggests that death-related education may support readiness for end-of-life care.

Introduction

Death and dying constitute an essential yet often challenging component of professional preparation for students entering geriatric service management [1–3]. As populations age globally, graduates in this field are increasingly expected to engage with end-of-life issues, support older adults and their families, and navigate care environments where mortality is ever present [4]. Despite this reality, undergraduate training often provides limited structured opportunities for students to explore personal beliefs, fears, and values related to death [5, 6]. Without adequate preparation, students may experience discomfort, avoidance, or emotional distress when encountering death in professional contexts, which may ultimately affect the quality of care they provide [7, 8]. Therefore, developing educational approaches that foster healthier and more reflective responses to death is crucial for building competencies in geriatric care [9, 10].

Terror Management Theory offers a valuable framework for understanding how individuals respond psychologically to thoughts of mortality [11, 12]. Rooted in existential psychology, Terror Management Theory posits that awareness of death can evoke profound anxiety, which individuals manage through cultural worldviews, self-esteem enhancement, and the pursuit of meaning and purpose [13–16]. When mortality becomes salient, people may engage in proximal defenses such as avoidance, denial, or suppression, or they may activate distal defenses, which involve affirming beliefs, strengthening identity, or seeking long-term goals that provide symbolic immortality. In educational settings, particularly those involving death-related content, students may move between these defensive responses as they confront existential concerns and reconstruct personal understandings of life and death, suggesting that different phases of death-related education may be associated with distinct psychological trajectories. Applying Terror Management Theory to health professions education has received growing attention [17–22]. Studies in medical, nursing, and allied health programs indicate that intentional exposure to death-related learning can reduce death anxiety, foster acceptance, and contribute to professional identity formation [23–25]. However, most existing research focuses on medical and nursing trainees. Much less is known about students enrolled in geriatric service management programmes, even though they play an increasingly important role in long-term care, community ageing services, and end-of-life support.

Students in geriatric service management form a distinct group of learners. This major was created in response to rapid population ageing in China [26], and was approved by the Ministry of Education as a new undergraduate programme to strengthen the workforce for ageing related services. Students often come from diverse educational backgrounds and many have had limited prior encounters with death. Their curriculum includes gerontology, ageing policy, service coordination, and care management, yet structured opportunities to reflect on death remain limited. As a result, their psychological responses to death-related learning and the developmental processes that follow remain poorly understood. Terror Management Theory suggests that responses to mortality involve interconnected processes related to death attitudes, self-esteem, and meaning-making, and that these responses may evolve over time as individuals move from defensive reactions toward meaning construction and identity reinforcement. Guided by this framework, the present study examined changes in death attitudes, self-esteem, and purpose in life among geriatric service management students participating in a structured death-related education programme.

Specifically, this study addressed the following research questions: (1) What temporal changes occur in death attitudes, self-esteem, and purpose in life among geriatric service management students following a course on death and dying? (2) Which dimensions of death attitudes show significant change, and which remain stable, across the course period? (3) How do students describe their experiential process of engaging with death-related content, and how do these qualitative accounts explain the quantitative patterns observed? By addressing these questions, the study seeks to inform the design of death-related education and contribute to the preparation of a more competent and resilient geriatric care workforce.

For conceptual clarity, this study uses the term death-related education as a broad term encompassing educational activities commonly described as death education [3, 27–31] and end-of-life education [32–35]. This term captures both psychological-existential reflection on mortality and preparation for future professional encounters with dying patients and their families, aligning with the study’s focus on students’ death attitudes, meaning-making and personal responses to learning about death and dying.

Methods

Design

This study used a sequential explanatory mixed-methods design to examine geriatric service management undergraduates’ psychological and attitudinal responses to structured death-related learning. The quantitative component comprised a repeated-measures observational design, with students assessed at three points across the course period. Following preliminary analysis of the quantitative data, semi-structured interviews were conducted to further explore students’ subjective experiences and to help explain and contextualise the quantitative patterns observed. Quantitative and qualitative findings were integrated at the interpretation stage to provide a more comprehensive understanding of students’ responses to death-related learning.

Theoretical framework

Terror Management Theory informed both the death-related education course and the mixed-methods design. At the course level, it guided the inclusion of learning activities addressing mortality awareness, emotional responses to death, meaning-making and professional identity. At the study-design level, it informed the selection of quantitative outcomes, including death attitudes, self-esteem and purpose in life, which reflect theoretically relevant responses to mortality awareness. It also informed the qualitative interview guide by sensitising the exploration of students’ emotional responses, reflections on self-worth, life purpose and future professional roles. Terror Management Theory further provided a theoretical lens for interpreting and integrating the quantitative and qualitative findings.

Participants and setting

Participants were purposely recruited from first-cohort undergraduates enrolled in the geriatric service management programme at Anhui Medical University, China. The programme had only recently been established at the time of the study, with one intact cohort available; this constrained the eligible pool and is consistent with the limited national enrolment in this emerging discipline. Eligibility criteria were: (1) first-cohort enrolment in the geriatric service management programme, and (2) internship preparation status without prior clinical experience. Students unable to complete all study components were excluded. A total of 28 students volunteered to participate. Three students subsequently withdrew because they transferred to another academic programme and were no longer enrolled in the geriatric service management curriculum, resulting in a final analytic sample of 25 students who completed all three quantitative assessments and the semi-structured interview (retention rate = 89.3%). A formal a priori power calculation was not performed because the entire eligible cohort was recruited; the study is therefore framed as exploratory.

Death-related education course

Students participated in a nine-week structured course on death and dying, comprising 27 class hours divided into two modules: a Theoretical-Learning (TL) module (9 class hours, weeks 1–3) and a Cooperative-Learning (CL) module (18 class hours, weeks 4–9) (Fig. 1). The TL module focused on systematic theoretical instruction across three content domains: general theory, preparation for end-of-life care, and symptom management. The CL module emphasised practical abilities and emotional insight through six content domains: comfort care, sorrow support, law and ethics, special groups, cultural diversity, and communication. Teaching methods in the TL module included instructor-guided lectures with textbook preparation required before each class. The CL module employed group discussions, scenario simulations, sharing sessions, and experiential activities (e.g., aromatherapy exploration for comfort care, picture books and cards for special groups, cross-cultural death customs, and a “Death Café” for open discussion).

Fig. 1.

Study design, terror management theory framework, and structure of the death-related education course

The course was designed with reference to Terror Management Theory. Consistent with this framework, the curriculum combined theoretical instruction and experiential learning activities intended to provide opportunities for students to engage with mortality-related issues, reflect on the meaning of death and life, and consider their future professional roles in end-of-life care. Further details of the course structure, content domains, teaching methods, and learning objectives are presented in Supplementary Table S1.

Measurement

Demographic Information

Included gender, age, ethnicity, only-child status, religious belief, prior death-related education, experience caring for terminally ill individuals, bereavement history, and caregiving experience within the past year.

Death attitude

Developed by Wong [36], and revised in Chinese [37]. The Death Attitude Profile-Revised assesses five dimensions of death attitude: fear of death, death avoidance, neutral acceptance, approach acceptance, and escape acceptance. The 32-item Chinese version has demonstrated good validity and reliability, with Cronbach’s alpha of 0.875 [37]. The scale uses a five-point Likert response format; higher scores reflect stronger endorsement of the corresponding attitude. Cronbach’s alpha coefficient was 0.833 from this study.

Self-esteem

Developed by Rosenberg [38] and revised in Chinese [39], this 10-item unidimensional scale uses a four-point Likert response format to assess global self-worth and self-acceptance. The Chinese version has demonstrated good internal consistency with Cronbach’s alpha of 0.835 [39]. Cronbach’s alpha coefficient was 0.889 in this study.

Purpose in life

Developed by Song [40], the Chinese revised version [41] assesses four dimensions: quality of life, life value, life goals, and life freedom, using a 20-item, five-point Likert scale. Higher scores indicate a stronger sense of life meaning. The Chinese version of the Purpose in Life scale has demonstrated good internal consistency (Cronbach’s alpha = 0.90) [41]. In the present study, Cronbach’s alpha was 0.776, which remains above the commonly accepted threshold of 0.70 for research use. The lower estimate compared with the original validation study may reflect sampling variability associated with the small cohort size (n = 25), differences in participant characteristics, and the multidimensional nature of the scale, which encompasses conceptually distinct domains including quality of life, life value, life goals, and life freedom. Nevertheless, the observed reliability was considered acceptable for the purposes of the present study.

Data collection

Data were collected between March and June 2024 during students’ sixth semester. Questionnaires were administered online via a secure survey platform at three time points: one day before the learning activities (baseline, T0), three weeks into the course (midpoint, T1), and one week after completion (final assessment, T2).

Semi-structured interviews were conducted by the two lead authors within one week of the final assessment using an open-ended interview guide informed by Terror Management Theory and designed to elicit students’ perspectives on death, dying, and related learning experiences. Preliminary findings from the quantitative component were also considered when refining the interview guide. The guide explored the following areas: (1) current understandings of life and death; (2) meanings associated with death; (3) ways in which contemplating death had influenced perceptions of life; (4) wishes and priorities in a hypothetical terminal illness situation; (5) personal and professional impacts of death-related learning; (6) the most memorable or meaningful aspects of the course; and (7) any additional reflections participants wished to share.

Data analysis

Quantitative analysis. Quantitative analyses were conducted in Python v3.11 with the SciPy library (v1.11). Given the small sample size (n = 25) and non-normal distribution confirmed by Shapiro-Wilk testing, descriptive statistics are reported as medians and interquartile ranges (Q1, Q3). Repeated-measures comparisons across the three assessment time points were performed using the Friedman test, with post-hoc pairwise comparisons by the Wilcoxon signed-rank test. Bonferroni correction was applied for multiple pairwise comparisons (α = .05/3 = .0167). Exploratory subgroup analyses comparing participants with formal versus incidental prior death-related education were conducted using Mann-Whitney U tests at each time point and Friedman tests for within-group temporal changes [42]. All tests were two-tailed; statistical significance was defined as p < .05 for omnibus tests and p < .0167 for post-hoc comparisons. Figures were generated using Matplotlib (v3.10) and Seaborn (v0.13).

Qualitative analysis. Interview transcripts were analysed using content analysis. Two researchers independently coded the data, compared coding decisions, and resolved discrepancies through discussion among research team. Inter-coder agreement was substantial (κ = 0.80) [43]. Themes were developed through an iterative analytic process. Trustworthiness was supported through independent coding, team discussion, analytic memos, and the use of participants’ verbatim quotations.

Integration. Integration followed the sequential explanatory mixed-methods approach described by Fetters et al. [44]. Quantitative findings were treated as the primary strand, and qualitative findings were subsequently examined to explain, contextualise, or elaborate observed quantitative patterns. Integration occurred during interpretation through comparison of findings across datasets, resulting in the identification of convergent, complementary, and silent relationships between quantitative and qualitative results.

Results

Quantitative results

Demographic data

Of 28 initially enrolled geriatric service management undergraduates, 25 (89.3%) completed all three assessments and the semi-structured interviews: the three non-completers had transferred to another academic programme. Participants had a mean age of 20.72 years (SD = 0.79). The sample included 13 men (52%) and 12 women (48%), with the majority identifying as Han ethnicity (96%). 12% were only-children. All 25 participants reported some form of prior exposure to death-related content: 10 (40%) had completed a formal course on death and dying, and 15 (60%) had encountered related content only incidentally within other courses; no participant reported being entirely naive to the topic. None had prior experience caring for terminally ill patients. During the past year, 72% reported no bereavement, 24% experienced the death of a non-direct relative, and 4% experienced the death of a direct relative.

Death attitude

Significant time-related changes emerged on three death-attitude subscales: fear of death, neutral acceptance, and approach acceptance. Importantly, the overall DAP-R total score did not change significantly (p = .399). However, exploratory subgroup analyses suggested that this null finding may have masked divergent trajectories between students with formal and incidental prior exposure to death-related education (Subgroup analysis by prior death education section; Table 1). Fear of death followed an inverted-U pattern, rising transiently during the early learning phase before declining significantly from midpoint to endpoint (pc = .004) and returning to slightly below baseline levels. Neutral acceptance showed the largest single-direction change, rising sharply between baseline and midpoint and plateauing thereafter, both post-baseline assessments differed from baseline, but the two assessments did not differ from each other. Approach acceptance exhibited the most theoretically informative pattern: a Friedman-significant change across the full study period (p = .002), with a Bonferroni-significant decline during the early phase (pa < .001) followed by partial recovery that did not survive correction (pc = .040).This transient destabilisation of transcendence-oriented acceptance, despite gains in neutral acceptance, is examined further in the Discussion. No significant changes were observed for death avoidance or escape acceptance.

Table 1.

Changes in psychological and attitudinal outcomes at baseline, midpoint, and final assessment (N = 25)

Outcome	Baseline (T0) Md (Q1, Q3)	Midpoint (T1) Md (Q1, Q3)	Final (T2) Md (Q1, Q3)	χ²	p	pa (T0–T1)	pb (T0–T2)	pc (T1–T2)
Death Attitude (DAP-R Total)	96.0 (93.0, 103.5)	100.0 (97.5, 105.5)	102.0 (93.0, 109.5)	1.838	0.399	–	–	–
Fear of death	20.0 (18.0, 23.0)	22.0 (19.0, 26.0)	18.0 (14.5, 20.5)	6.813	0.033*	0.047	0.037	0.004**
Death avoidance	13.0 (11.0, 16.5)	15.0 (12.0, 17.5)	15.0 (13.5, 17.0)	0.787	0.675	–	–	–
Neutral acceptance	13.0 (11.0, 15.5)	20.0 (19.0, 21.0)	20.0 (19.0, 22.5)	32.319	< 0.001*	< 0.001**	< 0.001**	0.523
Approach acceptance	34.0 (32.0, 38.0)	30.0 (25.5, 31.0)	32.0 (29.0, 36.0)	12.511	0.002*	< 0.001**	0.074	0.040
Escape acceptance	15.0 (11.0, 17.0)	14.0 (12.0, 15.5)	15.0 (13.5, 19.0)	4.022	0.134	–	–	–
Self-Esteem	23.0 (19.0, 25.5)	25.0 (20.5, 28.0)	28.0 (24.5, 33.5)	38.935	< 0.001*	< 0.001**	< 0.001**	< 0.001**
Purpose in Life	67.0 (64.5, 76.0)	75.0 (69.0, 80.5)	77.0 (69.0, 87.5)	13.959	< 0.001*	< 0.001**	0.001**	0.306
Quality of life	16.0 (15.0, 18.0)	18.0 (16.5, 20.0)	19.0 (16.5, 23.5)	6.326	0.042*	0.021	0.009**	0.185
Life value	20.0 (18.5, 22.0)	22.0 (19.5, 24.0)	24.0 (20.0, 25.5)	4.234	0.120	–	–	–
Life goals	25.0 (23.5, 28.0)	28.0 (24.5, 30.0)	30.0 (25.5, 31.5)	14.957	< 0.001*	0.012**	0.004**	0.213
Life freedom	7.0 (6.0, 8.0)	7.0 (7.0, 9.5)	8.0 (6.5, 9.0)	4.023	0.134	–	–	–

Friedman test was used to examine overall temporal changes; significant Friedman results (p < .05) were followed by Wilcoxon signed-rank tests with Bonferroni correction (adjusted α = .05/3 = .0167)

Md  median, Q1, Q3  First and third quartiles (SPSS-equivalent Type 6 method)

pa = T0 vs. T1, pb = T0 vs. T2, pc = T1 vs. T2

^*p < .05; ^**p < .0167 (Bonferroni-significant)

Self-esteem

Self-esteem demonstrated the strongest and most consistent change observed in this study, with progressive gains across all three time points and the largest effect size of any outcome (Table 1). All three pairwise comparisons reached significance under Bonferroni correction, indicating that improvement accumulated continuously across both the early and later phases of learning rather than emerging at a single point.

Purpose in life

Significant time-related improvements were observed in total purpose in life, life goals, and quality of life (Table 1). Gains in purpose in life and life goals emerged predominantly during the early learning phase and were sustained at completion. Quality of life increased more gradually, reaching significance only by the end of the programme. Life value and life freedom followed similar upward directions but did not reach statistical significance.

Subgroup analysis by prior death education

An exploratory subgroup analysis compared participants with prior formal course exposure (n = 10) and those with only incidental exposure (n = 15); no participant was entirely naive to death-related content, precluding a three-way comparison. After Bonferroni correction, the two subgroups did not differ at baseline on any of the twelve outcomes. The longitudinal trajectories of these outcomes are presented in Fig. 2. Students with formal prior exposure showed directionally higher medians throughout (Supplementary Table S2). Across thirty-six change-score contrasts, one result survived family-wise correction: the early-phase change (T0→T1) in DAP-R total moved in opposite directions in the two subgroups, decreasing in students with formal prior exposure (median Δ = −5) and increasing in those with only incidental exposure (median Δ = +10), with a very large effect size (Fig. 3). The finding remained robust to leave-one-out resampling, bootstrap confidence intervals, and outlier-removal sensitivity checks (Supplementary Table S3, Supplementary Figure S1).

Fig. 2.

Longitudinal trajectories of the twelve study outcomes by prior death-related education subgroup

Fig. 3.

Divergent trajectories of DAP-R total scores by prior death-related education subgroup

Qualitative results

Twenty-five participants completed the semi-structured interviews. Interview transcripts were analysed using directed content analysis informed by Terror Management Theory. The analysis generated three themes and seventeen sub-themes (Table 2): (Theme 1) Conceptualising life and death as interconnected, (Theme 2) Perceiving the constructive meanings of death, and (Theme 3) Engaging with death through anticipation and learning.

Table 2.

Qualitative themes and subthemes

Theme	Subtheme
Conceptualising life and death as interconnected	Mortality as biological inevitability
	Death as relief or liberation
	Death as continued spiritual presence
	Social death and being forgotten
Perceiving the constructive meanings of death	Cherishing life and the present
	Motivating purpose and achievement
	Death as release from suffering
	Renewal and continuity of life
	No positive meaning in death
	Social and utilitarian value
Engaging with death through anticipation and learning	Saying goodbye
	Travel and unspoken wishes
	Symbolic legacy
	Emotional reflection
	Professional identity
	Vocational commitment
	Humanistic-care competence

Theme 1: conceptualising life and death as interconnected

Students positioned life and death not as opposites but as parts of a continuous and interpenetrating whole. Four sub-themes captured the range of conceptualisations: mortality as biological inevitability, death as relief or liberation, death as continued spiritual presence, and an interpretively important minority view of social death and being forgotten. The theme encompassed both accepting and more troubled understandings of death.

A first group framed death calmly as a universal biological endpoint to be accepted rather than feared:

“I think death is something every person must pass through. I am not very afraid of death.” (P4)

A complementary perspective rejected biological cessation as the true ending, foregrounding remembrance and influence instead:

“Death is the disappearance of the body — a course every person must take. But death is not the endpoint of life. Being forgotten is.” (P3)

That second framing carried a darker corollary for some participants, who identified social erasure, being forgotten as a loss more profound than physical death itself:

“A person disappears from the world forever, appearing only in memory.” (P19)

Theme 2: perceiving the constructive meanings of death

Participants identified six ways in which mortality functioned within their evolving meaning systems: cherishing life and the present, motivating purpose and achievement, death as release from suffering, renewal and continuity of life, social and utilitarian value, and, importantly, a minority who recognised no positive meaning in death. The majority articulated some form of constructive meaning. Below we foreground the dominant constructive frame and the qualitative negative case to illustrate the heterogeneity of meaning-making within the cohort.

The most widely articulated perspective was that awareness of finitude intensifies appreciation of the present moment, of relationships, and of daily life:

“Because I know I will die, I cherish every day of my existence all the more, live in the present, and try to make every day happy.” (P12)

“Life is limited, and this makes us cherish the present.” (P6)

A minority of participants, however, explicitly rejected any constructive reading of death and framed it as pure loss:

“In my understanding, death has no positive meaning for life. For an ordinary person it means the end of life; for those around them it means separation; for the world it means being forgotten and disappearing.” (P8)

Theme 3: engaging with death through anticipation and learning

Participants described engaging with death through both personal anticipation of mortality and reflections arising from the course. Seven sub-themes were identified: saying goodbye, travel and unspoken wishes, symbolic legacy, emotional reflection, professional identity, vocational commitment, and humanistic-care competence.

When asked what they would want if they imagined themselves in a terminal scenario, the most common wish was to spend remaining time with family and friends in warm, reciprocal farewells:

“I would want to say goodbye to my family and friends, happily and warmly — thank them for everything they have done for me, ask them not to be too sad, accept my death calmly. I would also want some time alone, by the sea or any water, sitting and watching the wind move the surface; in inner stillness, I would leave this beautiful world.” (P3)

Other participants focused on fulfilling personal wishes, travelling, meeting significant others, or leaving a symbolic legacy through activities such as organ donation or farewell letters.

“(1) Eat a really good meal. (2) Go to Iceland — somewhere I have never been. (3) Meet the idol I have never met.” (P11)

Reflecting on which aspects of the course had mattered most, participants moved in two directions. A first group described an inward turn, the release of their own death anxiety, contemplative practice, or peer sharing of personal feeling:

“The session in which our teacher guided us to face death-anxiety directly was the most unforgettable. It loosened a long-held knot in my heart and let me bring a healthy mindset into geriatric-care learning and practice.” (P5)

A complementary group described an outward turn, reframing the boundaries, rituals, and professional responsibilities of geriatric and palliative care, most often around the simulated farewell ritual:

“The most unforgettable was the simulated farewell ritual. As I tidied the simulated elder’s appearance and spoke softly to say goodbye, I suddenly understood that palliative care is not just a set of procedures—it is also accompaniment that comes from the heart. I was deeply moved.” (P19)

A final and substantial sub-theme captured how learning was integrated into a reframed model of care, one that positioned humanistic accompaniment, emotional support, and communicative competence as central rather than ancillary to technical procedure:

“On a personal level, I have learned to look at the world with a more accepting heart. In my work, I understand that words of accompaniment and emotional support can soothe a dying elder more than physical care alone.” (P16)

Integration of quantitative and qualitative findings

The integration followed Fetters et al.’s sequential explanatory framework, in which qualitative findings supply explanatory context for quantitative patterns [44]. Three modes emerged. The first mode was convergence, whereby findings from the qualitative strand supported and elaborated quantitative trends. Increased neutral acceptance was consistent with participants’ descriptions of death as a natural and inevitable part of life, as well as a heightened appreciation of the present. Similarly, the decline in fear of death observed during the later phase of the course corresponded with qualitative accounts describing reduced anxiety and greater emotional readiness to engage with end-of-life issues. Improvements in self-esteem and purpose in life converged with narratives of strengthened professional identity, increased vocational commitment, and a more humanistic understanding of care.

A second mode was complementarity. Qualitative findings also complemented quantitative results by revealing heterogeneity that was not evident from scale scores alone. The DAP-R total score showed no significant time effect, yet the qualitative data included both constructive and negative interpretations of death. These opposing perspectives may have contributed to the stability of the overall DAP-R score despite significant movement in individual subscales.

The third mode was silence, referring to a quantitative finding without a clear qualitative counterpart. Specifically, the significant decline in approach acceptance during the early phase of the programme was not reflected in participants’ narratives. Although some students described spiritual continuity or death as relief, none reported questioning or weakening previously held transcendence-related beliefs. This discrepancy highlights an area requiring further investigation.

Discussion

This sequential explanatory mixed-methods study examined temporal changes in psychological and attitudinal outcomes during structured death-related learning for geriatric service management undergraduates. Quantitative results revealed differentiated changes in death attitudes, self-esteem, and purpose in life, which were further illuminated by semi-structured interviews. Death Attitude Profile-Revised total did not change significantly across the study; the patterns described below are therefore subscale-specific rather than evidence of a uniform shift in death attitudes. Fear of death initially increased and then declined, consistent with Terror Management Theory, which posits that mortality salience can provoke anxiety before prompting adaptive meaning-making [45–48]. Neutral acceptance steadily improved, suggesting that confronting mortality facilitates recognition of death as a natural component of life [49–51]. Approach acceptance showed the most complex trajectory, declining during the early phase of the programme before partially recovering thereafter. Taken together, these subscale trajectories are consistent with the view that engagement with death-related content may support the development of a balanced and realistic stance toward mortality relevant to future geriatric care practice [52, 53].

Cultural worldviews help explain students’ changing responses to mortality. In the Chinese context, Confucian, Taoist, and Buddhist traditions provide meaning systems that stabilise existential anxiety in ways consistent with Terror Management Theory [17, 54–57]. Confucian emphases on moral responsibility and relational bonds resonate with the professional expectations of geriatric service management, where supporting older adults and their families requires a strong sense of duty and relational sensitivity. Taoist views of natural transformation encourage calm acceptance of life transitions, a perspective relevant to working with ageing populations who frequently face declining health and end-of-life issues. Buddhist reflections on impermanence likewise offer cognitive and emotional resources that can reduce fear and facilitate compassionate engagement with frailty and loss. These culturally embedded buffers may have supported students’ reduced discomfort when engaging with death-related content. Western philosophical perspectives, such as Heidegger’s serious philosophical analysis of being-toward-death [58–61], similarly highlight the potential of mortality awareness to foster authenticity and meaning-making, aligning with Terror Management Theory’s proposition that worldviews sustain psychological equilibrium [62, 63]. Together, these perspectives likely shaped how students processed the curriculum and deepened their cognitive, emotional, and existential engagement in ways directly relevant to their future roles in end-of-life and geriatric care.

Compared with prior studies where reflections on death did not consistently influence emotions or self-esteem [64], the present findings suggest that the undergraduate education may represent an important period for shaping these outcomes, as students are simultaneously developing their professional identity, personal values, and attitudes toward death. Nevertheless, because no comparison groups from other developmental stages were included, this interpretation should be regarded as tentative and requires further investigation. Among the outcomes assessed, self-esteem showed the strongest and most consistent gains, with Bonferroni-significant increases at every adjacent contrast; these gains may reflect a sense of growing professional competence accruing through hands-on engagement with the structured learning activities. Students appeared highly responsive to structured learning that provided timely guidance, space for emotional processing, and recognition of their emerging competencies. These elements may have reinforced a sense of professional capability and reduced anxiety when engaging with mortality-related content [65]. Such ability-based appraisals may offer a more stable foundation for self-esteem than learning experiences that emphasise individual performance alone [64–66].

Improvements in purpose in life were also evident across the programme. Qualitative findings suggested that reflection on mortality encouraged students to reconsider personal priorities, future aspirations, and the meaning of their professional roles. Consistent with existential and terror-management perspectives, awareness of life’s finitude may stimulate meaning-making processes and strengthen individuals’ sense of purpose [47]. For students preparing to work with older adults and people approaching the end of life, such reflection may contribute to the development of a more coherent professional and personal value system.

Exploratory subgroup analyses suggested that students with prior formal exposure to death-related education responded differently during the early phase of the programme than those whose exposure had been incidental. Although this finding should be interpreted cautiously given the small sample size, it raises the possibility that prior educational experiences may shape students’ initial responses to mortality-related learning.

Collectively, these findings suggest that death-related education is not merely a process of knowledge acquisition but also a dynamic process of emotional adaptation, meaning reconstruction, and professional identity formation. The observed trajectory of fear of death, characterised by an initial increase followed by a subsequent decline, indicates that students may experience temporary emotional discomfort when first confronting mortality-related topics. Therefore, death education programmes may benefit from a gradual and appropriately sequenced pedagogical design, in which emotional support, guided reflection, peer discussion, and experiential activities are introduced before deeper existential exploration.

Furthermore, the sustained improvement in self-esteem, together with qualitative findings highlighting vocational commitment and humanistic-care competence, suggests that death education should extend beyond transmitting end-of-life knowledge to fostering meaning-making, self-reflection, and the development of professional values. Such an approach may better prepare future geriatric service professionals to engage compassionately and confidently with ageing, dying, and end-of-life care.

Limitations

This study has several limitations. First, the sample size was small and drawn from a single medical university. This constraint is partly due to the geriatric service management programme being newly established in China, and the number of enrolled students remains limited nationwide. As the programme expands and matures, future studies should recruit larger and more diverse cohorts from multiple institutions and regions to improve the generalizability of findings.

Second, the study design limits both causal inference and understanding of longer-term outcomes. The study employed a single-group observational design without a comparator group, and psychological outcomes were assessed only immediately after completion of the course. In addition, some participants had received formal death-related education before enrolment, which may have influenced their responses to the programme. Future studies should incorporate comparison groups, longer follow-up periods, and stratified analyses based on prior educational exposure.

Third, the study relied primarily on self-report measures and interview data, which may be influenced by subjectivity or social desirability. Future research would benefit from multimethod approaches that integrate behavioural indicators, simulation-based evaluations, or assessments conducted by instructors and clinical supervisors to provide more comprehensive and objective evidence.

Conclusions

This sequential explanatory mixed-methods study found that structured engagement with death and dying was associated with changes in death attitudes, self-esteem, and purpose in life among geriatric service management undergraduates. The most consistent improvements were observed in self-esteem, while changes in death attitudes occurred at the subscale level rather than as a uniform shift in overall attitudes toward death. Qualitative findings further suggested that students developed more reflective understandings of mortality, professional identity, and the meaning of care.

These findings indicate that death-related education may contribute not only to knowledge acquisition but also to students’ psychological and existential development. Educational approaches that combine theoretical learning, experiential activities, and reflective dialogue may help prepare future professionals to engage with ageing, dying, and end-of-life care with greater confidence, empathy, and understanding.

Future research involving larger and more diverse samples, comparator groups, longer follow-up periods, and consideration of prior educational exposure is needed to further clarify the effectiveness and mechanisms of death-related education in health-profession training.

Authors’ contributions

Huan Yu: Conceptualization, methodology, software, investigation, formal analysis, funding acquisition, writing – original draft, writing – review & editing. Zengxia Liu: Methodology, data curation, investigation, validation, formal analysis, writing – review & editing. Junli Yan: Methodology, data curation, investigation, validation, formal analysis, writing – review & editing. Yin Wang: Conceptualization, methodology, writing – review & editing. Jingfang Hong: Formal analysis, supervision, project administration, resources, writing – review & editing. Wenru Wang: Supervision, Resources, Writing – review & editing. All authors read and approved the final manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by grants from the Research achievements of Anhui Philosophy and Social Science Planning Project (Project Number: AHSKQ2024D052), the Key Project of Humanities and Social Sciences of Anhui Provincial Department of Education (Project Number: 2025AHGXSK30149) and the Teaching Research Project of Quality Engineering of Anhui Provincial Department of Education (Project Number: 2024jyxm0147).

Data availability

The datasets generated and/or analyzed during the current study are available in the Zenodo repository, https://doi.org/10.5281/zenodo.20724604.

Declarations

Ethics approval and consent to participate

This study was approved by the Human Research Ethics Committee of Anhui Medical University (Approval No. 84230107, January 1, 2023). All procedures were conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.