Three main themes emerged from the participants’ responses: (1) changes following the death education intervention, (2) the usefulness of the death education intervention in terms of the elaboration of traumatic grief in the community, and (3) motivations to reintroduce the death education intervention. The names of all participants have been replaced with pseudonyms.
Theme 1: Changes following the death education intervention
Some participants reported that the theme of death was not novel in this community, as a previous instance of student suicide and resulting traumatic grief had forced the community to consider the issue of youth suicide. Some teachers reported feelings of disbelief linked to this traumatic episode, saying that the community experienced the event as though it were not the death of a boy, but rather the case of a temporarily missing person. Community members struggled to convince themselves that it was a definitive event: the common feeling was that the boy would come back as if he had only gone away for a moment.
The experience of death education and, in particular, the visit to the hospice, made it possible to deal with this disbelief and denial and to reflect on its meaning. This act of reflecting on the meaning of dying enabled participants to explore ontological representations of death, as elaborated by Andrea, one of the hospice nurses:
The death education course allowed me, in the first place, to examine the ontological representations I had concerning death and, while reflecting upon them, to modify the most distressing ones. Initially, I saw death as something to avoid, something I preferred not to think about, that I preferred to cast aside, and now, instead, I am able to face the idea of death in a calmer way. I am able to speak about it, to mention it. I am able to accept death as, indeed, the conclusion of a path that is part of life. This allows me to act as a support for the patients’ relatives in the hospice and also as a support for my own relatives and friends.
For most of the hospice staff, understanding the meaning of the term ‘passage’ and being able to question it was important. For some people, this meant reconsidering their idea of death – not seeing it as the absolute end, but rather as a passage. This perspectival shift also helped these participants to change their view of life, regarding it as a succession of experiences that are preserved after death. This renewed vision of life manifested as greater appreciation for the little things in life, such as waking up in the morning and going to sleep at night, and it enabled these participants to turn their fear of death into a desire to live. Some teachers also came to understand and accept that death does not paralyse life but, on the contrary, allows one to live more consciously and more fully by learning to grasp the nuances of life that were previously taken for granted. Furthermore, the teachers perceived a change in students’ views on life, as students told them that they understood the importance of each lived moment and of being present with people who suffer, even in silence. According to these teachers, the students grew up after this experience, and the stories they exchanged about their experiences of loss made them feel closer to each other and part of the ‘great mystery of life’.
Evidently, there was a shift in how the community viewed the hospice (end-of-life care) and hospice staff after the death education project. Prior to the project, the hospice and hospice staff were surrounded by an aura of mystery and fear because of the community’s prejudice (i.e., social censorship). Giulio, a teacher, affirmed:
The general fear was of entering a sort of ‘factory of death’. When I proposed to visit the hospice, the students were full of prejudices that certainly came from what we, as adults, communicate to them, from the way we talk about the hospice in our society.
All the teachers stressed the intervention’s utility for overthrowing these prejudices, revising beliefs that the hospice was a place of sadness and death by inviting participants to view it instead as a place full of dignity. Prior to this experience, some teachers knew very little about end-of-life difficulties or the kind of work hospice professionals performed. They came to be very impressed by the hospice staff’s humanity. This experience also prompted students to address their inherited prejudices, instigating perspectival changes that extended to their conversations at home and with their friends. They shared with the teachers that they felt less fear and anguish about death and that they were able to look inside themselves and better understand their emotions and those of their classmates.
Theme 2: Usefulness of death education for the elaboration of traumatic grief in the community
Almost all the teachers and hospice staff confirmed that the intervention allowed them to elaborate their particular feelings of traumatic grief. Valeria, a psychologist at the hospice, affirmed:
There is a huge difference between being silent, as often happens after a suicide, and being able to talk about it, considering death as something natural. In the latter case, the elaboration of grief helps people draw on resources that they need to face the situation and the distress without isolating themselves … talking about grief at the community level offers support to all.
Fabio, a doctor, declared:
Talking about death can make us reflect upon the fact that death is part of life and that, therefore, it is not something obscene but rather something that is natural. It is important to encourage philosophical reflection on life, framing it as a good that is not endless, but, on the contrary, available for a limited amount of time.
Many of the teachers also had a very positive view of the death education intervention. Some reported positive feedback from their male students, who stated that they were able to talk about the loss of their comrade and gradually move on with their lives in a more peaceful and serene way. In addition, some teachers claimed that death education helped them and their students to accept that the path of life, which ends with death, is made of both joyous steps and steps that are full of unavoidable suffering. They also believed that community support and sharing could help to make people feel less lonely by involving them in meaningful relationships, which could help reduce the risk of suicide.
Hospice workers reported that they are willing to take further steps of this kind, as they aspire to promote cultural change regarding death representations by nurturing relationships between end-of-life workers and the community. Lucio elaborated:
Death education is useful because it means going back to our origins; in the past, indeed, when there wasn’t a very sophisticated health network, people would care for those who were facing death at home, and therefore there was much more solidarity. A communitarian path would help us rediscover what we already have inside of us – that is, the importance of accompanying a person right until his/her last instant of life. Thanks to these death education courses, there is a more welcoming atmosphere in the hospice, and our sense of responsibility towards the patients and their families has increased because we now operate in a cultural environment that needs to seriously deepen the themes of death.
The teachers’ declarations on the usefulness of death education at the community level appeared to be just as positive as those of the hospice staff. In some cases, they favoured a proactive approach, with some putting forward innovative proposals to facilitate death education in schools, parishes and city squares. Teachers agreed that more interventions would be useful because they provide psychological and emotional support for patients’ relatives and promote human growth. Through them, everyone could become aware of the fact that each one of us will one day die.
Theme 3: Motivations to reintroduce the death education intervention
Hospice workers reported that they would be willing to redo the death education course and welcome students into the hospice because they believe in its educational, pedagogical and formative potential to engender understanding and acceptance of separation, loss and illness. According to some of them, the intervention also helped professionals themselves to reformulate their knowledge and skills and to question them with the students.
From the teachers’ point of view, the intervention was significant because it helped them to relate to each other and allowed them to break down some barriers with students, resulting in closer teacher–student relationships and a learning environment where individuals can share their emotions. Some teachers also found it useful because, through it, they acquired tools to talk about death and dying at home with their own children, who they worried might otherwise have little ability to process illness or death.
Both the teachers and the professionals believed that new cohorts of students would also welcome this course. Teachers asserted that it is important that children of a certain age group reflect on the topics of death and dying. As such, they would like the courses to be implemented every year as part of the school curriculum and for the courses to continually involve the local community. According to teachers, the course’s multidisciplinary approach should be retained in future iterations, alongside the possibility to meet different figures working at different levels in the end-of-life field. Moreover, it would be useful to maintain a space for students to open up to each other and share their experiences, fears and anxieties about death. Some teachers reported that they were impressed by students’ willingness to confide in their classmates, given that, before, some students confided only in the teacher, and only outside the classroom. This openness also allowed them to resolve some critical issues in class, such as quarrels and discussions, and to build relationships based on empathy. According to the teachers, the visit to the hospice was a fundamental step in this process because it allowed students to revise their perceptions of palliative care and share this insight with their families and the wider community.
Finally, in the confirmability phase of the study, the results of all the analyses were submitted to the participants, and we asked them whether they confirmed our findings. The answers were all positive, and some participants even suggested that we include additional considerations. For example, priest Luigi emphasised: ‘The tests are going great. I confirm that the project has paved the way … for a new understanding of palliative care and spiritual accompaniment [among hospice staff]’. Among the nurses, Maria affirmed:
Yes, all well and good, but I would like to stress more that, here in the hospice, we were all amazed at the maturity shown by the students. They discussed with us and showed great depth of thought despite their young age, and this is even more important because it means that they really think about death even though no one seriously talks to them about it, and this course permitted them to reflect on this issue in a more profound way.
Giovanni, a teacher, said:
Yes, I absolutely agree, but I want to make some additions. It is very important to affirm that all schools should realise death education courses, inserting them into the educational system in a structural and interdisciplinary way. In fact, I do not believe that only the spiritual dimension can help to manage death. Indeed, there are important [religious] texts, but also theatrical, musical and pictorial works. Art also helps to manage anguish. We all need good and beautiful readings that enrich our language and our ability to name experiences of loss and mortality.
Francesco, another teacher, wanted to add:
I agree with everything, but now that I have the chance, I feel I still have something to express. The project has highlighted the relationship between love and death. Yes, love is what allows us to live, but it is also what allows us to face the passage of death. Without love, death is unbearable. The project has therefore enhanced love and this aspect must be highlighted. I believe that the students understood, first and foremost, that those who do not love are already dead, while those who love do not die. This is the synthesis of what we all understood together.