The hospice as a learning environment: A follow-up, qualitative study with palliative care professionals and school teachers involved in a previous death education intervention

Abstract

Background: In Western society, discussions about death have shifted from the domain of the everyday to the domain of medicine. Such censorship does not reduce the fear of death; rather, it deprives people of the means to elaborate their experiences of death, generating negative effects such as difficult mourning and stigmatisation of palliative care environments. The objective of this follow-up study was to detect whether and how death education can help to improve individuals’ relationship with death.

Methods: This was a qualitative research study based on grounded theory. We conducted semi-structured interviews with both palliative care professionals and teachers who had taken part in a death education intervention three years earlier. The interviews were interpreted through thematic analysis.

Results: The results confirmed death education’s positive effect for both palliative care professionals and teachers. These individuals reported that the education initiative helped them to positively modify their perspectives on death and dying, as well as their attitudes towards life. It also helped to improve community attitudes towards the hospice and its workers.

Conclusions: This study confirmed that school education initiatives can create continuity between hospices and local communities. The death education project provided an educational space in which it was possible to elaborate experiences linked to death and to re-evaluate and appreciate hospices and their staff.

Background

The theme of death in Western society has been removed from everyday life and replaced with specialised medical language. On the one hand, this can be attributed to medical progress, which has eradicated many once life-threatening illnesses, thereby alleviating peoples’ fear of infections and contagions. On the other hand, it may be related to humans’ innate tendency to avoid anything that reminds them of their mortality [1]. As affirmed by Terror Management Theory (TMT), awareness of death is inevitable, and such awareness may occur at any moment for uncontrollable reasons, generating a feeling of latent and constant terror. According to this perspective, it is natural for human beings to suppress their thoughts about mortality because the terror of death can become paralysing and prevent the normal flow of everyday life [2].  It is reasonable to assume that all living being are afraid of death, but only humans have demonstrated a capacity to recall death experiences and conceive of death as an irreversible and universal condition. This level of understanding means that even thoughts of death can lead to anguish, and this is precisely why they can be so crippling for individuals.

Humans commonly deploy two psychological strategies to defend themselves against the paralysing terror of death. The first is the ‘proximal defence’, which is an automatic and subconscious ‘removal’ mechanism that obstructs conscious perceptions and thoughts that could indicate one’s mortality. When this mechanism is insufficient, the ‘distal defences’ intervene. These consist of existential reflection on the meaning of finitude and the construction of cultural apparatuses that allow individuals to give meaning to their lives and actions. These distal defences are the basis of all cultural products, and they enable individuals to feel that they are living in a meaningful world in which their value can be recognised. Religions, for example, are very important in this area because they make it possible to represent individual existence beyond earthly life and beyond death [3, 4].

However, these systems are fragile because they are constantly being questioned, both by common and rational thought. Furthermore, they may be undermined by mortality salience, which arises in the course of everyday life [5–8]. Discussions about what ‘death’ means can be very complex, and it is difficult to determine through rational analyses whether cultural attitudes about existence beyond death are true or false. The resulting uncertainty leads to the widespread use of proximal defences – namely, the unconscious suppression of thoughts related to death and dying. One of the most prevalent examples of this type of denial is the stigmatisation of funeral homes, morgues and their workers [9, 10], as well as hospices and hospice workers. Such stigmatisation arises due to people’s inability to identify with these professionals, who are consequently isolated from community life and made to suffer increased levels of stress [11–13]. This form of social denial contributes to an overall weakened cultural relationship with death, and to decreased cooperation and solidarity – both of which are necessary for authentic human relations.

Another striking example of social obfuscation of death and dying is adults’ unwillingness to talk to children and adolescents about death. They often do not bring their children to funerals because they are afraid that they may suffer or be traumatised. However, young people are bombarded by media messages that sensationalise death, and they are surrounded by adults who are incapable of addressing the topic in their daily lives [14–16]. In truth, this type of censorship does not reduce fear or anxiety related to death [17]. Rather, it restricts the possibility of developing a symbolic language to elaborate the experiences of grief and terror that surround death [17]. This can give rise to negative effects, especially in the case of traumatic grief [17].

The school environment could be an effective place to implement educational initiatives that allow children to talk about death and elaborate mourning situations that have involved them. To do this, however, teachers would have to be specially trained, and this does not usually happen in the Western world [18]. In fact, many teachers say that their preparation on such topics derives almost exclusively from personal reading rather than specialist preparation, and this makes them uncertain of their ability to deal with the topics of grief and loss with students [19].

Death education courses are designed to offer precisely this type of training, both in schools and in the community. In schools they allow children and adolescents to deal with death, whether or not they have had personal experiences of bereavement [20]. In community settings (schools, hospitals, therapeutic communities, groups, associations, etc.), death education courses teach adults how to deal with death and dying so that they can better support children and adolescents [20, 21]. Death education can even instigate collaboration between schools and communities by aligning school-based programs aimed at students and community-based programs aimed at adults who want to help young people cope with grief. This is especially so when there is a need to process the suicide of a young person [21, 22].

In 2016, in a little county in Southern Italy, we implemented a school-based death education program that involved the local community after a teenage student committed suicide. High schools in the area decided to take action to address the resulting mourning period by broaching the theme of death with students [22]. The project was discussed and elaborated between death education experts and some of the teachers who had dealt directly with the suicide’s consequences. The fundamental idea was to break down the censorship of death in order to talk about the subject freely and give free rein to feelings, fears and anxieties, but also to offer important answers to students’ questions about meaning using philosophical, religious and artistic content. For this reason, the organisers decided to involve the local hospice. Meetings between hospice operators, experts and teachers created a very tight-knit team, making it possible to implement lessons in both the school and the hospice [22].

Before the start of the program, organisers held meetings with the students to see if they were willing to participate. Some were very motivated because they felt the need to deal with the traumatic grief of their companion’s suicide. Others were less motivated, but the discussions with the more motivated classmates sufficiently demonstrated the importance of this proposal. At the end of this long preparation process, the death education intervention involved 138 students (males, n = 63; females, n = 75) from three high schools. The intervention drew on a previous model based on experiences of death education [23] and was divided into two parts. In the first part, teachers facilitated discussions and conducted philosophical lessons on the topics of death and spirituality, while also incorporating meditation, psychodrama and moviemaking practice to help students reflect upon the relationships between mortality and transcendence and upon the meaning of suicide. In the second part, the students visited a local hospice where they had the opportunity to discuss various issues with the hospice staff, including forms of dying and questions like how the patients were supported by the palliative care team, and how their families handled their grief. The intervention produced very positive results [22].

The part of the death education intervention that was carried out within the hospice with doctors, nurses, religious officials and psychologists was intended to engage students in the discourse on death and provide them with the opportunity to confront people who had effectively managed it. These more experienced individuals could demonstrate that it is possible to manage one’s emotions by cultivating an ability to think and deal with pain – both one’s own and that of others. Expressed differently, the aim of this segment was to make students understand how people with inauspicious prognoses face their illnesses, and how students could help these people by activating community networks. This part of the program encouraged young people to consider (1) that it is possible to manage death and dying, and (2) the generosity of those who work with competence and passion to improve suffering peoples’ quality of life. Life was framed as a precious gift that must be safeguarded – not by denying death (or prolonging or accelerating it), but by acknowledging its temporality. Hospice staff explained the model of palliative care to students, including the practice of attending to those who suffer, the value of life and the promotion of its quality right up to the last moment [24]. This partially served to demystify the institution, counteract its image as a ‘place of death’ inhabited by ‘angels who bring death’, and affirm its significance for the community. Indeed, the program was designed to emphasise how the community can help these professionals and the families of those who die by changing their perspective on the hospice.  

Two years after the very positive conclusion of this project, some local people proposed that we re-implement the program. Before starting all the planning work again, however, we decided that it was necessary to confirm the utility of the intervention by analysing the perceptions of those teachers and hospice professionals who had participated. This would help us to understand if it was appropriate to propose the project again. As such, the present study investigated the effects of the death education intervention for the participants (teachers and hospice staff) three years after its implementation.

Methods

Method Selection

We employed the grounded theory perspective [25] because this research explored a field that is rarely addressed and often censored, as the founders of grounded theory themselves noted when they began to study how people deal with death and dying [26]. This approach uses qualitative interviews that allow research objectives to be pursued even when there are no previous studies that offer standardised survey models. We have therefore adopted this methodology to perform follow-up interviews with participants about their experiences with death education.

Aims

Our main objective was to detect whether and how death education had a positive impact on teachers and hospice professionals, especially with respect to their relationship with death representations. Furthermore, we wanted to see if the intervention changed the relationship between the community and the local hospice, from the perspective of both teachers and hospice professionals involved in the project. Finally, we analysed participants’ perspectives on the intervention’s effect on students – namely, their relationship with death representations.

Interview Questions

Some of the questions we used with the hospice staff were: ‘How was the intervention relevant for professionals?’; ‘How do you think the death education course influenced the relationships between the hospice members?’; ‘Do you think this experience should be repeated?’; ‘In light of this experience, how do you think community (and social) views of the hospice and the professionals working in the field of end-of-life care have changed?’ Some questions for teachers were: ‘How do you think the death education course has influenced the relationships between teachers/directors and students?’; ‘What were the program’s strengths and weaknesses?’; ‘In light of this experience, how has your perception of end-of-life care (and the professionals who perform it) changed?’; ‘Do you think death education can be useful at the community level? If so, how?’.

Analysis

The interviews were carried out in places chosen by the participants. Each interview lasted about 60 minutes and was recorded and transcribed verbatim in Italian. The texts thus obtained were then subjected to thematic analysis using the ATLAS.ti program [27, 28] to decipher key meanings and concepts [29, 30]. The thematic analysis shed light on patterns in the dataset, allowing us to develop a conceptual framework [31]. In accordance with the CORE-Q checklist [32] and the principles of thematic analysis, we allowed the ontological representation of death to partially guide our exploration [33, 34]. To ensure the transferability and dependability of our results, we based our interpretative process on both a-priori categories (with regard to the representation of death) and categories that arose as the analysis progressed (with regard to the effects of the death education experience) [23, 35]. Six main phases characterised the process: preparatory organisation, generation of categories or themes, coding data, testing emerging understanding, searching for alternative explanations, and writing up the report [36].

Lastly, in order to check the confirmability of our results, we submitted the results of all analyses to the participants six months after the interviews, asking them to confirm our interpretations and provide additional opinions, suggestions or modifications.

Participants

The study involved 20 individuals who had taken part in the death education project three years earlier: 11 hospice professionals (males, n = 5; females, n = 6) aged between 29 and 50 years (µ = 44; σ = 5.98) and 9 school teachers (males, n = 3; females, n = 6) aged between 29 and 63 years (µ = 48.1; σ = 9.18). The hospice staff comprised two psychologists, three doctors, four nurses, a family liaison officer and a spiritual guide. Among the hospice staff, 70% of individuals were university graduates, 8 of 11 individuals were married/cohabiting, and 9 of 11 individuals had children. All the interviewees were Italian citizens.

The teachers who took part in the intervention were staff members at local schools in the same town where the original study took place. The schools were as follows: two classical lyceums, a scientific lyceum, a European linguistic lyceum, an Upper Secondary Educational Institute and a linguistic lyceum. In this study group, 90% of the participants taught humanistic classes (religion, history, and Italian) and their ages ranged between 31 and 63 years (µ = 53,11; σ = 10,20). All the teachers were university graduates and Italian citizens (Table 1).

As the students who had participated in the original intervention had finished their studies and could not be traced due to anonymity protocols in the original intervention, they could not be included in the present research.

Each participant was asked to sign an informed consent form authorising their participation, the data treatment, and the audio-recordings of the interviews. The study was approved by the ethics committee for psychological research at the University of Padova, Italy.

Results

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.

Discussion

The objective of this study was to explore, through thematic analysis of death, dying and suicide, how the relationship between a community and a local hospice changed following a death education intervention. We did this to evaluate the efficacy of this intervention three years after its introduction in local schools. Our analysis of the interviews revealed three main themes and proved that the death education intervention had produced meaningful changes. The analysis also confirmed that the death education intervention had a particularly positive effect on teachers and hospice staff.

The first major theme addressed changes in death representations, attitudes towards life and perspectives concerning the hospice and palliative care. This intervention modified teachers’ (and in the previous project, students’, as well) perspectives on death and dying by enhancing their understanding of palliative care processes. It also emphasised that the last moments of life can be a time of serenity, and that patients’ dignity and respect are of paramount importance in palliative care. The process of reconstructing the meaning of dying allowed teachers and students to reflect together upon the valorisation of life [22, 37]. The participants’ perspectives on death education confirmed the findings in the literature. According to various studies, death education can be an important component of a school’s curriculum because it promotes positive attitudes towards life and reflection upon existential themes [38, 39]. The intervention proved useful by eliminating various barriers and cultural prejudices, thereby promoting a perspectival shift concerning the hospice and palliative care. This intervention promoted a change in the teachers’ perspectives, and teachers claimed that it did so for students as well. At the end of the course, teachers and students gathered together to discuss their views on the hospice and the work of its staff, and it became evident that students’ prejudices towards hospices, hospice staff and palliative care had dissipated [40].

The second major theme involved the particular effects of the program for addressing a specific traumatic incident in the community. According to teachers, the death education experience in the hospice enabled participants to elaborate their feelings about a student’s suicide. Many of the teachers stressed that the opportunity to talk about death and to discuss themes related to death enabled teachers and students to reflect upon the value of life and the importance of respecting its fragility. Some suggested that suicide may be linked to young peoples’ fascination with death as a means that could free them from their anxieties [41]. The scientific literature supports the idea that a mature concept of death may prevent risky behaviours by encouraging individuals to value life [16, 42]. Death education interventions, which aim to increase social support, optimism and spirituality through specific and adaptive coping strategies, can promote post-traumatic growth among those who have dealt with sudden grief [43–45]. The participants also stressed that the death education project served as a bridge to promote death literacy among the whole community.

The last major theme – regarding willingness to reimplement the intervention – revealed that participants were indeed interested in repeating the experience in the future. Participants believed that introducing similar death education interventions in high schools would be worthwhile partly because it would allow hospice professionals to improve their knowledge and relational competencies in their everyday work, much as other healthcare professionals do [46–50]. The hospice staff stated that this intervention allowed them to improve both their teamwork skills and their knowledge concerning themes related to death education. It also enabled them to cultivate a more positive attitude towards their work – namely, the provision of assistance to the terminally ill and their families – as previously described in the literature [51–53]. The teachers reported that they appreciated the opportunity to visit the hospice and to have discussions with experts in palliative care. Though the hospice professionals represented a privileged point of view in discussions regarding death, students and teachers were able to perceive the professionals as simple human beings with no omniscience or omnipotence, thereby removing the aura of mystery and terror linked to hospices, palliative care and themes of death [54–56].

Perhaps the most interesting result of this study is the profound effect that the intervention had for hospice professionals and teachers, who were inspired to reconsider the meaning of death and what lies beyond. The meetings with the students allowed them to broach important existential questions regarding the materiality of everyday life and its relationship with the transcendent ‘beyond’. According to TMT, this outcome was possible because students’ questions forced teachers and hospice staff to address the theme of death without censoring it or evading the issue. Consequently, they began to value life more than before.

However, one of the main limitations of the present study was that it did not involve the students who took part in the original project. Future studies should involve a greater number of follow-ups to assess the ongoing efficacy of death education programs, thereby extending the existing literature on death education for adolescents. Another important limitation of this study concerns transferability. To achieve transferability, subsequent studies must exhibit the following characteristics: ability to conduct and implement a death education project; ability to involve schools and local hospices and facilitate collaboration between teachers and hospice professionals; and ability to monitor all steps and maintain constant contact with the actors involved. Indeed, the present qualitative research resulted from such a process, and it took years for the idea to mature. Given the positive feedback, it will likely be possible to replicate the intervention in the same setting with the same actors. However, to transfer the project to other places, the research team would have to guide the prospective project, explaining and illustrating everything to the new actors, but adapting the intervention to the different cultural and social contexts of the new setting. It would also be desirable to provide teachers and hospice professionals with ex ante and ex post surveys, as these would help to capture the information that emerges from death education.

Conclusions

This study confirmed that school-based death education interventions are able to create continuity between hospices and communities. Furthermore, our follow-up enquiry demonstrated that participants confirmed the results of our analysis and acknowledged the efficacy of death education. This last phase of the study identified meaningful and positive changes among teachers in terms of their orientations to death and approaches to life, as well as their perceptions of end-of-life care. Hospice staff members also perceived a positive change in community attitudes towards them. In sum, the intervention produced many positive outcomes. In particular, the continuity between the hospice and the schools engendered a psycho-educational space in which students could explore their fears and worries surrounding death and teachers could learn more about their students, as well as tools to continue their discussions and support students in future situations. This space allowed the participants to elaborate the grief caused by a student’s suicide, to consider death without dread and to explore emotions that are usually concealed. The death education experience improved the moral environment of the schools and contributed to community-building.

Abbreviations

DeEd: Death Education program; TMT: Terror Management Theory

Declarations

Ethics Approval and Consent to Participate

Participants provided written informed consent authorising their participation, the data treatment, and the audio-recordings of the interviews. The study was approved by the ethics committee for psychological research at the University of Padova, Italy (n. 8B6C35ED41F82A9E6BEA6C9094DEE972).

Each participant was asked to sign a written informed consent form authorizing their participation, the data treatment, and the audio-recordings of the interviews.

Consent for publication

Not applicable.

Availability of Data and Materials

The datasets generated and/or analysed during the current study are not publicly available to protect the participants’ privacy, but are available from the corresponding author on reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Funding

No funding has been received for this research

Co-authors’ informations

Ines Testoni, professor at the Department of Philosophy, Sociology, Education and Applied Psychology (FISPPA), and director of the Master in Death Studies & The End of Life, University of Padova, Via Venezia 14, Padova (PD), 35131, Italy. Research fellow at the Emili Sagol Creative Arts Therapies Research Center, University of Haifa, Israel.    
Email: [email protected]

Phone number: +39 0498276646 

Vito Fabio Sblano, Department of Philosophy, Sociology, Education and Applied Psychology (FISPPA), University of Padova, Via Venezia 14, Padova (PD), 35131, Italy. 
Email: [email protected] 

Lorenza Palazzo, Department of Philosophy, Sociology, Education and Applied Psychology (FISPPA), University of Padova, Via Venezia 14, Padova (PD), 35131, Italy. 
Email: [email protected] 

Sara Pompele, Department of Philosophy, Sociology, Education and Applied Psychology (FISPPA), University of Padova, Via Venezia 14, Padova (PD), 35131, Italy.       
Email: [email protected] 

Authors’ contributions

All authors contributed to the study conception and design I.T., V.F.S., L.P., S.P.  and M.A.W. Material preparation, data collection and analysis were performed by I.T., V.F.S., L.P., S.P.  and M.A.W. The first draft of the manuscript was written by I.T. and all authors commented on previous versions of the manuscript. All authors have read and approved the final manuscript I.T., V.F.S., L.P., S.P.  and M.A.W.

Acknowledgements

Dr. Antonio Stizzi (theologian), Dr. Michele Galgani (psychologist)

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Table

Table 1. Demographic variables of the participants