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

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.