Article

OMEGA—Journal of Death and

The Impact of Death Dying

2015, Vol. 71(4) 343–361
! The Author(s) 2015
Education on Fear of Reprints and permissions:
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Death and Death DOI: 10.1177/0030222815572606
ome.sagepub.com
Anxiety Among Human
Services Students

Irene Searles McClatchey1 and Steve King1

Abstract
Human services professionals will undoubtedly work with the dying and bereaved
populations at one time or other. Yet, they are poorly prepared to do so since death
education, that is, lessons about the human and emotional aspects of death, its
implications, and subsequent bereavement issues, is often not part of their curricu-
lum. This nonequivalent comparison group study (N ¼ 86) examined death fear and
death anxiety among human services students before and after receiving death
education using the Multidimensional Fear of Death Scale. The results showed a
statistically significant decrease in death anxiety among the group of students who
participated in death education compared to those who did not.

Keywords
death anxiety, death education, human services, death, dying, bereavement

Death anxiety has been defined as “the affective dimension of death attitudes
and refers to the perceived amount of emotional distress provoked by the antici-
pated total nonexistence of the self” (Ka-Ying Hui, Harris Bond, & Sze Wing
Ng, 2007, p. 200). Fear of death, known as thantophobia, comes from the words
thanatos (death) and phobia (fear) and has been described by Hoelter and

1
Department of Social Work and Human Services, Kennesaw State University, GA, USA
Corresponding Author:
Irene Searles McClatchey, Department of Social Work & Human Services, Kennesaw State University,
1000 Chastain Road, Kennesaw, GA 30144, USA.
Email: imcclatc@kennesaw.edu
344 OMEGA—Journal of Death and Dying 71(4)

Hoelter (1978) as consisting of eight components: fear of the dying process, fear
of premature death, fear for significant others, phobic fear of death, fear of being
destroyed, fear of the body after death, fear of the unknown, and fear of the
dead. Other authors simply refer to feelings that come up when thinking about
death as death anxiety (Schultz, 1979).
A perfunctory consideration of the abstract concepts of fear and anxiety may
generate disagreements about whether these are interchangeable constructs.
While these concerns warrant consideration, the field of behavioral science has
directly connected fear and anxiety in behavioral and diagnostic terminology. By
way of an example, the Diagnostic and Statistical Manual-5 (APA, 2013) specif-
ically references “fear or anxiety” (p. 116) when conducting assessments and
evaluations. Thus, for this paper, the term fear of death will encompass
“death anxiety” as described above.
Although fear of death and death anxiety are subjects that have appeared in
the literature for generations, little is known about what might lessen this type of
fear and anxiety among professionals such as human services workers, many of
whom will undoubtedly one day find themselves working with dying and
bereaved populations. This study is an attempt to fill this void in the literature
by describing the impact of death education on fear of death and death anxiety
among human services students.

Death, Dying, and Bereavement Theoretical

Framework and Manifestations
Theorists and practitioners have long considered the role of death in human
development and experience. A variety of theoretical frameworks, while con-
sidered by many to be dated, nevertheless, inform and influence how death,
dying, and bereavement (DD&B) are experienced in our culture. These theories
generally focus on the fear and anxiety people feel about their own death, with
limited attention paid to the impact of DD&B on those emotionally and other-
wise removed from the experience of facing their own death.
Freudian constructs, such as denial and rationalization, suggest that people
use these defense mechanisms to avoid the reality of their own mortality and the
accompanying fears and anxieties about death (Toomer, 1994). Erickson’s final
stage of human development (integrity versus despair) posits that individuals
experience either an enlightened sense of a meaningful and satisfying acceptance
of the quality of their lived life or a painful realization of a life devoid of mean-
ing or purpose (Erickson, 1959).
Existentialists emphasize an intertwining of “search-for-meaning” and “self-
actualization” frameworks for understanding an individual’s experience of
coming to terms with their own death. Lantz (2001) describes two essential
aspects to finding meaning in one’s life as one nears death, order, and purpose.
Order represents an individual’s understanding of how his or her world is
McClatchey and King 345

structured and the individual’s place within it. Purpose is the degree to which a
dying person has incorporated his or her life experiences as meaningful and
significant to the world he or she is leaving.
Helping those coping with DD&B can provoke confusing and frightening
existential questions and painful feelings of personal loss. Coming to terms
with death involves both internal and interpersonal processes that are influenced
by individual and societal death attitudes (DeSpelder & Strickland, 2005). These
attitudes profoundly influence how one copes with death on an “up close and
personal” level as well as an abstract and complex concept.

Literature Review
Fear of Death and Death Anxiety
DD&B researchers have found informative statistically significant differences in
DD&B anxieties, fears, and attitudes between males and females. It has been
empirically demonstrated that in general women tend to report higher overall
levels of DD&B fear and anxiety than men (Russac, Gatliff, Reece, &
Spotswood, 2007). Study participants consistently also report significant differ-
ences in DD&B anxieties, attitudes, and fears based on age (Fortner &
Neimeyer, 1999). Studies have demonstrated an inverse relationship between
age groups with older respondents reporting lower levels of death fear and anx-
iety (Thorson & Powell, 1994). Additionally, study participants reporting high
levels of religiosity have been found to report lower levels of DD&B anxiety and
fear than those reporting low levels of religiosity (Thorson, 1991; Thorson &
Powell, 1991).
In specific case scenarios, preexisting beliefs and feelings regarding DD&B are
influenced by situational and existential factors as well. For example, an indi-
vidual’s perception as to whether someone’s life had been meaningful may result
in lower levels of death anxiety. Perceptions that a person’s life had no purpose
may result in higher levels of death anxiety (Wong, 1989; Wong, Reker, &
Gesser, 1994). The level of physical pain an individual is experiencing, as they
are dying, may also increase levels of death anxiety (Neimeyer, 1994). Neimeyer
and Moore (1994) demonstrated that individuals who reported an introspective
and well-developed philosophy of life and death reported significantly lower
levels of fear of death than those who did not.

DD&B Education for Helping Professionals

The fear and anxiety associated with death and dying are ingrained in our
culture, and helping professionals are not immune to the influence of their atti-
tudes about death on their direct practice efforts (Braun, Gordon, & Uziely,
2010).
346 OMEGA—Journal of Death and Dying 71(4)

Kastenbaum (2012) stated,

Students who persevered to a graduate degree received only further lessons in death
avoidance. Nurses, physicians, psychologists, social workers, and others who
would be relied upon to provide human services were not helped to understand
their own death related feelings, let alone anybody else’s (p. 8).

Helping professionals share society’s reluctance to discuss death and struggle to

disentangle their own death attitudes from their professional roles and behaviors
as they care for individuals and families faced with death. Helping professionals
across a wide variety of disciplines report being unprepared from a professional
and personal standpoint to work with dying or grieving clients (Harrawood,
Doughty, & Wilde, 2011; Kovacs & Bronstein, 1999).
The importance of death education to impart content knowledge about the
death process and gaining insight into the death attitudes of helping profes-
sionals has been emphasized by students, practitioners, educators, and ethicists.
It is clear there is a near universal agreement on the need for the inclusion of
death education in the training of helping professionals. Within a pedagogical
and professional context, this current approach leaves frontline health care prac-
titioners lacking the information, skills, and, self-awareness necessary to provide
effective psychosocial services to this population (Head, 2008).
While the concepts underpinning the personal fear or anxiety of death and the
professional concerns about working with the DD&B population cannot be
unconditionally differentiated, studies reveal that direct practice clinicians see
them as closely intertwined. As an example, researchers in the field of nursing
have demonstrated a significant relationship between the death attitudes of
nurses and their personal approach to clinical work with dying patients using
the Death Attitude Profile-Revised (DAP-R) (Wong et al., 1994). A recent study
of this relationship found that positive attitudes about caring for dying patients
were significantly correlated with low levels of negative death attitudes such as
fear of death and death avoidance in a sample of practicing oncology nurses
(Braun et al., 2010). These health care providers continually call for a more
comprehensive education regarding DD&B to inform their practice and enhance
their own capacity to provide relevant and effective interventions.
Several helping professions have identified an alarming lack of education
in DD&B. The nursing profession has long been at the forefront of working
with patients who are dying as well as their families; yet, the quality and quantity
of DD&B education for nurses has been found to be inadequate (Barrere,
Durkin, & LaCoursiere, 2008). This combined with the immediacy of nurses’
proximity to the issues (professional and personal) associated with DD&B has
prompted nursing educators to implement DD&B education into their curricula
(Barrere et al., 2008; Brown & Smith-Cumberland, 2006; Hurtig & Stewin,
1990).
McClatchey and King 347

The same does not appear to be true for other helping professionals. Social
work educators and clinicians have repeatedly pointed out the need for social
work curricula to place more emphasis on social worker’s attitudes toward
DD&B. Citing the Council on Social Work Education (CSWE), Luptak
(2004) reported, “knowledge related to death and dying was recently identified
as one of the five basic competencies needed by all social workers” (p. 12).
Oncology, hospice, and medical social workers have identified a lack of training
concerning death and dying to have been a major deficiency in their preparation
for this growing area of social work practice (Kovacs & Bronstein, 1999).
Framing the issue for social work in terms of professional ethics, Keigher
(2001) stated, “many states require continuing education for social workers on
ethics and boundaries, but the more subtle boundaries undulating between life
and death also need to be understood” (p. 132).
Likewise, a survey of 161 university and college psychology department chairs
or program directors revealed that 127 (78.9%) did not offer a DD&B course. Of
the 33 schools that did offer DD&B courses, 13 offered the DD&B course less
than once per academic year. These figures point to a low level of DD&B edu-
cational opportunities within the departments surveyed (Eckerd, 2009).
In a review of the extent to which introductory psychology textbooks
addressed issues of DD&B, 27 of the 28 texts examined dedicated less than
three pages of text to the subject. With regard to bereavement and loss, 13 of
the 28 addressed these topics and 12 of 28 discussed hospice care. Strikingly,
only 8 of the 28 textbooks explored the issue of societal and individual death
attitudes (Coppola & Strohmetz, 2002).

Outcome Studies
As the notion that DD&B education is an essential component of the training of
helping professionals has become increasingly accepted, empirical studies eval-
uating DD&B education outcomes are needed. Frequently, one of the goals of
DD&B education is to guide students through a process that not only provides
content information but also helps them to examine their own personal attitudes
and beliefs about DD&B (Kastenbaum, 2012).
Utilizing a sample of 256 undergraduate college students, Wong (2009) eval-
uated the students’ personal attitude changes regarding DD&B after participat-
ing in a DD&B course. The researchers used a two group, pretest–posttest
design to examine whether greater attitude changes were noted in course par-
ticipants versus controls. Statistically significant differences in the mean scores at
posttest were found between the groups. A paired sample t-test demonstrated
that students receiving death education reported decreased fear of death versus
no significant change in controls.
Nursing scholars and educators have endeavored to evaluate the outcome of
DD&B education on the death attitudes of students preparing for a career
348 OMEGA—Journal of Death and Dying 71(4)

in nursing. A quasi-experimental, longitudinal, repeated measures research

design was used to study the impact of DD&B education and found that an
experientially based DD&B course improved students’ attitudes toward working
with the DD&B population as well as lowering their own personal feelings of
fear and anxiety about death. Notably, older students reported less change in
their death attitudes than younger students (Barrere et al., 2008).
In a study utilizing a pretest–posttest design, Hurtig and Stewin (1990) eval-
uated the outcomes regarding death attitudes among first-year nursing students
after taking a DD&B course. Some students participated in an experiential death
education class while another group participated in a didactic, lecture-based
DD&B training. Findings revealed a statistically significant decrease in anxieties
and fears related to DD&B in students receiving death education in both the
experiential and didactic courses versus controls receiving no death education.
Of note, these researchers, using a two-way ANOVA to analyze the data,
reported that students who had personal experiences with death were less likely
to have lower levels of death anxiety and fear, when participating in the didactic-
based course versus the experiential course. Students with no prior personal
experience with DD&B reported lower levels of death anxiety and fear when
participating in the experiential course. According to Hurtig and Stewin (1990),
these differences were found to be statistically significant.
In an effort to examine the impact of DD&B education on emergency medial
technicians (EMTs), researchers compared death attitude scores for EMTs who
received two different types of DD&B education courses using a pretest–posttest
design (Brown & Smith-Cumberland, 2006; Smith-Cumberland & Feldman,
2005). The first group received a one and a half hour lecture on death notifica-
tion procedures followed by a brief question and answer session. The second
group received a two-day experiential seminar with small group exercises and
role-plays in addition to didactic material. The death attitudes for the brief
educational group showed little change, particularly when it came to notifying
a family of the death of a family member. The experiential education partici-
pants reported greater comfort, knowledge, and intentions to change their cur-
rent personal approach when providing families with a death notification in a
compassionate and thoughtful way (Brown & Smith-Cumberland, 2006; Smith-
Cumberland & Feldman, 2005).
The DD&B attitudes of 41 medical students and 127 healthcare workers
(nurses, physicians, physiotherapists, psychologists, and volunteers) were mea-
sured before and after participating in DD&B education (Hegedus, Zana, &
Szabo, 2008). This research revealed mixed results. Overall death anxiety was
reduced but the change was not statistically significant. Interestingly, some
dimensions of fear increased, while others decreased significantly especially
among males and older participants. These differences between males and
females with women reporting higher levels of death anxiety and fear and
older individuals reporting lower levels of death anxiety than younger people
McClatchey and King 349

support the demographic differences found across DD&B education studies

(Hegedus et al., 2008).
Although no quantitative study on the impact of death education on social
workers could be found in the literature, qualitative research on the effects of the
addition of DD&B education to an advanced social work program curriculum
found that students felt better prepared for social work practice with a dying
population after participating in the course. Social work educators utilizing the
“decision case method” found that students overwhelmingly (97%) reported
that DD&B education had not only significantly improved their preparation
for working with the dying but also had a positive effect on their own personal
feelings and attitudes about DD&B (Head, 2008). In another qualitative study,
Harrawood et al. (2011) found that advanced counseling students reported
feeling less anxious and fearful regarding DD&B from a personal standpoint
after receiving DD&B education. Due to their participation, they reported being
better prepared to work with the DD&B population, underscoring the need for
death education among helping professionals.

Study Purpose
Due to the current approach to DD&B education for helping professionals,
further evaluation of the impact of DD&B education is warranted. No con-
trolled outcome studies evaluating the impact of DD&B education specifically
within the human services field could be found in the literature. Human services
professionals are increasingly providing psychosocial services to clients dealing
with DD&B issues. The educational needs of these professionals in the area of
death and dying are significant yet not well addressed, and the evaluation of
existing programs remains an essential component of their training (Cagle &
Kovacs, 2009; Coppola & Strohmetz, 2002; Csikai & Durkin, 2009). Despite the
DD&B education evaluation research that exists, current scholars, practitioners,
and educators persist in their calls for improved educational and outcome stu-
dies to determine the most effective methods for addressing the deficiencies in
this process. These concerns drive the purpose of this study: Does death educa-
tion reduce fear of death and death anxiety among human services students?

Method
Design and Sample
The sample in this study consisted of undergraduate students preparing to earn a
bachelor of science degree in human services at a state university in the
Southeastern United States. These human services students are trained to pro-
vide community-based social services to a wide variety of client populations.
This purposive sample was chosen to examine the impact of death education on
fear of death and death anxiety among human services students.
350 OMEGA—Journal of Death and Dying 71(4)

Two classes were held in death education, one during the summer semester
and one during the fall semester. Appropriate IRB approval was obtained, and
56 human services students in the DD&B classes, and 59 human services stu-
dents in three other human services classes—community intervention (18 stu-
dents), groups (24), and working with families (17 students)—were introduced to
the research project and agreed to participate. The students in the community
intervention, groups, and working with families classes served as the nonequi-
valent comparison group and had not participated in the elective DD&B class at
this university at any time. This resulted in a total sample of N ¼ 115 who
completed a pretest using the (MFODS) (Neimeyer & Moore, 1994).
To protect against response bias, students were asked to assign a number to
their pretests that was unknown to the researchers. The students were then asked
to use the same number when completing the posttests. In addition, at the time
of posttest, grades had already been given, which mitigated any fear of academic
retribution.

Instrumentation
Numerous DD&B researchers have attempted the empirical assessment and
measurement of death attitudes using objective rating scales and questionnaires.
Despite their proliferation, these death attitude evaluation instruments tend to
suffer from poorly developed conceptual frameworks and questionable psycho-
metric properties (Neimeyer, Moser, & Wittkowski, 2003).
One exception to some of these limitations that has been noted by researchers
in the DD&B field is the MFODS (Neimeyer & Moore, 1994). The MFODS is a
42-item self-report pen and paper instrument listing situations and conditions
related to death. The scale measures eight dimensions: fear of the dying process,
fear of the dead, fear of being destroyed, fear for a significant other, fear of the
unknown, fear of conscious death, fear of the body after death, and fear of
premature death. Using a Likert scale, the informants rate the extent to which
they agree or disagree with various statements, such as “I am afraid of being
buried alive” and “I am afraid of experiencing a great deal of pain when I die,”
from strongly agree to strongly disagree. Scores range between 42 and 210 with
higher scores indicating less fear of death and death anxiety. To lower response
bias, five items are reverse scored.
The MFODS has been repeatedly found to have strong internal consistency
with a mean Cronbach’s alpha value of a ¼ .75 (Neimeyer & Moore, 1994).
Interestingly, the removal of one item “I am not afraid to meet my maker”
increases the value to a ¼ .85. Repeated factor analyses have established
strong construct validity for the MFODS. The scale has strong discriminant
and convergent validity as well (Neimeyer & Moore, 1994; Neimeyer et al.,
2003). The use of the MFODS in evaluating DD&B education was justified
by Hegedus et al. (2008) as they considered it to be the strongest of any
McClatchey and King 351

standardized and valid scale evaluating DD&B attitudes stating, “. . . the

MFODS seems to be more detailed and sensitive than other comparable
scales.”(p. 268).

Procedures
The authors, one the professor of the DD&B class, one the professor of the
working with families class, explained the research project to the students in the
four classes at the beginning of the first class of the semester. Students, who
decided that they wanted to participate in the study, were given a consent form
to participate and then completed the MFODS. The professor of the DD&B
class and the professor of the working with families class, both licensed clinical
social workers, were at hand during the administration of the instrument to
answer any questions and concerns raised by the students.
Students who were registered for the DD&B class received death education.
This undergraduate course is a longstanding course at the university. A prior
faculty member originally developed the syllabus several years ago. The current
professor of record, one of the authors of this study, has revised and expanded
the syllabus while teaching the course over the past 6 years. The class lasted for
16 weeks, meeting for 3 hours once a week.
A textbook by Leming and Dickinson (2007) was used. The class consisted
of discussions around the view of DD&B in modern American society and
the history of the views of DD&B. Guest speakers from various
religions—Buddhism, Islam, Christianity, Judaism, and Hinduism—explained
and answered questions about their respective religion’s viewpoints on
DD&B. Other guest speakers such as a social worker from a cancer clinic, a
nurse and a social worker from a hospice program, an attorney from an elder
law practice, and a county coroner all described their various professions and
their work with the dying population and the bereaved. A visit to a funeral home
was also part of the course. In addition, there were lectures on bereavement
theories and suicide as well as discussions on euthanasia and movies to reflect
these various topics. Students wrote reflection papers (1–2 pages) after each
speaker, movie, and discussion, formulating their views and reflections on the
topic at hand. Furthermore, the students wrote their own obituaries and planned
their own funerals. The students wrote a final paper on a personal loss and tied
their grief reactions and grieving process to a self-selected bereavement theory.
(See Table 1 for a breakdown of sessions.) Students in the community interven-
tion, groups, and working with families classes received instructions in their
respective topics with no reference to DD&B except for one lecture in the work-
ing with families class addressing loss as it relates to family functioning, such as
divorce, financial distress, and unemployment.
To help assess the impact of death education on those students who attended
the DD&B class, students in the community intervention, groups and working
352 OMEGA—Journal of Death and Dying 71(4)

Table 1. Course Breakdown by Week.

Week Activities Important notes

Week 1  Introduction to the course, outline,

and reading materials
 Discuss student’s
interest and goals for the
progression of the class
Week 2  Examine students’ perceptions and
assumptions about grief and loss
 The study of dying, death, and
bereavement (class exercise)
 Definition of death, meaning of
death, and the American death
experience
 Origin of death
 Awareness of death
Week 3  Living with life-threatening illness Guest speaker—oncology social
(video, class exercise, and discus- worker
sion of Breaking Bad News Better
(Buchman))
 Coping with a terminal diagnosis
 Living with dying
Week 4  The dying process Reflection paper on oncology social
 Dying in the American health care worker visit due
system
 Hospice
Week 5 Guest speakers—hospice SW and RN
Week 6  Public policy & the cost of dying “The suicide tourist”—Video
 Biomedical issues and euthanasia Reflection paper on hospice RN and
hospice SW visit due
Week 7  Death and dying across different Panel of religious leaders
religions Reflection paper on the Suicide
Tourist due
Week 8  Establishing cause of death Guest speaker: County Coroner
Reflection paper on religious panel
discussion due
Week 9  Advance directives Guest speaker from a law firm
 Property disposition Reflection paper on county Coroner
visit due
Week 10  The business of dying, the American Visit to a funeral home Reflection paper
funeral on speaker from law firm due
 Preparing and disposing of the body
(continued)
McClatchey and King 353

Table 1. (continued)

Week Activities Important notes

Week 11  The grieving process Reflection paper on funeral home visit

 Importance of rituals
Week 12  Death in the lives of children and
adolescents
Week 13  Suicide
 Class presentations
Week 14  Discussion of Tuesdays with Morrie
 Class presentations
Week 15  Violence, terrorism, and disaster
 Class presentations
Week 16  Class presentations
due
Play: Fragments of Grief Obituary &
Funeral arrangements due
Video: “Helping children understand
suicide”
Reflection paper on Fragments of
Grief due
Reflection paper on “Helping children
understand suicide” video due
Time: 1 p.m.—3 p.m. Final paper due

with families served as the comparison group. During the last 20 minutes of the
last class of the semester, the students of all four classes, who were willing to
participate, were asked to fill out the MFODS again, and these scores served as
the posttest scores. Students who did not want to participate in the study were
excused and allowed to leave the classroom without any academic or other
penalty.

Results
Comparisons of Groups
All statistical analysis was done using IBM SPSS 20 (2011). To examine any
possible differences in the demographic data of the participants in the two
groups—treatment and nontreatment groups—the researchers used chi-square.
No significant differences were shown between the two groups in gender, ethni-
city, religiosity, and spirituality (see Table 2). The sample consisted of 82.6%
females; 62.3% of the sample identified as white, 25.4% as black, 4.4% as
Latino, 1.8% as Asian, 4.4% as bi-racial, and 1.8% as other. Ninety-two percent
viewed themselves as spiritual, and 67.9% saw themselves as religious. To exam-
ine possible differences in age and on pretest scores, independent samples t-tests
were used. No significant differences between the two groups were shown (see
Table 3). The mean age was 29.06 (SD ¼ 9.99) with a range from 19 to 61. The
overall mean score of the MFODS for the total sample at pretest was 116.27
(SD ¼ 22.80) ranging from 60 and 185. Computation of the internal consistency
for the total sample resulted in a value of a ¼ .87.
354 OMEGA—Journal of Death and Dying 71(4)

Table 2. Gender, Ethnicity, Religiosity, and Spirituality.

DD&B class Comparison class

Demographics n % n % 2 df p

Gender
Female 48 85.7 47 81.0 0.45 1 .50
Male 8 14.3 11 19.0
Ethnicity
White 37 67.3 34 57.6 4.43a 5 .49
African American 14 25.5 15 25.4
Latino 2 3.6 3 5.1
Asian 0 0.0 2 3.4
Biracial 2 3.6 3 5.1
Other 0 0.0 2 3.4
Religious
Yes 36 66.7 40 69.0 0.07 1 .80
No 18 33.3 18 31.0
Spiritual
Yes 48 88.9 56 95.0
No 6 11.1 3 5.0 1.40 1 .24
Abbreviation: DD&B, death, dying and bereavement.
a
Eight cells have expected count less than 5. The minimum expected count is .96.

Table 3. t Tests of Mean Differences in Age and MFODS Scores by Group.

DD&B class Comparison group

Variable M SD n M SD n t df p

Age 28.21 10.11 56 29.86 9.90 59 .89 113 .38

Range 20–57 19–61
MFODS
Scores 116.31 22.69 56 116.24 23.09 59 .02 113 .99
Range 64–147 60–185
Abbreviations: MFODS, multidimensional fear of death scale; DD&B, death, dying and bereavement.
McClatchey and King 355

Table 4. Regression Coefficients Model Results for Fear of Death Outcome Model.

Fear of death outcome (N ¼ 86)

Variable B SE p F r2

Class 13.02* 3.42 .00** 14.91 .57

Pretest 0.67* 0.08 .00**
Gender 3.77 4.86 .44
Age 0.09 0.17 .61
Race 5.00* 1.86 .01**
Religion 6.14 3.69 .10
Spirituality 0.29 5.70 .96
**Significant at alpha  .01.

Impact of Death Education

Forty-seven students in the DD&B class and 44 students in the comparison
group completed the Death Anxiety Scale at posttest. Course withdrawals,
last day absenteeism, and students exercising their rights not to participate in
the study can partly explain attrition. Additionally, three posttests from the
students in the DD&B class were discarded because of excessive absenteeism
(three or more of the semester’s 16 class sessions). Furthermore, two of the
posttests from the students in the comparison group were discarded because
of evidence of suspected response bias where the same number had been circled
throughout the MFODS including the reverse scoring items. This left a total of
N ¼ 86 at posttest.
To examine the research question, does death education reduce fear of death
and death anxiety of human services students, the researchers used a regression
model to test for mean differences in total scores of fear of death and death
anxiety between students who participated in the DD&B class and students in
the comparison classes at posttesting controlling for total test scores at pretest-
ing. The researchers also added extraneous variables both to control for differ-
ences across the two groups of students and to study whether these variables
were connected with fear and anxiety scores at posttesting. Students participat-
ing in the DD&B class had statistically higher scores at posttesting than the
students in the comparison group (class ¼ 13.02; p < .01). Thus, this indicated
that students who attended the DD&B class experienced a statistically significant
lowering of fear of death and anxiety symptoms than those students who did not
participate in the death education class. Only one of the covariates, ethnicity,
was associated with fear of death and anxiety at posttesting (ethnicity ¼ 5.013;
p  .01; see Table 4).
356 OMEGA—Journal of Death and Dying 71(4)

Table 5. Regression Model; Predictors of Fear of Death.

N ¼ 115

Variable B SE p F r2

Gender 14.14 5.81 .02* 2.46 .105

Age 0.05 0.21 .81
Race 2.99 1.93 .13
Religion 8.15 4.59 .08
Spirituality 3.72 7.94 .64
*Significant at alpha  .05

The researchers were also interested in predictors of fear of death and death
anxiety. To examine possible predictors, a regression model was used. Age,
gender, race, spirituality, and religiosity were entered as independent variables
with pretest scores as the dependent variable. Gender was not only a predictor
independent of other potential predictors but also when other possible pre-
dictors were added to the regression model (gender ¼ 15.88; p ¼ .01; and
14.14; p ¼ .02) respectively (see Table 5).

Discussion
This research study was conducted to close the gap in the literature in reference
to the knowledge of the impact of death education on fear of death and death
anxiety among human services students. The results showed that human services
students experienced statistically significant less fear of death and death anxiety
after participating in a DD&B class. This finding is consistent with previous
studies conducted with undergraduate students and nurses (Barrere et al.,
2008; Hurtig & Stewin, 1990; Wong, 2009). The result also supports effects of
death education as reported by social worker and counseling students in quali-
tative studies (Harrawood et al., 2011; Head, 2008).
In the current study, gender was the only predictor of fear of death and death
anxiety. Such findings correspond with many previous studies (Russac et al.,
2007). It has been speculated that women may be more honest in acknowledging
uncomfortable feelings (Stillion, 1985) and, thus, more open to admitting fear of
death and death anxiety. Age was not a predictor in the current study, contrary
to previous findings (Fortner & Neimeyer, 1999). However, differences of fear of
death and death anxiety among age groups apparently do not occur until middle
age and older age. This study had very few middle-aged participants and no
older age participants. This fact may explain this discrepancy in findings. In
addition, religion was not a predictor of fear of death and death anxiety
McClatchey and King 357

among these participants. This finding is in contrast to previous studies

(Thorson, 1991; Thorson & Powell, 1991). Religion was a dichotomous question
in this study where students did not rate their commitment to religion. People
with only moderate commitment to religion experience more fear of death and
death anxiety than those with high commitment to religion (Thorson, 1991;
Thorson & Powell, 1991). Because commitment was not measured in this
study, the findings may be due to a moderate level of commitment to religion
among participants in the current study.
Interestingly, ethnicity was connected with fear of death and death anxiety
scores at posttesting. One explanation to this connection may lie in the compos-
ition of the black student body of the DD&B class in this study. The university
where this study was conducted has a large immigrant population from Africa,
and this class was not an exception. Many of the African immigrants voiced
concerns during the semester that they were not accustomed to talking about
death and dying as openly as some of their American classmates and the pro-
fessor. Some of the African students raised fears to the professor that talking
about death would invoke some kind of misfortune. This fear may have influ-
enced scores on the posttest and may explain the findings. These were surprising
findings emphasizing the need for further research in DD&B education consider-
ing ethnicity.

Limitations
This study is not without limitations. The nonequivalent comparison group
design controls for most threats to internal validity. However, it does not control
for external validity concerns such as the Hawthorne effect (Campbell & Stanley,
1963). It is possible that the students were affected by the knowledge that they
were participating in a study rather than by the intervention itself. The lack of a
random sample means that the results of this study cannot be generalized to
other students and geographic locations. The southeast area of the United States
is different in several aspects from other areas of the country, and the results may
be specific to the students of this class and of this area. In addition, confounding
variables that may have influenced the participants and study outcomes were not
considered. For example, it was unknown to the researchers whether students in
the two groups, treatment or comparison, had experienced a recent, or any
previous, loss to death.
Furthermore, the DD&B class was an elective course, and students who took
this class chose to be there. This means that selection bias may have impacted the
study results. Also, although students in both groups were asked not to complete
the instrument if they had had any previous formal death education from another
institution, it is unknown whether the students adhered to this request.
Yet another limitation may be related to instrumentation. The subjective and
complex nature of personal attitudes and beliefs makes the objective
358 OMEGA—Journal of Death and Dying 71(4)

quantification and measurement of death attitudes a significant challenge

to DD&B researchers. Abdel-Khalek (2011) stated, “death elicits many differ-
ent cognitions and emotions, mostly negative in nature. Subjective distress
about the matter of death is multi-faceted” (p. 171). Although the MFODS
has good psychometric properties, the complexity of the constructs defining
the fear of death and death anxiety raises questions appropriate for further
inquiry.

Implications for Future Research and Practice

Although this study has limitations, there are clear implications for future
research and practice. Future studies with a more geographically and racially
diverse sample that includes more males would increase the generalizability of
the study findings, as would randomization to treatment and control groups.
Also, although the results indicate that death education decreased fear of death
and death anxiety in this sample, the results do not tell us what in the death
education was helpful and created the lessening of fear and anxiety. A qualita-
tive research design may shed light on some of these questions. Furthermore, the
unexpected finding connecting ethnicity to fear of death and death anxiety at
posttesting indicates the need for additional studies examining these suspected
culturally bound fears. In addition, the findings of age and religion as nonpre-
dictors of fear of death and death anxiety in this study contradict findings in
previous studies and warrant further examination.
The results of this study also have important implications for practice. As
human services workers enter the workforce they will be met with the challenges
of working with an increasingly aging population in nursing homes, assisted
living facilities, hospitals, and hospice care networks. It is imperative that they
are not only knowledgeable about the dying process but also feel a certain
comfort level working with this population and have increased insight into
their personal attitudes and feelings about DD&B. To this end, they will need
effective DD&B education.
This research study indicates that death education is an effective way to help
decrease the anxiety of students who plan to work with the death and dying
population. Decreasing death anxiety among human services professionals
should increase their potential impact in helping dying patients and their
families, as there is a relationship between death attitudes and clinical work
with the dying population by helping professionals (Wong et al., 1994;
Harrawood et al., 2011). It is, therefore, the hope of these researchers that
human services training programs across the country add death education as
a course to their curricula. With powerful DD&B learning experiences, human
services professionals would have a meaningful impact on the process of work-
ing with their dying patients and their families through the end of the patient’s
life and beyond.
McClatchey and King 359

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publica-
tion of this article.

References
Abdel-Khalek, A. M. (2011). The death distress construct and scale. Omega, 64, 171–184.
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual for
mental disorders (DSM 5). Arlington, VA: Author.
Barrere, C. C., Durkin, A., & LaCoursiere, S. (2008). The influence of end-of-life edu-
cation on attitudes of nursing students. The International Journal of Nursing Education
Scholarship, 5, 1–18.
Braun, M., Gordon, D., & Uziely, B. (2010). Associations between oncology nurses’
attitudes toward death and caring for dying patients. Oncology Nursing Forum, 37,
43–49.
Brown, C., & Smith-Cumberland, T. (2006). The evaluation of two death education
programs for EMTs using the theory of planned behavior. Death Studies, 30, 637–647.
Cagle, J. C., & Kovacs, P. J. (2009). Education: A complex and empowering social work
intervention at the end of life. Health and Social Work, 34, 17–25.
Campbell, D., & Stanley, J. (1963). Experimental and quasi-experimental designs for
research. Chicago, IL: Rand McNally.
Coppola, K. M., & Strohmetz, D. B. (2002). How is death and dying addressed in intro-
ductory psychology textbooks? Death Studies, 26, 689–699.
Csikai, E. L., & Durkin, A. (2009). Perceived educational needs and preparation of adult
protective services workers for practice with end-of-life issues. Gerontology &
Geriatrics Education, 30, 146–163.
DeSpelder, L. A., & Strickland, A. L. (2005). The last dance: Encountering death and
dying. New York, NY: McGraw-Hill.
Eckerd, L. M. (2009). Death and dying course offerings in psychology: A survey of nine
Midwestern states. Death Studies, 33, 762–770.
Erickson, E. H. (1959). The identity and the life-cycle. Psychological Issues Monograph,
1(1), 50–100.
Fortner, B. V., & Neimeyer, R. A. (1999). Death anxiety in older adults: A quantitative
review. Death Studies, 23, 387–411.
Harrawood, L. K., Doughty, E. A., & Wilde, B. (2011). Death education and attitudes of
counselors-in-training toward death: An exploratory study. Counseling and Values, 56,
83–95.
Head, B. A. (2008). Use of the decision case method of teaching a course on death and
grief. Journal of Social Work in End-of-Life & Palliative Care, 4, 229–251.
Hegedus, K., Zana, A., & Szabo, G. (2008). Effect of end of life education on
medical students and health care workers’ death attitude. Palliative Medicine, 28,
264–269.
360 OMEGA—Journal of Death and Dying 71(4)

Hoelter, J. W., & Hoelter, J. A. (1978). The relationship between fear of death and
anxiety. Journal of Psychology, 99, 225–226.
Hurtig, A. H., & Stewin, L. (1990). The effect of death education and experience on
nursing students’ attitude towards death. Journal of Advanced Nursing, 15, 29–34.
IBM Corp (2011). IBM SPSS statistics for windows. Version 20.0. Armonk, NY: Author.
Kastenbaum, R. (2012). Death, society, and human experience. New York NY: Pearson.
Ka-Ying Hui, V., Harris Bond, M., & Sze Wing Ng, T. (2007). General beliefs about the
world as defensive mechanisms against death anxiety. Omega, 54(3), 199–214.
Keigher, S. M. (2001). Clinical ethics, living and dying: New challenges for changing
times. Health and Social Work, 26, 131–135.
Kovacs, P. J., & Bronstein, L. R. (1999). Preparation for oncology settings: What hospice
social workers say they need. Health and Social Work, 24, 57–63.
Lantz, J. (2001). Existential theory. In P. Lehmann & N. Coady (Eds), Theoretical per-
spectives for direct social work practice: A generalist-eclectic approach (pp. 240–254).
New York, NY: Springer.
Leming, M. R., & Dickinson, G. E. (2007). Understanding dying, death, & bereavement
(6th ed.). Belmont, CA: Thomson Higher Education.
Luptak, M. (2004). Social work and end of life care for older people: A historical per-
spective. Health and Social Work, 29, 7–14.
Neimeyer, R. A. (1994). The threat index and related methods. In R. A. Neimeyer (Ed.),
Death anxiety handbook: Research, instrumentation, and application (pp. 61–97).
Washington, DC: Taylor and Francis.
Neimeyer, R. A., & Moore, M. K. (1994). Validity and reliability of the multi-dimen-
sional fear of death scale. In R. A. Neimeyer (Ed.), Death anxiety handbook:
Research instrumentation and application (pp. 103–120). Washington, DC: Taylor
and Francis.
Neimeyer, R. A., Moser, R. P., & Wittkowski, J. (2003). Assessing attitudes toward dying
and death: Psychometric considerations. Omega, 47, 45–76.
Russac, R. J., Gatliff, C., Reece, M., & Spottswood, D. (2007). Death anxiety across the
adult years: An examination of age and gender effects. Death Studies, 31, 549–561.
Schultz, R. (1979). Death anxiety: Intuitive and empirical perspectives. In L. A. Busen
(Ed.), Death and dying: Theory/research/practice (pp. 66–87). Dubuque, IA: William.
Smith-Cumberland, T., & Feldman, R. H. (2005). EMTs’ attitudes toward
death before and after a death education program. Prehospital Emergency Care, 10,
89–95.
Stillion, J. M. (1985). Death and the sexes. Washington, DC: Hemisphere/McGraw-Hill.
Thorson, J. A. (1991). Afterlife constructs, death anxiety, and life reviewing: Importance
of religion as a moderating variable. Journal of Psychology and Theology, 19(3),
278–284.
Thorson, J. A., & Powell, F. C. (1991). Life, death, and life after death: Meanings of the
relationship between death anxiety and religion. Journal of Religious Gerontology, 8(1),
41–56.
Thorson, J. A., & Powell, F. C. (1994). A revised death anxiety scale. In R. A. Neimeyer
(Ed.), Death anxiety handbook: Research, instrumentation and application (pp. 31–43).
Washington, DC: Taylor and Francis.
McClatchey and King 361

Toomer, A. (1994). Death anxiety in adult life-theoretical perspectives. In R. A. Neimeyer

(Ed.), Death anxiety handbook: Research, instrumentation and application
(pp. 121–148). Washington, DC: Taylor and Francis.
Wong, P. T. P. (1989). Successful aging and personal meaning. Canadian Psychology, 30,
516–525.
Wong, P. T. P., Reker, G. T., & Gesser, G. (1994). Death attitude profile—Revised: A
multidimensional measure of attitudes toward death. In R. A. Neimeyer (Ed.), Death
anxiety handbook: Research, instrumentation and application (pp. 121–148).
Washington, DC: Taylor and Francis.
Wong, W. (2009). The growth of death awareness through death education among uni-
versity students in Hong Kong. Omega, 59, 113–128.

Author Biographies
Irene Searles McClatchey is an assistant professor at Kennesaw State
University’s department of social work and human services. She teaches
death, dying, and bereavement and is the founder and director of a healing
camp for bereaved youth.

Steve King is an assistant professor in the department of social work and human
services at Kennesaw State University. He supervises undergraduate capstone
research theses and teaches family and group treatment courses.