Living amongst the dead: How morticians coped during the COVID-19 pandemic

Introduction

The significance of funeral services was thrust to the forefront with unparalleled fervour when the World Health Organization (WHO) designated the Coronavirus disease (COVID-19) outbreak a global pandemic in March 2020 (Ciotti et al., 2020). Since then, the COVID-19 death toll in South Africa continued to rise exponentially, thus putting more pressure on funeral parlours and their morticians (Mokhoali, 2021). COVID-19 frontline workers who operated in high infection rate areas experienced severe degrees of psychological symptoms (Greenberg et al., 2020; Vizheh et al., 2020). Morticians are frontline workers facing excessive work-related demands associated with continuous physical contact with human remains (Kurz, 2018). They experienced extraordinary workloads during the COVID-19 pandemic due to increased mortality rates. Yet, there are no studies that have explored the psychosocial impact of COVID-19 on South African morticians. This study investigated the psychosocial stressors encountered by South African morticians as well as the coping strategies they employed.

Morticians’ excess workload during COVID-19

Morticians’ close contact and exposure to the virus increased their occupational exposure to COVID-19 by 23.5% (Moosavi et al., 2023). Their constant exposure to deceased individuals may compromise their psychological well-being (Temsah et al., 2020), as they frequently encounter traumatic injuries and are required to provide emotional support to grieving families (Brysiewicz, 2007). The COVID-19 pandemic exacerbated work distress among morticians to unprecedented levels (Hicks et al., 2022).

For instance, as supported by previous research during the COVID-19 pandemic, morticians experienced high levels of stress, with some being diagnosed with depression (Bensimon, 2021). Conceivably, they would employ both positive (adaptive) and negative (maladaptive) coping strategies to maintain a healthy work-life balance.

Adaptive coping strategies, including sharing feelings with others, remaining busy, maintaining faith, using humour, engaging with bereaved relatives, and maintaining hope, were frequently employed during the COVID-19 pandemic (Kar et al., 2021; Patwary, 2010). Conversely, maladaptive coping mechanisms such as substance abuse and avoidance were also observed (Holland et al., 2021). Contextual factors, including country-specific settings, may explain whether morticians exhibited similar responses to COVID-19 mortality management (Vidua et al., 2020).

Morticians spend a significant amount of time working with deceased individuals and are often undervalued for their contributions to society (Mridula & Ganesh, 2016). Soria Batista and Codo (2018) discussed how morticians experienced a substantial amount of stigma due to their immersion in human remains. According to Afifi et al. (2023), 77% of morticians expressed that their greatest challenge since the beginning of the pandemic is the stigma they face in communities.

Goals of the Study

This study aimed to understand the psychosocial stressors faced by morticians during the COVID-19 pandemic and the coping mechanisms they employed. We sought to address the following research questions:

•   What psychosocial stressors did morticians experience during the COVID-19 pandemic?

•   How did morticians cope with the psychosocial stressors associated with COVID-19 mortality?

Method

Research design

An interpretative phenomenological analysis (Smith et al., 2009) was conducted to understand the psychosocial stressors and coping mechanisms of morticians. The use of IPA is particularly appropriate as it allows for an in-depth exploration of morticians’ lived experiences during the COVID-19 pandemic, capturing the nuanced emotional and psychological challenges they faced. This design prioritises individual narratives, enabling a rich understanding of how these professionals navigated their unique stressors and coping strategies in a highly contextualised environment.

Participants and setting

The participants were a purposive sample of 10 male Black morticians from the North West province, South Africa. Purposive sampling was chosen because it allows for the selection of participants who can describe their experience of working as a mortician during the COVID-19 pandemic (De Vos et al., 2011). The morticians were required to have been employed for at least 3–5 years by the funeral parlour as they had experienced a “normal working environment” before the COVID-19 pandemic. The final inclusion criterion was that the participants should have worked at a funeral parlour that received COVID-19 cases, as the study aimed to understand how those in such roles coped with psychosocial stressors.

Data collection

We used semi-structured interviews to explore the participants’ perspectives and experiences of COVID-19 and its relationship with psychosocial stressors and their coping mechanisms. This allowed the participants to freely express their viewpoints and introduce the experiences that were important to them in a flexible approach (De Vos et al., 2011). The semi-structured interviews asked questions about morticians working with COVID-19 human remains, types and levels of work stress during the COVID-19 pandemic and the activities the morticians engaged to cope with COVID-19 work related stress. Interviews took approximately 45–60 min and were audio-recorded and were then transcribed verbatim. To ensure credibility and trustworthiness of the data, we employed triangulation, using multiple data collection methods such as interviews, field notes and precise participant selection criteria (Shenton, 2004). To further enhance trustworthiness and reduce researcher bias, the researcher used reflexivity through continuous self-reflection and documented field notes detailing personal thoughts, ideas, questions, and observations during interviews. These notes served as a valuable resource during data analysis and interpretation (Phillippi & Lauderdale, 2018).

Procedure

Ethical clearance for the study was provided by the North-West University Human Research Ethics Committee (HREC) (NWU-00171-22-S1). The mortuary management provided study permission. The participants provided study consent. Interviews were carried out by a trained intern clinical psychologist.

Data analysis

We employed an IPA informed thematic analysis (Braun & Clarke, 2020; Duiker & Booysen, 2022; Smith et al., 2009). This procedure allowed for iterative interpretation of the participants’ narratives. We then selected appropriate and meaningful names for each theme. To ensure dependability of findings, we created an audit trail documenting methodological decisions and theoretical considerations throughout the study (Nowell et al., 2017; Tobin & Begley, 2004). The second and third authors independently assessed the themes to enhance dependability.

Results and Discussion

Five themes emerged from the analysis: (i) death overload distress, (ii) insomnia, (iii) stigmatisation, (iv) social isolation and anxiety, and (v) adaptive and maladaptive coping. We present on each of these with the evidence for them.

Theme 1: Death overload distress

Morticians have been under immense pressure due to the skyrocketing death rate, resulting in a significant increase in burials. During the COVID-19 pandemic morticians experienced several psychosocial stressors in their lives. All 10 participants reported death overload distress during the pandemic as follows.

“It would be COVID funerals; I am a mortician and had to do my job. In the beginning, it was stressful. I luckily never contracted COVID” (Participant 2, male, 27 years old)

“Eish, we never rested. There were so many deaths … we hardly rested. We also dealt with difficult customers (families). We would drive 150 km in the early am to please our customers” (Participant 7, male, 52 years old)

“Working with COVID deaths, there was no way of even running from it. Most people who died were COVID corpses. We would wear PPE and wear three pairs of gloves.” (Participant 5, male, 42 years old)

“One hardly rested; with COVID-19, you could not have a corpse for five days, we had funerals every day to cater for all the deaths.” (Participant 10, male, 38 years old)

All of the morticians mentioned that they often found themselves feeling overworked and over-exposed to COVID-19 corpses. These findings are consistent with the literature to the effect that workload and over-exposure to mortality amplified morticians’ stress (Hernández-Fernández & Meneses-Falcón, 2022). McCarty et al. (2023) similarly reported that the surge in stress levels during the COVID-19 pandemic, resulting from increased mortality, had a devastating impact on the lives of morticians.

Theme 2: Insomnia

Insomnia was a common symptom of mental health distress among the morticians participating in the study. The majority of participants reported experiencing insomnia. To illustrate this, consider the following representative statements: “Thousands of people were dying every day. l had insomnia because my mind didn’t close off. I was always thinking about what awaited tomorrow.” (Participant 2, male, 27 years old)

“Uhm… Most hospitals could not accommodate dead bodies so we would have to go get the body and we would have to attend a funeral the following day. And after the funeral, one had to attend to more bodies to prepare them for burial.” (Participant 9, male, 25 years old)

“I would wake up in the middle of the night, heart racing, just thinking about all the bodies we had to process. It was like I couldn’t escape it, even in my sleep.” (Participant 6, male, 46 years old)

“The worst part was the nightmares. I’d dream about being surrounded by corpses, unable to breathe. It was terrifying, and it made it hard to face going back to work.” (Participant 4, male, 36 years old)

The current study revealed a previously undocumented phenomenon among morticians: the “fight-or-flight” response (Gorban et al., 2016). The chronic stress and overwhelming workload triggered a state of hyperarousal, disrupting normal sleep patterns and activating the sympathetic nervous system (Kalmbach et al., 2018). This constant state of alert, combined with the emotional burden of dealing with death (Jordan et al., 2019), led to persistent insomnia as the morticians’ bodies remained in a state of heightened readiness for perceived threats (Threatt, 2022).

Theme 3: Stigmatisation

Many participants experienced stigmatisation from the public due to their high risk of contracting the COVID-19. They responded variously as follows:

“Some people knew where I worked and they would gossip about me, about where I worked, and they stayed far away from me in fear because they feared contracting COVlD.” (Participant 5, male, 42 years old)

“The worst was in the taxis; people treated me differently and almost in a judgemental manner because they knew where I worked, or they would see due to my uniform.” (Participant 7, male, 52 years old)

“People would avoid me in public spaces, like grocery stores, because of my job. I felt like I was carrying the virus with me.” (Participant 2, male, 27 years old)

“Even my neighbours started acting distant. They’d cross the street when they saw me coming, like I was some kind of threat.” (Participant 9, male, 25 years old)

The literature indicates that failing to meet societal norms and facing stigmatisation can contribute to chronic stress (Sorokin et al., 2020). Stigmatization risk intensified the challenges morticians faced (Van Overmeire & Bilsen, 2020; Van Overmeire et al., 2021). Therefore, the primary appraisal of the stigmatisation, according to the transactional model of stress (Krohne, 2002; Lazarus & Folkman, 1987), highlights the risk of social isolation.

Theme 4: Social isolation and anxiety

The morticians reported psychosocial experiences as follows:

“After fetching a body, I could not see or be with my family for up to 2 days, I did not spend time with them at all.” (Participant 10, male, 38 years old)

“It was hurtful … l had to communicate with them via cell phone. We couldn’t share our work struggles with our families.” (Participant 3, male, 32 years old)

“lt was tough; you stayed in fear of even contracting COVID-19. l was always anxious when l had to go for tests.” (Participant 10, male, 38 years old)

“People were just dying; l was scared of contracting COVlD even from the corpses. Any symptom would cause me stress, thinking that I might have contracted COVID-19.” (Participant 5, male, 42 years old)

“I was always stressed about whether I will come home okay and not get COVID-19 and pass it on to my family.” (Participant 1, male, 23 years old)

These findings align with previous research, which indicates that social isolation negatively affects well-being and contributes to heightened stress levels among morticians (Chandra & Vanjare, 2020; Kaplan, 2013). Furthermore, the perceptions of COVID-19 as a form of a life-threatening event resulted in emotions such as fear and anxiety (Wang et al., 2020), which was evident in the morticians’ experience.

Theme 5: Adaptive and maladaptive coping

The morticians reported adaptive coping with acceptance, resilience, external support, and religiosity for maintaining overall well-being, managing stress and navigating life’s challenges. They demonstrated acceptance of their work conditions, built resilience by managing their emotional responses, sought external support from colleagues, family, and managers, and depended on their faith for strength. They said of acceptance as follows:

“lt was hard at first, working with COVID-19 bodies. But you get used to it as time goes, and you accept it.” (Participant 4, male, 36 years old)

“As the pandemic continued, you learn to accept the workload.” (Participant 10, male, 38 years old)

“l just accepted, whatever happens, will happen according to God’s will.” (Participant 8, male, 57 years old)

The participants described their resilient coping as follows:

“I did not take it personally; I understood that they wanted to protect themselves.” (Participant 3, male, 32 years old)

“During the pandemic, I did some introspection in my life to see what works for me and what doesn’t.” (Participant 10, male, 38 years old)

Even when you fetch the corpses at the hospitals, I was informed of the strict protocols and guidelines on how to go about my work. And I ensured I followed the right steps so that COVID-19 doesn’t affect me.” (Participant 6, male, 46 years old)

External support was helpful to the morticians as follows:

“We helped each other to get through. There were of course those who looked down on us and judged us, but others were much more supportive and comforted us.” (Participant 1, male, 23 years old)

“Personally, it did not affect my life deeply; like I said, we got motivation everyday … we were even given support throughout the vaccination process as well. We received great support from our manager.” (Participant 3, male, 32 years old)

“I like talking, so I would talk with my colleagues every morning and we comforted each other. Our boss will come to us saying are we having a meeting. We helped each other so that we would not work with the dead bodies for too long.” (Participant 7, male, 52 years old)

“Even at home it was hectic, but my family was supportive.” (Participant 5, male, 42 years old)

Regarding their religiosity, participants coped as follows:

“We stayed in fear of the virus; we got vaccinated, and we prayed for the pandemic to end as well.” (Participant 9, male, 25 years old)

“On a daily basis, I sit at home and would read my Bible with my family. There are verses that spoke on the virus issues, such as people will close themselves in their houses … God told us before it happened.” (Participant 6, male, 46 years old)

“l just accepted … whatever happens will happen according to God’s will.” (Participant 8, male, 57 years old)

“lt is God’s will for my life, and he gave me the strength to go through this journey.” (Participant 4, male, 36 years old)

The morticians’ reliance on adaptive coping mechanisms, including acceptance, resilience, external support, and religiosity, underscores the importance of proactive strategies in managing occupational stress during crises. Acceptance of the reality of their work, as highlighted by participants’ quotes, allowed them to confront their challenges head-on rather than being overwhelmed by them (Lazarus & Folkman, 1987). Resilience, which involved managing emotional responses and developing a sense of personal strength, enabled morticians to maintain psychological equilibrium amidst constant exposure to death (Rutten et al., 2013). Furthermore, the seeking of external support from colleagues, family, and managers provided crucial emotional validation and practical assistance, buffering against feelings of isolation and burnout (Kurz, 2018; Miguel-Puga et al., 2021; Ozbay et al., 2007). Finally, the role of faith and spirituality in providing solace and meaning during uncertain times (Maier et al., 2022) highlights the potential of religious beliefs as a coping resource for morticians.

The participants described their maladaptive avoidance behaviours as follows:

“l watched a lot of TV and movies, just to forget so to speak.” (Participant 2, male, 27 years old)

“I would just read a lot, and sometimes I would read up about soccer games and when they will be reinstated, especially soccer overseas. I didn’t want to think about work”. (Participant 9, male, 25 years old)

“Sometimes you go out with friends, and you always want to have company but then they leave, and you are left with your thoughts.” (Participant 1, male, 23 years old)

While adaptive strategies provided crucial support, some morticians also engaged in maladaptive coping mechanisms, primarily involving avoidance behaviours. As evidenced by the participants’ reported reliance on television, movies, reading, and socializing to distract themselves from work-related stressors, avoidance can offer temporary relief but may exacerbate underlying issues in the long term (Sun et al., 2023). Such avoidance strategies, while providing momentary escape from the emotional demands of their profession, have been associated with increased anxiety, depression, and prolonged grief when used as primary coping responses (Szuhany et al., 2021). Thus, while these behaviours may have served as immediate coping mechanisms, their potential for negative long-term consequences underscores the need for more adaptive strategies that directly address the stressors faced by morticians.

Implications for practice

The findings of this study have practical implications for the mental health and occupational support services provided to morticians, especially during pandemics or periods of increased community mortality. Morticians experienced significant psychosocial stressors which negatively impacted their psychological well-being (Chersich et al., 2020; Dyregrov et al., 2024; Wallace et al., 2020). Consequently, mental health professionals and policymakers should prioritise the development of tailored psychosocial interventions, including psychoeducation programmes designed specifically for morticians. These programmes should address the recognition and management of stress symptoms and coping strategies and provide accessible mental health support tailored to the unique occupational demands of morticians (Chersich et al., 2020; Wallace et al., 2020).

Moreover, employers in the mortuary services sector should implement comprehensive workplace wellness programmes that encourage proactive mental health management. Support mechanisms could include structured peer-support groups, regular debriefing sessions, counselling services, and training aimed at promoting resilience and adaptive coping strategies (Dyregrov et al., 2024; Wallace et al., 2020). Given that participants emphasised acceptance, resilience, external support, and religion as helpful coping mechanisms, programmes should integrate culturally sensitive support systems, recognising the role of religious and community-based resources (Wallace et al., 2020; World Health Organization (WHO), 2020).

Furthermore, it is crucial for public health messaging and community education campaigns to address and reduce the stigma associated with mortuary workers. Awareness initiatives can demystify morticians’ roles and alleviate the social exclusion and isolation experienced by these essential workers (Dyregrov et al., 2024; World Health Organization (WHO), 2020). By fostering an inclusive community environment, morticians can be better supported socially and psychologically, ultimately improving their mental health outcomes and professional resilience during challenging periods (Chersich et al., 2020; Hicks et al., 2022; Mudenda et al., 2022; World Health Organization (WHO), 2020).

Limitations of the study and future directions

This study was limited by the small, homogeneous sample comprising ten Black male morticians from the private sector in South Africa. This lack of diversity in gender, race, and cultural background restricts the exploration of varied psychosocial experiences and coping strategies. Moreover, the exclusive inclusion of male participants could have biased the findings towards particular coping styles, such as avoidant coping mechanisms often associated with men. Consequently, the generalisability and representativeness of the findings to broader mortician populations are limited.

Future studies should therefore engage larger and more diverse samples, including female morticians and those from different racial, cultural, and socio-economic backgrounds. It is also recommended that research include morticians working in both the private and public sectors to gain a comprehensive understanding of psychosocial stressors and coping strategies across diverse contexts. Conducting detailed clinical assessments of morticians and exploring the specific impacts of their work environment could provide deeper insights, leading to improved psychological support services and targeted interventions.

Conclusion

Our findings revealed that the participants faced significant challenges, such as stigmatisation, health and safety concerns, increased workload, isolation and changing regulations because of their social exclusion from the larger society and their lack of recognition. Although most morticians utilised positive coping mechanisms, the study indicated that different approaches to coping during the COVID-19 pandemic, such as avoidance, acceptance and positive reframing had different impacts on experiencing stress. Overall, the morticians involved in this study demonstrated a deep appreciation for the various resources and supportive structures managing their demanding jobs as morticians.

Acknowledgement: The authors wish to thank Mr Solani Ngobeni (Centre for Scholarly Publishing Services) for providing valuable comments on an earlier version of this manuscript.

Funding Statement: The authors received no specific funding for this study.

Author Contributions: Melissa Mashaba led the data collection, analysis, and interpretation, forming the core of this study. Curwyn Mapaling served as principal supervisor, overseeing the project’s conceptual framework and providing strategic guidance. Wandile F. Tsabedze contributed as co-supervisor, supporting methodological development and ensuring alignment with research objectives. All authors reviewed the results and approved the final version of the manuscript.

Availability of Data and Materials: The data generated during this study can be made available upon reasonable request to the corresponding author.

Ethics Approval: This study involved human subjects and was conducted with ethical approval from the North-West University Human Research Ethics Committee (NWU-00171-22-S1). The necessary permissions were obtained from mortuary management, and informed consent was secured from all participants.

Conflicts of Interest: The authors declare no conflicts of interest to report regarding the present study.

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