Psychosocial Demands in Death Care During COVID-19 Pandemic: Qualitative Study on Italian Workers

Abstract

The recent COVID-19 pandemic has fundamentally changed the long-established approach to death. Among the workers who suffered most from the effects of this new situation are those in death care, who had to take care of the disposal of bodies throughout the pandemic. This study explores the experiences of these professionals to better understand the difficulties they faced in their daily work during the first wave of the pandemic. The narratives of 29 Italian death care professionals were collected. The data were analysed using Template Analysis, and four main themes were identified: the changes in funeral practices, the management of the increased workload, stigmatisation and a lack of support. The results of this study have also shown that institutions and the public know too little about the death care system, a factor that significantly influenced the difficulties faced by these professionals in coping with the pandemic.

1. Introduction

The outbreak of COVID-19 was a major shock to the world’s population, bringing with it a range of governmental, societal and individual challenges. Unpreparedness for this unforeseen event made it difficult to manage the pandemic, especially the policy of containing the virus. There were several abrupt changes in the social environment: the lockdowns imposed in many cities led many people to stay at home, which radically changed lifestyles, and many activities shifted to remote work (Grandi et al. 2021b; Grandi et al. 2022). However, some professions were still “in presence” to ensure the continuation of services defined as “essential”. In the field of care services, healthcare professionals were on the frontline to respond to the ongoing emergency, facing a situation full of uncertainty, a high workload and a high risk of contagion. The interest in the working conditions and health of these workers has been remarkable, both from the media and the point of view of research (Vizheh et al. 2020). Surprisingly, another professional group that continued to perform an activity considered essential on a social level, namely death care workers, has received little attention regarding the physical, biological and psychosocial risks they were exposed to during the pandemic. In fact, professionals in this sector were also on the frontline—as healthcare and emergency service workers—as they were responsible for the preparation, disposal and burial of bodies at a historical moment when mortality was very high and when funeral practices underwent profound changes. To date, few studies have examined the critical situation experienced by death care workers during the COVID-19 pandemic (Van Overmeire et al. 2021; Van Overmeire and Bilsen 2020; Durand-Moreau and Galarneau 2021; Clavandier et al. 2021); further research is therefore needed to gain deeper knowledge about this particular professional context.

Background

The funeral industry sector, better known as death care, includes professionals who work in mortuaries, crematoria, cemeteries and funeral directing services. Their work includes all tasks ranging from receiving the body of the deceased to burial or the scattering of the ashes and therefore involves constant exposure to death. An important part of their job is also to support the relatives of the deceased, who need guidance and support in organising the funeral at a time of potentially great suffering. The role of the death care professional therefore involves a high degree of responsibility and organisational, technical and relational skills (SEFIT 2008).

Death care work can be physically, cognitively and psychologically demanding. The psychosocial risks to which these workers are exposed due to the work context in which they are employed have been studied for several years, albeit only scarcely. From a mental and physical health perspective, anxiety and depression (Cegelka et al. 2020; Goldenhar et al. 2001; Keith 1997; Guidetti et al. 2022), work-related stress (Bailey 2010; Bartlett and Riches 2007; Kroshus et al. 1995; Goldenhar et al. 2001) and occupational burnout (Guidetti et al. 2021; Smith et al. 2009; Tetrick et al. 2000) have been identified. The results of recent studies have also examined the negative consequences of the overexposure of these professionals to death and suffering, recognising the risk of secondary traumatic stress and vicarious traumatisation (Colombo et al. 2019; Grandi et al. 2023; Guidetti et al. 2022) and emotional dissonance (Guidetti et al. 2022). Death care has also been studied in particular with regard to its relationship with occupational stigma, a phenomenon that is still current among those who work with death and can have a serious impact on the private, social and professional lives of these people (Thompson 1991; Soria Batista and Codo 2018; Guidetti et al. 2021).

According to the literature, death care professionals can turn to several resources to compensate for the negative consequences of their work. Among professional resources, for example, organisational support was found to be an important element (Grandi et al. 2024; Cegelka et al. 2020; Guidetti et al. 2021; Tetrick et al. 2000), along with professional identity (Emke 2002; McCarthy 2016; Szkil 2016; Thompson 1991) and the use of coping strategies, such as humour (Grandi et al. 2021a). From a personal perspective, the attribution of value and meaning to work has been shown to be a valuable resource against the occurrence of occupational burnout (Guidetti et al. 2021). In addition, the opportunity for personal growth following direct and vicarious work-related traumatic experiences was found to be another important resource for these professionals (Grandi et al. 2023).

During the COVID-19 pandemic, death care work fundamentally changed due to the restrictions and new regulations imposed by the government to ensure public health and safety. As there was no scientific evidence of the actual infectivity of COVID-19 corpses (Mahajan et al. 2020; Suwalowska et al. 2021), precautionary measures were introduced in the handling of potentially infectious corpses. This change had a particularly strong impact on the work of funeral directors and mortuary staff, who could no longer come into direct contact with the corpse and thus lost the opportunity to dress and care for it in an appropriate and dignified manner (Clavandier et al. 2021). Together with the suspension of funeral ceremonies, this state of affairs had a major impact at the social level, preventing a healthy ritual process of farewell, which is essential for the elaboration of grief (Turner and Caswell 2020). The high mortality rate also led to serious difficulties in managing spaces to accommodate bodies and coffins (Clavandier et al. 2021) and significantly increased the daily workload that had to be managed to ensure the continuity of funeral services. The impact of the pandemic on the death care sector has so far been analysed in terms of the biological risks to which the professionals were exposed (Van Overmeire and Bilsen 2020; Mahajan et al. 2020) and mental health outcomes (Hicks et al. 2022; Durand-Moreau and Galarneau 2021; Van Overmeire et al. 2021). On the other hand, little research has been conducted on the difficulties encountered in complying with the new ways of working (Moreras 2023; Mas’amah et al. 2023; Clavandier et al. 2021).

This study therefore seeks to understand, through the lived experience of death care workers, the main critical problems they faced during the first wave of the pandemic, the most difficult phase to manage due to the general unpreparedness of governments and the health system. This study focuses in particular on the experience in Northern Italy, which was the first area in Europe to be significantly affected by the pandemic.

2. Materials and Methods

2.1. Data Collection

This study comprised a convenience sample of Italian death care workers. The participants were selected from the funeral agencies, mortuaries and crematoria of the provincial capital and some neighbouring municipalities of Piedmont (Northern Italy). The first contact was made by telephone, explaining the project, answering doubts and questions and asking for willingness to participate in this study. Twenty-nine death care workers agreed to take part in this study, nineteen women and ten men, aged 26–58 years old and with 1–32 years of service in the sector. The employees worked in various areas of death care: funeral directing (6), crematoria (9) and mortuaries (14).

In order to try to better understand the experiences of the professionals, a qualitative research design was chosen, involving semi-structured interviews. All sessions were held at the participants’ place of work, on the days and at the times that they themselves described as most convenient. This research is in line with the Declaration of Helsinki (with the Edinburgh revisions of 2000). This project has been approved by the Bioethics Committee of the University of Turin (Prot. no. 0598340).

The interviews were conducted between 2021 and 2022 and were audio-recorded with the consent of the participants; they ranged from 18 to 119 min in duration (mean length 55.6 min). During the sessions, the safety protocol in force under Italian law (wearing a mask and sanitising hands) was followed. The interviews were fully transcribed and anonymised with the use of alphanumeric codes.

The interviews were conducted by the first researcher who was assisted by one Work and Organisational Psychology student and one intern, who in turn took on the role of observer.

The interview protocol was developed based on the results of a literature review on the professional context of death care and the main critical issues that arose during the COVID-19 pandemic. In order to explore the participants’ professional experience, some more general questions were asked first, aimed at obtaining information about the respondent’s professional background. Subsequently, the questions became more specific and aimed to delve into the difficulties encountered in the daily performance of the job and the strategies or resources used to cope with the most critical situations at work during the pandemic period. At the end of each session, time was left for respondents to provide further information/comments.

2.2. Data Analysis

The transcripts were read several times by the researchers in order for them to familiarise themselves with the data. The analysis technique chosen is Template Analysis—TeA (Brooks et al. 2015)—a particularly flexible thematic analysis approach adapted to organisational contexts, as already demonstrated in other studies in different work contexts, including in death care (Grandi et al. 2021b). A special aspect of TeA is that it offers the possibility to include some themes defined in advance—so called a priori themes—in the analysis process that might be relevant. However, these themes must be considered provisional, as they can be changed or eliminated if they are not conducive to the analysis (Brooks et al. 2015). The first version of the template was created based on the coding of the data from the first three transcripts. The identified categories were grouped into significant clusters in a hierarchical manner. The preliminary coding of the first transcripts was then applied to all the transcribed material, and changes were made where necessary. An iterative process was followed until the final version of the template that could be applied to all transcribed data was achieved. The researchers coded the data independently. They then came together to discuss similarities and differences and to define and redefine themes accordingly. The method of analysis used was paper and pencil.

During the research, attention was paid to the issue of reflexivity (Berger 2015) by writing field notes, which were useful to improve self-awareness in relation to the emotions that could arise during the interviews and any prejudices and/or bias. This process was helpful for the analysis as it made it possible to separate personal feelings and perspectives from the reading of the participants’ narratives.

Since TeA allows the use of theoretically derived a priori themes, the Job Demands–Resources Theory—JD-R (Demerouti and Bakker 2023; Bakker and Demerouti 2014)—was used as a theoretical framework. The JD-R theory states that each occupation is characterised by specific job demands and specific resources, whether occupational, personal or social. Job demands (e.g., workload, emotional strain, role conflicts, unfavourable work environment, etc.) refer to physical, psychological, social and organisational aspects that require adaptive efforts and an expenditure of psychophysical energy from the person. On the other hand, resources include the physical, psychological, social and organisational aspects that enable work goals to be achieved and that can mitigate the impact of job demands on psychophysical discomfort outcomes. The JD-R theory also predicts outcomes in terms of indicators of malaise but also in terms of well-being at work. It is therefore designed to identify both the risk factors that can increase discomfort and decrease well-being and health and the protective factors that can promote motivation, engagement and well-being at work. Recently, the JD-R theory has been extended to include more factors related to crisis management in the framework, making it more suitable for the current pandemic context. Specifically, more factors were considered, namely the characteristics of the work context, the organisational procedures implemented, the interactions with people inside and outside the organisation and the social and personal sphere (Demerouti and Bakker 2023).

3. Results

The analyses identified four main themes related to the critical issues faced by death care professionals during the pandemic, with varying numbers of subthemes (see

Table 1. Final template.

1. CHANGES IN FUNERAL PRACTICES	1.1. Treatment/disposal of the body	1.1.1. New procedures in death care work
		1.1.2. COVID-19 vs. non-COVID-19 deaths
		1.1.3. No sight of the body
	1.2. Relationships with the bereaved	1.2.1. Changes in “taking” the funeral service
		1.2.2. Difficulty in explaining the new regulations
	1.3. Funeral ceremonies
		1.3.1. Ceremonies with no relatives
		1.3.2. Restricted numbers
2. WORKLOAD	2.1. “Huge numbers” to deal with
	2.2. Overexposure
3. STIGMA	3.1. “Making money with death”
	3.2. Seen as corpse carriers/plague spreaders
4. LACK OF SUPPORT	4.1. Practical
		4.1.1. No inclusion in the vaccination plan
		4.1.2. No inclusion in PPE delivery
	4.2. Psychological

); these are presented in detail below.

3.1. THEME 1. CHANGES IN FUNERAL PRACTICES

This theme captures the most important changes that occurred in the performance of death care work, as experienced by our participants. In particular, it covers the way in which the bodies were handled, the relationship with the bereaved and the management of funeral ceremonies.

3.1.1. Treatment/Disposal of the Body

Like many other professions, the death care industry had to change the way work was conducted to adapt to government regulations put in place at the beginning of the COVID-19 epidemic to contain the virus and protect public health and safety.

New pathways were established for mortuaries to follow when recovering bodies from hospital wards, to ensure a clear separation between “clean” and “dirty” pathways (with higher risk of virus infection). Specifically, this meant that the operator was dressed in PPE, arrived outside the ward, placed the body on a stretcher and returned to the mortuary. The new route was longer, went through the basement to avoid the gaze of staff from other departments/offices and, according to the operators, was much more strenuous, partly because the recovery was sometimes carried out by a single member of staff, and the body could be excessively heavy. The body was already disinfected by the ward staff (wrapped in a sheet soaked in a chlorine solution) and delivered sealed in a bag. The task of the morgue worker was therefore to retrieve the body and bring it to the morgue premises, where it was absolutely forbidden to touch it in any way. The COVID-19 deceased were placed in special areas to separate them from those deceased from other causes. This new procedure was a precautionary measure with regard to the possible infectivity of the corpses, a topic that was still being discussed scientifically during the first wave of the pandemic. The funeral chambers (chapels of rest) were no longer set up, as mourners were not allowed to visit the body and keep watch near it.

Funeral directors had to adapt to the regulations of the healthcare facilities—which were not always the same and differed depending on the hospital—and were no longer allowed to enter the mortuaries. They only had to deliver the coffin—the bottom of which had to be covered with a protective layer to contain any leaks, a so-called “barrier”—collect the deceased (already in a bag) and close the coffin as quickly as possible. The same applied to nursing homes.

In the crematoria, the work was limited to disposing of the coffins, as funeral ceremonies were suspended; the cemeteries instead were closed.

In the experience of the participants, the general unpreparedness for the pandemic and the lack of knowledge of the funeral sector on the part of the bodies in charge of drafting the new regulations led to the creation of new rules and procedures that were not always appropriate. For example, the Civil Protection Department required that an additional external zinc coffin be used when transferring a COVID-19 deceased person from home to the cemetery. According to the funeral directors, this procedure was not justified, as transporting the same type of deceased from home to the crematorium did not require this measure, although the dynamics of the transport were the same. In addition, the outer zinc was very heavy to carry and had no handles, so there was a risk of operators dropping it (and injuring themselves) during handling due to its heavy weight and slippery surface. A funeral director added the following:

“…they are not prepared, that is, at the government level, our rulers do not know what happens to people when they die, regulations, things… they do not care” [funeral director].

It was initially impossible for some mortuary staff to identify the bodies, as the bracelet of the deceased had been left in the sealed bag. It was only after some staff reported this that ward staff were asked to also attach a copy of the bracelet to the outside of the bag.

The extreme confusion that prevailed in the early days of the pandemic and the hectic pace with which the work was carried out cast doubt on the correct diagnosis given to the deceased. According to some employees, deaths from causes other than COVID-19 were also misdiagnosed as “Covid”. This is evident from several interviewees, such as a mortuary worker, who explained the following:

“Huh… some yes, but because there… maybe the nurse or the doctor on the early shift who left something, there was the one who was handed over, maybe they didn’t speak to each other, and then one thing was another. So yes, that happened…” [mortuary worker].

A fundamental change that took place at a professional level was the fact that funeral directors and mortuary staff could no longer see the deceased. Dealing with “faceless corpses” had a major impact on operators:

“…You don’t even see the faces of the people you bring down, and… the fact that you don’t even know who you’re taking down was devastating because it dehumanises everything.” [mortuary worker];

“…they came in bags and there was practically nothing left of the human side.” [mortuary worker].

In practice, this led to problems with the identification of bodies with the result that there was a risk of confusion between the deceased. The issue of professional responsibility was also repeatedly raised by professionals: funeral directors, for example, had to sign a form stating that they recognised the body, which was objectively impossible, as they could only see a sealed bag. In addition, this new regulation meant that funeral directors and mortuaries could no longer take care of the body—one of their main tasks—so the bodies could no longer be dressed and cared for. This task has always been very important, as seeing the loved one well groomed and in a relaxed, almost sleeping position is seen as a relieving element in the grieving process, a kind of “psychological support” for the bereaved.

3.1.2. Relationships with the Bereaved

The need to comply with the new health and safety provisions, as we have seen, led death care workers to change their usual—and entrenched—way of working, which also led to significant changes in their relationship with bereaved clients. Funeral directors, for example, had to minimise contact with their clients and tried to receive them in their offices where possible to avoid the risk of entering their homes. If this was not possible, they tried to limit their presence in the home by finding alternative ways to get them to leave or hand over documents (e.g., these were left on the doormat and then sanitised or were sent by email). The most important consequence of this new way of working was the loss of direct contact with the bereaved. Physical presence and the ability to be there for the bereaved in times of great suffering is an essential part of the work of death care professionals. This lack, evident in all interviews, undermined the value and importance that the professionals placed on their work. An employee of a crematorium recounted the following:

“… We realised that… We cannot give what we have to give, that is, what are we doing? We load and unload and in this matter there was a bit of alienation, there was a bit of imbalance for us emotionally as well… So you lingered from time to time, maybe went into the furnace room, put your hand on a coffin and wanted to, I don’t know, say hello to him/her, somehow […] [we lost] the human part that we have… We were missing a piece.” (crematorium worker).

Even from the words of the funeral directors and mortuary workers, a sense of “emptiness” experienced in a time that required “aseptic” methods of contact emerged:

“…The impact, that is, the biggest one was to stop going to the families, to stop having the management of the funeral as a ceremony, because in any case it was no longer a ceremony, it was basically just transport, doing everything online, in the sense that we were kind of used to getting in touch with people… instead you sent them the photos, explained the numbers and did everything over the phone, then you sent the documents, they signed them and then you came to collect them…” (funeral director);

“That period there left me with a bit of sadness, an emptiness, also the different way of working, no longer having contact with the families. […] I missed that, yes, I really missed the human relationship with the people, because it was all very aseptic.” (mortuary worker).

It was a daunting task for death care workers to communicate the new regulations to the bereaved. Explaining to the bereaved—most of whom had seen their loved ones being taken away in an ambulance—that they would never see the body again was said to be one of the most difficult tasks, especially as the operators themselves were sceptical about the implementation of this ban:

“I tried to do my best, because it was difficult for me too… to make people understand something that I could not imagine either, because frankly… it was also difficult for me to have to explain to them: «You can’t see your relative because… is contagious», also because we were told that it was no longer contagious at the time of death, so you had to explain to them something that you were not even convinced was so…. it was not easy.” (mortuary worker).

Although some of the bereaved gradually understood and accepted this new reality, others reacted aggressively to this imposed deprivation and vented their resentment against the operators, who were merely executors of the procedures decided from above. The morgue staff said that they had to send some bereaved people to the Health Directorate because they could not control their anger and threatened to call the police to enable them to see their loved ones. There were also reports of bereaved people who were not sure if it was really their relative lying in the closed coffin because they could not identify him/her.

3.1.3. Funeral Ceremonies

The nationwide lockdown was accompanied by government decrees that suspended funeral ceremonies. This took place in both churches and crematoria and was seen as a major social problem: in fact, the funeral ceremony is a fundamental step in the process of coping with grief. Only a limited number of people could be present to accompany the coffin to the crematorium. There were situations in which more people wanted to attend, and the death care workers had to explain with difficulty that the rules had to be followed, and others in which the people who wanted to be present were quarantined, so no one was present except the funeral director in charge of the funeral service.

“No farewell, no relatives, nothing… Zero. Zero. Ten people at the first lockdown, ten people just relatives, so if there was a friend, they already couldn’t attend. […] I did funerals without anyone I filmed live with Whatsapp the funeral for relatives who were maybe either in quarantine or in isolation or in another region.” (funeral director).

3.2. THEME 2. WORKLOAD

3.2.1. “Huge Numbers” to Deal With

During the outbreak of the pandemic, the workload of death care workers increased exponentially, as the high mortality rate led to “huge numbers” that had to be dealt with. In the crematoria, work had to be organised in shifts to ensure that the facilities could operate around the clock, and on-call duty increased considerably for the funeral directors. In addition, both funeral directors and mortuaries were under constant pressure from hospitals to “close the coffins as quickly as possible”, so the former had to constantly “race” to deliver the coffins in the shortest possible time and facilitate the latter’s encasement of the body and then close them. In general, an increase in overtime was reported across all professions to cope with the heavy workload.

The exponential increase in mortality caused serious problems in the management of spaces, as the facilities were not prepared to receive such a large number of bodies and coffins: from 25 funerals per day in the main city, peaks of around 70 were reached during the COVID-19 pandemic.

Special rooms were used in the mortuaries to accommodate all the COVID-19 bodies. The funeral chambers (chapels of rest) and in some cases even the chapels within the hospitals were used as storage rooms for the sealed coffins.

“So there were rooms where there were coffins on the floor at the time, because maybe there were 20 closed coffins in one room of the [name of hospital]. They used the funeral chambers. Sometimes the chapels were also used: there are often chapels in the mortuary, the chapels were used for Covid coffins. So that’s what it looked like” (funeral director).

The crematoria had to hire external refrigerated containers to accommodate the large number of coffins and store them in appropriate and dignified conditions.

Although the suspension of funeral ceremonies partially reduced the management time of the funeral service and attempts were made to better organise arrival and departure times to facilitate the work of the operators, the high number of bodies to be managed led to an increase in the time required to carry out the activity in the crematoria. Previously, the average time from the arrival of the coffin to the delivery of the ashes was 1/2 days; it increased to 7/10 days at the beginning of the pandemic. In fact, the average daily number of cremations in the main city increased from 24 to 50.

The high number of bodies and sealed coffins and the hectic pace with which the work was carried out on a daily basis also required more time from the operators to carry out all the necessary checks and ensure that they “did not make any mistakes”.

“…In the quiet moments I took it all back in and checked everything again, because during the day there was a lot of movement, the phone kept ringing, a lot of people, and so maybe there was a typo and a date, I don’t know: 11 instead of 12, let’s fix it. That’s taking each other, saying «Okay, everybody stop, let’s get on with it, cross-check, look». We do that on a daily basis, but of course in less time and also with a fresher mind… instead there, with the fiftieth document I see today, I squint, I write nonsense, let’s wait a moment.” (crematorium worker).

Finally, another element that led to an increase in the workload was the greater responsibility placed on the shoulders of supervisors. Not only did they have to keep up to date and orientate themselves with the applicable regulations, but they also had to bear the burden of implementing and constantly monitoring the safety procedures that had to be applied in their work environment to ensure the protection of workers. They also had to be able to answer workers’ many questions about the current situation and make decisions about major changes in working practices.

“…It was coordinating, just learning how to manage and make the right decision, with everyone asking you the question «but now this, the other, how do we do that…», so it was one question that you had to give an answer to… It was intense, really intense…” (crematorium worker).

3.2.2. Overexposure

Although efforts were made to reduce contact with the bereaved, some funeral services were held in the mourners’ homes by the funeral directors. This led to an increased risk of exposure to the virus, especially if the cause of death was not communicated to professionals in time.

“… right at the beginning, a lady called me one day and said, «Huh listen, I wanted to tell you that my aunt did the swab, but I forgot to ask the doctor, she was [Covid] positive», I told her, «Huh well, madam, we dressed her, encased her!», […] Or people who told you, «Listen, three days ago, I accompanied my [deceased] uncle on the hearse… I just wanted to tell you that I’m [Covid] positive», so even on the hearse, at a certain point, we didn’t let anyone on because it was a risk…” (funeral director).

Another factor reported was the failure of the bereaved present at home to comply with the regulations and the failure to report their possible positivity to the virus. Some funeral directors reported several cases of going into homes and finding people without masks there to welcome them. Some of them had COVID-19 and had not thought to communicate this to the professionals.

3.3. THEME 3. STIGMA

An important theme that emerged in the interviews is the aura of stigmatisation that these professionals felt during the pandemic. Some workers reported incidents in which they were treated by customers or laypeople as if they were spreading the virus.

“They were afraid to see us, I think they thought we were a bit of plague spreaders. We sensed it, that is, I sensed it, in the sense of «No, no, I will stay at home, we can solve this differently».” (funeral director).

“I came [home], I came back from work, there were all the neighbours on the balcony sunbathing quietly and someone who was also making jokes because my wife also works in a hospital, saying, «Huh, but you are from the healthcare service, then we have to stay away from you», idiotic jokes… really” (mortuary workers).

Workers employed in crematoria or funeral directing also had to deal with the widespread opinion at the time that they were “making money from death”.

“… I mean, they were all heroes, and the funeral directors were the bitchy arseholes who got rich off people’s deaths.” (crematorium worker).

“«It went well for you, huh!» so… Okay, if you say so… It’s always, «Of course you make money from death, it went well for you last year!»” (funeral director).

This issue is a source of discomfort, if not annoyance, for the participants, who pointed out that although they had a greater economic return than in previous years (which, however, was not as high), it is necessary to consider the context. Indeed, the requested funeral services were much cheaper than traditional ones: as there were no more ceremonies, customers chose simpler (and cheaper) options; moreover, many customers opted for cremation, which requires less money than burial. In this context, some death care professionals still argue that mortality has demographic trends, so they assume that they will work less in the coming years.

“…and now we know instead that [work] will decrease a lot because it is natural. And therefore also at the level of investments that may be made, or simply in the taxes that we will pay… now this year we are paying last year’s high taxes [smiles] and maybe this year we are working less. So you are always there, even from an economic point of view, to travel on sight. That’s another problem in our job, that you do not know what’s going to happen until the end of the year… that means you can make predictions, but only up to a certain point.” (funeral director).

3.4. THEME 4. LACK OF SUPPORT

During the pandemic, while death care professionals tried to reach out to each other to provide funeral services, they also encountered a lack of support on several fronts. Difficulties were reported with general practitioners, some of whom did not want to enter patients’ homes to determine the causes of death (and therefore possible COVID-19 infection).

“Yes, I understand, but if you’re afraid, I’m afraid too… that is, the [Hippocratic] oath… you did it, I have not done it [smiles], that is, I am working, you have taken the oath… Yes, and then in any case, the Prime Minister’s decree said that I must know beforehand in order to intervene, because when I have a Covid [body], I bring a certain type of coffin and the deceased is also cared for differently…” (funeral director).

Further difficulties arose from the lack of co-operation from Civil Status Registrars, especially in the first period, which was the most critical. Despite the high mortality rate in hospitals, the offices did not extend their opening hours to facilitate the completion of the paperwork related to death and did not allow the electronic transmission of the documents until a later date.

Other situations in which workers perceived a lack of support were, in their view, related to the lack of recognition of their professional category. In particular, they had great difficulty in obtaining the PPE required by the regulations, as they did not belong to the “risk groups” to which the equipment had been distributed. Furthermore, although they belonged to the few categories working “in the presence” and in possible contact with the virus, they had not been included in the vaccination plan. This omission was described as very serious and as a symptom of a lack of knowledge and recognition of the professional sector. In fact, only mortuary staff, who are recognised as part of the healthcare sector, were subjected to the first vaccinations. Funeral directors and crematorium workers had to “join the queue” and wait their turn, like the rest of the non-healthcare population.

“…it made me angry, I wrote to the Ministry of Health, to the President of the Republic, I did not know where to write anymore, that the guy who does the maintenance of the hospital boiler was… [vaccinated]. We who went to the mortuary were not a protected category, we went into the houses… […] We were also at the frontline, but nobody paid any attention to us” (funeral director).

“Right during the first lockdown, the first wave, we obviously spent many hours at work, like healthcare workers, because… But nobody, really nobody—neither the media, nor the newspapers, the radio, nobody—paid any attention to the work of the death care…” (crematorium worker).

Of course, working in the death care sector involves being constantly confronted with death. During the pandemic, the very high number of bodies to be managed, the hectic pace with which the work had to be carried out and the impact that the loss of contact with the bereaved had on the staff, as well as the experience of empathising with their suffering, left its mark. They lacked psychological support to share and process their experiences during a traumatic time.

“…neither at the level of the hospital nor at the level of the company. There was no psychological support… No, we had to come to terms with it, as we always have. In the moment of the pandemic, at the height of the pandemic, you do not want that, but as soon as it subsides: «Okay, let’s stop for a moment, let’s sit down, let’s see how you are doing guys. Are you all right?» Then it hits you after a while, huh… […] I think we needed some psychological support.” (mortuary worker).

4. Discussion

The aim of this study was to investigate which psychosocial factors negatively impacted the death care sector during the COVID-19 pandemic. Therefore, the narratives of several professionals from the mortuary, crematorium and funeral directing sectors were collected to understand their experience in depth, and four particularly relevant themes were identified in relation to the critical issues they faced.

The first issue addressed the impact that changing funeral practices had on death care workers. Like all other professions, the death care sector had to adapt to the new health and safety regulations to contain the virus. One important element that emerged from the narratives is the lack of knowledge about the funeral sector on the part of the institutions. The regulations were issued without factual knowledge of the context in which they were to be implemented and without the involvement of the professionals concerned. Unfortunately, this situation is not limited to the local/national context but has also been highlighted at the international level (Clavandier et al. 2021). The new regulations for the treatment of the body specified disinfection, isolation and immediate closure, thus excluding any type of contact by staff. On the one hand, this procedure should have met the need for prevention and protection, as there was no scientific evidence of the possible infectiousness of the bodies. Indeed, the treatment of the bodies of those who have died in epidemics is an issue whose practical, socio-cultural and ethical implications remain to be clarified (Suwalowska et al. 2021; Mahajan et al. 2020). On the other hand, one of the main impacts that the change in work activity had after the introduction of this new procedure was the loss of a central aspect of the role of funeral directors and mortuary staff. One of their main tasks is to take care of the body and hand it over to the bereaved well cared for and well placed in a coffin. This is in fact an important element in facilitating the final farewell to a loved one and thus easing the grieving process (Colombo 2022; Thompson 1991). In the absence of this fundamental part of the work, the professionals experienced “emptiness” and a sense of dehumanisation in the face of all these “faceless bodies”. Furthermore, the lack of the usual contact with the bereaved called into question the meaning of their work: if they could no longer offer (psychological and practical) support to families at the loss of a loved one, “what were they doing?”. To compensate for this negative feeling, all professions tried to somehow dignify the deceased despite the strict regulations: from mortuary workers and funeral directors, who placed their clothes over the body bag before closing the coffin, to crematoria, who found dignified solutions for storing the coffins. The suspension of funeral ceremonies was another restriction related to the containment of the virus, which unfortunately had far-reaching consequences on a social level (Carr et al. 2020; Zavattaro et al. 2021; Mas’amah et al. 2023), which funeral directors tried to compensate for by taking the place of absentees and/or filming the event to allow people to attend remotely (Clavandier et al. 2021).

As a result of the exponential increase in mortality, the daily workload increased considerably, which led to several difficulties. First and foremost was the need to provide funeral services which required a considerable commitment from the staff. Work shifts were organised and increased, a lot of overtime was worked, and constant availability was required. Another problem which the staff were not prepared for was the storage of bodies and coffins, which arrived in considerable numbers compared to the maximum capacity of the premises. To deal with this new situation, it was necessary to utilise the existing rooms differently and, as in the case of the crematoria, to rent containers that could hold all the coffins. The latter solution in particular is due to the professionalism with which funeral work is carried out, i.e., the desire to preserve the dignity of the deceased, who would otherwise have been roughly “piled up” outside, at the mercy of climatic conditions that were not always favourable. As they had to guarantee a public service, these professionals always worked during the pandemic, taking a serious risk of contracting the virus (Van Overmeire and Bilsen 2020). Funeral directors in particular took a considerable risk, as they had to visit the homes of the bereaved, albeit to a lesser extent than before. Failure to comply with current regulations, such as not wearing a mask or not reporting the infectiousness of corpses or bystanders in a timely manner, created a state of overexposure to biological risk. These behaviours were attributed by the interviewees to a lack of consideration for death care work.

Another important topic that emerged from the participants’ stories is related to stigma. Death care work has always been associated with stigmatisation (Thompson 1991) and still is due to the denial of death in contemporary society: those working in this sector are in fact “a living symbol of a dreaded subject” (Stephenson 1985, p. 223). One of the main factors why these professionals are surrounded by stigmatisation is that they earn their living from activities that are still considered taboo and are seen as those who make money from the death and suffering of others (Thompson 1991). Although death care workers have attempted to combat this aura of stigma over time by emphasising and reinforcing their professionalism and the importance of their work (Thompson 1991; Guidetti et al. 2021), it appears that their efforts were thwarted during the pandemic in favour of a return to stereotypical views. They are people who get rich from death and even become spreaders of the virus. Although these professionals are used to living with a certain aura of stigma associated with their profession, this feedback from public opinion was perceived negatively and as a lack of recognition of the value of their profession and the active contribution they made during the global crisis.

A final theme that emerged in the interviews was related to the lack of support perceived by the death care sector. In particular, a lack of co-operation between general practitioners and Civil Status Registrars was reported, which made it difficult to carry out the work. The decision not to include the death care sector in the vaccination plan caused disappointment—if not anger—and was perceived as a further lack of recognition of their professionalism and commitment “on the frontline” during the pandemic. In addition, the lack of psychological support to deal with the traumatic experiences during the pandemic was perceived as showing a disregard for the risk that their profession entails.

Our study has provided a deeper understanding of the critical issues faced by those working in death care in Italy during the recent pandemic. Some of the problems identified have also emerged in other international contexts. Clavandier’s (Clavandier et al. 2021) study, for example, reports on the difficulties in applying the new regulations imposed by the government in the field of death care in France and Switzerland, the increase in workload and the impossibility of caring for the body and the relationship with the bereaved. Turner and Caswell (Turner and Caswell 2020), on the other hand, addressed the critical issues surrounding the changing nature of funeral ceremonies and the role of death care workers in the UK during the COVID-19 pandemic. Although some studies have addressed the issue of biological risks during the pandemic for this professional context (Mahajan et al. 2020; Van Overmeire and Bilsen 2020), it should be noted that the issues related to non-inclusion in the state vaccination plan had not yet emerged. An important element that emerged in our study is also the experience of stigmatisation of death care workers, which appears to have worsened during the pandemic.

These results are also consistent with the theoretical framework of the JD-R theory (Demerouti and Bakker 2023). It has been shown how the pandemic has profoundly changed the working context of death care. The psychosocial demands identified are closely related to the introduction of new procedures that brought new challenges, such as the absence of important parts of their professional role, a high workload and responsibility and stigmatisation, all conditions that had a significant impact on their professionalism and the meaning of their work. According to the JD-R model, challenging demands can lead to negative outcomes in the form of lower motivation and commitment, as well as a deterioration in the employees’ psychophysical health. Some of these aspects have already been highlighted in the context of death care during the pandemic period, such as burnout, work-related stress, depression, anxiety, compassion fatigue and secondary traumatic stress (Durand-Moreau and Galarneau 2021; Hicks et al. 2022; Van Overmeire et al. 2021; Grandi et al. 2023). It is therefore essential to draw public attention to this overlooked occupational context in order to identify its critical aspects and take effective measures to promote and maintain the physical and psychological well-being of employees, also with regard to the medium-term impact of the pandemic on mental health. Despite the important results that this study has produced, its limitations must also be taken into account. For example, this study did not investigate how differently the difficulties were perceived by newly hired and experienced workers. Further research is also needed to understand what resources can counterbalance the negative effects of these demands and encourage a possible motivational process in these difficult times.

5. Conclusions

From the results of this study, it is clear that most of the challenges faced by the death care professionals during the COVID-19 pandemic were largely due to a lack of knowledge about the professional sector, both on the part of the government and public opinion. Surprisingly, while much attention was paid to the healthcare sector—which tried to “save lives”—little was paid to those who cared for the dead (a failure of the healthcare system, some may say). In this context, the following question arises: what would have happened if the death care sector had not guaranteed funeral services? Based on the findings of this study and this final question, it is hoped that a greater awareness of the role of these professionals can arise. While research in this area is slowly expanding, particularly with quantitative studies that aim to measure and understand the relationships between certain factors which death care workers faced during the pandemic (Grandi et al. 2023; Van Overmeire et al. 2021; Durand-Moreau and Galarneau 2021; Grandi et al. 2024), it is important to remember the role that qualitative research can play in this area. Precisely because, as we have seen, the death care sector is little known, capturing the lived experience of these professionals can help to better understand the underlying—or hidden—dynamics that they deal with on a daily basis and that would be difficult to measure. Furthermore, by overcoming the taboos of engaging in “dirty work” and the fear of their own personal resonance in relation to death and bereavement, researchers could engage in immersive ethnographic experiences that allow them to see the challenges that death care workers deal with on a daily basis “with their own eyes”.