Psychological Consequences of the Delay in the Silent Mentor Programme During the COVID-19 Pandemic: Perspectives From Family Members of Silent Mentors

Introduction

The 2019 coronavirus disease (COVID-19) outbreak was first reported in Wuhan, China, in December 2019. Since then, it has become a global health challenge and resulted in significant disruption in the well-being and general flow of social life and education. As of mid-September 2020, there have been nearly 29 million infections of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19 (World Health Organization, 2020). As in many countries around the world, Malaysia, located in southeast Asia, has been significantly impacted by the COVID-19 pandemic. Malaysia announced the first three cases of COVID-19 on 25 January 2020. The rapid increase in COVID-19 cases prompted the government to introduce confinement measures to contain the epidemic. The country implemented a nationwide Movement Control Order (MCO) to curb the outbreak on 18 March 2020. The MCO included self-isolation and in-home confinement; closure of schools, higher education institutions and ‘non-essential’ businesses; a general prohibition of mass movements including for religious and social events; and suspension of cultural activities. Malaysia has gone through four MCO phases, with each phase lasting two weeks (18th March to 31st March 2020, 1st April to 14th April 2020, 15th April to 28th April 2020, and 29th April to 12th May 2020). A Conditional Movement Control Order (CMCO) was implemented from 13 May to 9 June, and a Recovery Movement Control Order (RMCO), with more lenient restrictions, have been in effect from 10 June to 31 August. The RMCO phase was recently extended until the end of 2020.

The silent mentor programme (SMP, formerly named as “Cadaver Donation and Caring Unit”) was established in 1996 by the Department of Anatomy, Tzu Chi Medical College (now known as Tzu Chi University, Taiwan). SMP is a pioneering form of medical education based on either formaldehyde-embalmed or freezing preserved bodies donated by registered pledgers. The students are required to know the identity and life history of the donors, and regard them as teachers or mentors. The aim of the program is to provide knowledge, skill training, and to infuse elements of humanity into the training program. The programme involves a series of sessions that include 1) home visits, 2) brief introduction of the silent mentors, a day before the workshop, 3) initiation ceremonies, on the day of the workshop, 3) gratitude ceremonies and, lastly, 4) the sending-off ceremony. Attending the SMP sessions is a precious and memorable moment for family members of the silent mentors. The gratitude and sending-off sessions of the SMP ceremonies serve to pay respect to the selfless contribution of the silent mentors and bid them a noble farewell. However, due to the MCO for the pandemic, these ceremonies could not be held as scheduled.

The COVID-19 pandemic has affected the educational system in Malaysia, leading to the closures of schools, universities and colleges. The pandemic has presented a unique challenge to medical schools; in particular, the pandemic has led to unprecedented conditions for holding the 30th SMP, which was scheduled for April 2020. One of the greatest emotional turmoil faced by family members of silent mentors is holding the SMP, because there is a delay before their loved ones may be laid to rest. In the conventional SMP, the delay can be 1–6 months after death. In Malaysia, many funerals and burial rituals or traditions are still maintained and practised by society at large. Customs concerning holding funerals may trigger social and personal uneasiness for many in the community. Negative emotions and grieving among relatives of silent mentors associated with holding or delaying the funeral had been common even prior to the COVID-19 pandemic. Family members of mentors often have to battle the bereavement and grief associated with the funeral delay (Rajaendram, 2018). They had often been pressured by relatives or friends when they announced their loved one had decided to join the SMP, where some traditional rituals cannot be performed and an immediate funeral cannot be carried out (Rajaendram, 2018). The postponement of the SMP during the pandemic is anticipated to not only prolong the mourning period but also enhance pressure over the funeral delay. We would anticipate that the grieving of the relatives of silent mentors during the COVID-19 pandemic becomes much more complex and adds to the burden of mental health and psychosocial well-being during the pandemic.

After the number of COVID-19 cases had subdued in Malaysia, the SMP was carried out on 11–16 August 2020, during the CMCO phase. There were a total of six silent mentors in the workshop; the time between the death of mentors and commencement of the SMP session after the pandemic ranged from 8 to 11 months. During the CMCO phase, new rules and regulations were in effect where the authorities placed restrictions on the number of people allowed at key life events (such as funerals) and prohibited large gatherings. Hence, in the SMP initiation and sending-off ceremonies, a limited number of family members were allowed to attend. Children and elderly above the age of 60 years were also prohibited from attending the session due to evidence showing an increased susceptibility to SARS-CoV-2 infection among children (Viner et al.,2020), and because the elderly are more likely to develop a more severe form of COVID-19 (Davies et al., 2020; Zhang et al., 2020). Moreover, a ban on all international travel has caused relatives and friends from other countries unable to travel to our country to bid farewell to the mentors. Due to these restrictions, the sessions were live streamed on Facebook to enable family and friends to attend the events virtually.

In this context, this research explored the impact of a longer period of delay before the funeral and the uncertain wait among the family members of silent mentors during the COVID-19 pandemic. The second objective was to provide descriptive insight into the impact oftravel restriction enforcement and the adaptation to ‘new norms’, which entail social distancing in every aspect of life, in the conduct of the SPM ceremonies. Without an effective vaccine or treatment, it is uncertain when the pandemic will end; thus, the SMP sessions will likely continue to adopt precautious measures with limited interaction among students and family and friends of the silent mentors. The viewpoints from the family members of silent mentors in this qualitative study will provide important insights to improve the conduct of the SMP sessions to minimise emotional and psychological issues in preparation for future epidemics.

Methods

We approached close family members of the six silent mentors of the 30th SMP to participate in the in-depth interview. Between 16 and 27 August, seven first-degree relatives of silent mentors agreed to participate. We conducted four interviews face-to-face after the sending-off session. Three other interviews were carried out via telephone due to social distancing practice and logistical reasons. We used an empirical phenomenological approach to obtain detailed descriptions of the experiences of the participants during the waiting period before the SMP.

We first asked a broad data-generating questions: ‘Please tell me about your feeling about holding the silent mentor programme?’ and ‘Please tell me about your experiences of the virtual attendance of the silent mentor sessions?’. We used open-ended follow-up questions to obtain detailed descriptions, for example: ‘What is the difference between the traditional physical event and virtual events?’ and ‘How did you or your family members feel attending the virtual sessions?’. We also used probing questions, such as ‘Please tell me more about the delay of funeral.’ and ‘How did you respond to queries from family members?’, to enhance the depth of the discussion.

Data collection occurred concurrently with data analysis. We audio-recorded the interviews and then transcribed them verbatim. The interviewer reviewed the transcription for accuracy. The interviews were conducted in English, except for two that were conducted in Chinese. Interviews conducted in Chinese were transcribed and translated to English and then back-translated to Chinese to ensure that the meaning was retained. We analysed the transcripts using an iterative thematic approach incorporating a number of stages to systematically organise, reduce, refine and finally synthesise the data (Braun & Clarke, 2013). We used the qualitative software QSR-NVivo 10 to manage, code and analyse the data (QSR International Pty Ltd, 2012).

Ethical Considerations

The University of Malaya Research Ethics Committee approved this study (Approval code: UM.TNC2/UMREC - 999).

Results

We interviewed seven family members of silent mentors. Five of the participants are the siblings of silent mentors and two are children of silent mentors. Most have a college degree (five individuals) compared with secondary school and below (two individuals). The ages of silent mentors range from 41 to 63 years old.

We first asked the participants whether the COVID-19 outbreak in Malaysia has had a tremendous impact on their emotional well-being or psychological health. Most of them reported that they indeed felt worried, fearful and anxious during the pandemic, especially during the MCO periods. Nevertheless, all participants reported that the pandemic did not enormously impact their emotional or psychological well-being.

It is really worrying especially when you watch in the news, but we try not to look at it (news feed) and try to move on with our lives as usual. 52-year-old female, sister of silent mentor

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Figure 1.

The Illustration of Themes Identified From the Data.

Discussion

The COVID-19 pandemic has posed and will continue to pose unprecedented challenges to the psychological well-being of people worldwide (Kontoangelos et al., 2020; Rajkumar, 2020) and likewise among the Malaysian public (Wong & Alias, 2020). It is anticipated that grief during the pandemic will impose additional emotional breakdown for family members of silent mentors due to the postponement of the SMP and the delay in laying their loved ones to rest. The SMP comprises a series of prestigious ceremonies, but the COVID-19 pandemic suspended most of these activities due to nationwide lockdown. When the movement restrictions were lifted, relatives and friends were obliged to bid farewell in live streaming sessions rather than in person. As a consequence, the family members of silent mentors are anticipated to have a double impact from the pandemic: first, from the nearly two-month isolation and home confinement; and second, from the prolonged grief period due to the postponement of the SMP programme during home confinement.

Our findings revealed that the delay in the SMP during the pandemic led to minor psychological disturbances in the study participants. Based on recent studies, the COVID-19 pandemic in Malaysia has had a prominent impact on the economic, psychological and emotional well-being of the general public (Elengoe, 2020; Wong & Alias, 2020). The psychological impact was reportedly most prevalent among the lower socioeconomic groups in Malaysia (Wong & Alias, 2020), similar to other countries (Abrams & Szefler, 2020; Takian et al., 2020). One possible reason that the study participants did not experience a tremendous impact could be that most of our interviewees are highly educated and, hence, less likely to encounter enormous social and economic hardships from the pandemic.

Our findings indicate that self-coping styles played an important role in maintaining their mental health because the majority of the participants reported that they were able to cope by themselves and bearing in mind that fulfilling the wish of the mentors matters most. Negative emotions appeared more pronounced among the elderly relatives in the family. Older individuals have stronger traditional beliefs surrounding death and funeral or burial rituals; hence, they tend to face greater psychological impact. In addition, due to generation gaps, older individuals may be unaware of the impacts related to the COVID-19 pandemic, a factor that makes it difficult to understand the restriction regulations issued for COVID-19 mitigation (Banerjee, 2020). This perhaps explains why the elderly family members are more vulnerable to negative emotions of the delay in laying their loved ones to rest. Therefore, safeguarding the psychological well-being of the elderly during an infectious disease pandemic is of the utmost importance owing to their emotional vulnerability as well as the proportionately higher risk of infection and severity of disease outcomes in that population (Chen, 2020; Davies et al., 2020). The constant queries by the elderly family members may have also had psychological effects on others in the family. Hence, our findings imply the need to establish an early support system for family members, particularly for the elderly, such as interpersonal interactions with assistants from counsellors to facilitate dealing with the psychological burden of elderly family members.

One of the issues that emerged was the concern over the physical condition of the body during the prolonged storage: some worried that the increased storage time may lead to their loved one not being suitable as a silent mentor. Family members should be informed that the mentors are preserved at a temperature of -17°C, which will allow the bodies to be preserved indefinitely (Sharma et al., 2012). We found that constant communication with the programme manager helped alleviate their concerns and answer their queries. Given that the COVID-19 pandemic is still an ongoing crisis and there has been a resurgence in COVID-19 cases in many countries (Anderson, Heesterbeek, et al., 2020; Anderson, Hollingsworth, et al., 2020; Ruktanonchai et al., 2020), our study provides important insights for the SMP in other countries, such as Taiwan, Singapore and Myanmar, of the importance of proper communications to moderate the emotional impact associated with the delay of the programme and holding the funeral during the COVID-19 pandemic or other future crises.

The participants expressed positive and negative emotions with regard to live streaming the ceremonies due to attendance restrictions. The gratitude and sending-off ceremonies are regarded as important final events; hence, not being able to physically attend the sessions may cause remorse, particularly for close elderly family members of silent mentors. Having these sessions live-streamed was generally accepted. One advantage of the live streaming was that it was regarded as a form of emotional release to many who intended to come but who were unable to do so because of the pandemic. On a positive note, live streaming allowed virtual attendance of a larger audience, including friends and colleagues of silent mentors’ relatives. In the past, the SMP sessions had been video recorded and uploaded to the SMP Facebook and website after the sessions were completed. Our participants suggested that the live streaming sessions should continue in the future.

Some limitations of our study warrant discussion. First, the goal of this qualitative study was not to generalise but rather to provide a rich, contextualised understanding, as well as insights, experiences and opinions. The second limitation lies in the small number of participants owing to challenges in conducting interviews during the COVID-19 pandemic. Thirdly, all information obtained from the interview was self-reported and reporting bias due to tendency to respond in a more socially desirable manner might exist. However, these limitations should inspire further research. Additional research with a larger number of family members would be useful to provide empirical evidence on how a crisis such as the COVID-19 pandemic impacts health promotion.

Conclusion

The SMP ceremonies are prestigious and dignified moments for family members of silent mentors to mark their loved one’s invaluable contributions, to pay their last respects and to bid farewell. However, the traditional format of these ceremonies has not been possible due to the restrictions imposed during the COVID-19 pandemic in Malaysia. Nearly two months of home confinement coupled with the prolonged grief period due to the postponement of the SMP programme had little impact on the physical and emotional well-being of family members of silent mentors. We found that the delay increased negative emotions particularly among some elderly family members; however, there was no prominent negative effect on their functional health and well-being. Nonetheless, when holding the SMP in the future – be it in the COVID-19 pandemic or any emergency crisis – constantly reaching out to the family members of mentors to identify individuals who need psychological or mental support is essential. Although virtual events do not offer the same experience as the traditional physical events, they have the advantage of drawing a wider audience. This study has important implications to ensure better preparedness for future pandemics.