Town hall 1: Everybody hurts

0:00:00.000,0:00:05.340
Hello everyone. Hello, hello. Welcome 
come on in. Thanks so much for taking time 

0:00:05.340,0:00:08.760
in your day to be here with us. My 
name is Amy Van Es and I’m going to  

0:00:08.760,0:00:15.660
be your host and discussion moderator today for
this session. I’d like to begin by acknowledging  

0:00:15.660,0:00:20.160
the land on which McMaster University is
located which is the traditional territory  

0:00:20.160,0:00:24.180
of the Haudenosaunee and Anishinaabe 
Nations and within the lands 

0:00:24.180,0:00:27.960
protected by the Dish with One Spoon 
Wampum Belt. The wampum uses the  

0:00:27.960,0:00:32.220
symbolism of a dish to represent the
territory and one spoon to represent  

0:00:32.220,0:00:35.760
the people who share the resources of 
the land and only take what they need. 

0:00:36.300,0:00:40.560
We seek a new relationship with the 
original peoples of this land one based  

0:00:40.560,0:00:44.820
in honour and deep respect. May we be
guided by love and right action as we  

0:00:44.820,0:00:48.300
transform our personal and institutional 
relationships with our Indigenous 

0:00:48.300,0:00:52.980
friends and neighbours. It’s in 
the same spirit that I welcome  

0:00:52.980,0:00:56.880
you all of you to the first of three
town halls on moral injury and moral  

0:00:56.880,0:01:00.840
distress in healthcare providers during 
the COVID-19 pandemic. This work is 

0:01:00.840,0:01:04.200
supported by the Public Health Agency of 
Canada as part of their work to address  

0:01:04.200,0:01:09.540
PTSD and trauma in those most affected
by COVID-19. Over the past two and a half  

0:01:09.540,0:01:12.840
years we’ve heard so much about the strain 
on the healthcare system and on the health 

0:01:12.840,0:01:17.400
care providers due to the pandemic. We owe a 
debt of gratitude to all of the physicians,  

0:01:17.400,0:01:21.600
nurses. Therapists, personal
support workers, and public safety  

0:01:21.600,0:01:26.160
personnel who, despite facing incredible 
challenges in their daily work lives, 

0:01:26.160,0:01:30.240
still found time and courage to talk 
to us and share their experiences. 

0:01:32.280,0:01:36.480
So this research project seeks to shine 
a light on the impact that the pandemic  

0:01:36.480,0:01:39.120
has had on the mental health of all
those healthcare providers who have  

0:01:39.120,0:01:42.360
given so much of themselves to the service 
of others and continue to do so today. 

0:01:42.960,0:01:47.580
The evidence-based resources and tools we are 
offering to help build mental health literacy,  

0:01:47.580,0:01:51.360
supports and resiliency
are our healthcare salute,  

0:01:51.360,0:01:54.360
our way of saying thank you 
so much for your service. 

0:01:58.260,0:02:02.160
So oh so one more thing actually before we 
get into the meat and potatoes of today’s  

0:02:02.160,0:02:04.560
topic. I wanted to let you know 
that there will be time for our 

0:02:04.560,0:02:08.220
speakers to answer questions towards 
the end of the hour, so feel free to  

0:02:08.220,0:02:11.820
put the put them in the chat or use the Q&A
function and someone on our team will take  

0:02:11.820,0:02:16.980
note of them and we can address them later 
on. So to begin our program today we’re 

0:02:16.980,0:02:21.660
going to first watch a pre-recorded presentation 
by Kim Ritchie and Andrea D’Alessandro,  

0:02:21.660,0:02:24.900
both who join us live today
as well. In the talk they’ll be  

0:02:24.900,0:02:28.260
diving into some findings from their recent 
research about moral injury and healthcare 

0:02:28.260,0:02:32.520
providers during the pandemic. I’m going to tell 
you a little bit about each of them before we uh  

0:02:32.520,0:02:36.360
before we go into the recording so
Dr Kim Ritchie is a postdoctoral  

0:02:36.360,0:02:39.720
research fellow in the Department of 
Psychiatry and Behavioural Neurosciences 

0:02:39.720,0:02:43.860
here at McMaster. She holds a PhD in 
Rehabilitation Science from Queen’s  

0:02:43.860,0:02:47.340
University and is a registered nurse
with extensive clinical experience  

0:02:47.340,0:02:50.700
in mental health, geriatric mental 
health, and professional practice. 

0:02:52.020,0:02:55.980
As I mentioned before, Kim is involved in this 
research project meant to develop an understanding  

0:02:55.980,0:03:00.300
of the unique and shared lived experiences and
psychological impacts among healthcare  

0:03:00.300,0:03:03.900
providers resulting from their 
work during the pandemic. This

0:03:03.900,0:03:06.540
research will contribute toward 
the development of novel approaches  

0:03:06.540,0:03:10.200
to address the needs of healthcare 
providers and public safety personnel

0:03:10.200,0:03:15.540
during and after the pandemic. Andrea 
D’Alessandro also joins us. Andrea

0:03:15.540,0:03:18.720
is a graduate student of the Neuroscience 
Program also here at McMaster.  

0:03:19.260,0:03:21.300
Her thesis focuses on Respiratory

0:03:21.300,0:03:25.080
Therapists’ mental health and experiences 
with moral injury during the pandemic.  

0:03:25.080,0:03:26.760
Beyond her thesis, work she’s a core

0:03:26.760,0:03:30.600
member of the COVID-19 related moral 
injury and healthcare workers and  

0:03:30.600,0:03:32.820
public safety personnel research team in the

0:03:32.820,0:03:36.540
Trauma and Recovery Lab. I was 
joking with everybody earlier that  

0:03:36.540,0:03:39.120
the titles are a mouthful, so please forgive

0:03:39.120,0:03:45.840
me if I am bungling any of them. Thank you both so 
much for contributing to the discussion today and

0:03:45.840,0:03:48.000
I think we’re ready to take 
a peek at the recording.  

0:03:48.540,0:03:50.820
Hi, thank you so much for the introduction.

0:03:50.820,0:03:55.500
We’re really pleased to give you a 
very brief overview of moral injury  

0:03:55.500,0:03:57.900
and moral distress today along with some of our

0:03:57.900,0:04:03.060
early research findings. As 
everyone knows COVID-19 has impacted

0:04:03.060,0:04:07.320
all of our lives in so many ways 
and for health care providers there  

0:04:07.320,0:04:09.480
have been additional impacts as they’ve really

0:04:09.480,0:04:14.760
served the public in their healthcare 
over the past two years. Moral injury and

0:04:14.760,0:04:17.820
moral distress have drawn 
increasing attention during  

0:04:17.820,0:04:21.240
the pandemic. Although there’s not one unifying

0:04:21.240,0:04:26.400
definition of these terms, they generally 
refer to being involved in or witnessing

0:04:26.400,0:04:32.760
situations that transgress moral values. 
And although many moral challenges were

0:04:32.760,0:04:37.800
present in healthcare providers’ work 
prior to the pandemic, COVID-19 has

0:04:37.800,0:04:41.700
introduced new situations that 
have really presented challenges  

0:04:41.700,0:04:44.880
for healthcare providers as they’ve really strived

0:04:44.880,0:04:50.520
to continue providing the same 
high-quality care while adapting to

0:04:50.520,0:04:51.900
an ever-changing situation.  

0:04:53.220,0:04:57.540
It’s important here to also mention 
that not everyone who experiences these

0:04:57.540,0:05:02.940
types of morally challenging situations 
will develop moral injury or moral

0:05:02.940,0:05:07.260
distress but for those who do, they 
tend to have a range of emotional,  

0:05:07.260,0:05:10.440
physiological, and cognitive impacts such

0:05:10.440,0:05:16.140
as feelings of shame, guilt, 
anger, PTSD and/or depression,

0:05:16.140,0:05:21.000
disruptions in sleep, feelings of 
worthlessness or powerlessness,

0:05:21.000,0:05:27.000
lost in trust of self or others, 
impairments in both work and at home,

0:05:27.000,0:05:30.960
increased substance use, and 
increased risk of suicide.

0:05:32.040,0:05:37.860
Since February 2021, we’ve 
been conducting interviews  

0:05:37.860,0:05:41.160
with healthcare providers 
from across Canada in order to

0:05:41.160,0:05:47.340
understand the impact of COVID-19 on their 
mental health. In our study we asked healthcare

0:05:47.340,0:05:50.280
providers to tell us about the 
types of situations they faced  

0:05:50.280,0:05:53.400
during the pandemic that really have transgressed

0:05:53.400,0:05:57.600
or challenged their moral values 
and beliefs. We’ll briefly share a  

0:05:57.600,0:05:59.880
few of these findings with you today along with a

0:05:59.880,0:06:01.380
quote from the healthcare providers.  

0:06:02.160,0:06:06.120
Throughout the pandemic, and in 
particular during lockdown periods, many

0:06:06.120,0:06:10.320
hospitals had policies that restricted 
visitors from coming to the hospital.

0:06:11.340,0:06:15.060
Although these policies were intended to 
protect patients and staff from infection,  

0:06:15.060,0:06:18.240
many of our participants perceived that

0:06:18.240,0:06:23.220
these policies were a violation of their 
moral values of having family members

0:06:23.220,0:06:29.220
present at end of life and that believed that some 
exceptions should be made in these circumstances.

0:06:30.720,0:06:32.340
Because family couldn’t be there,  

0:06:32.340,0:06:36.900
many healthcare providers stepped in 
and they replaced family at end of life

0:06:36.900,0:06:40.620
holding the hand of these patients. This was also  

0:06:40.620,0:06:43.260
very emotionally difficult 
for healthcare providers to

0:06:43.260,0:06:48.960
take on this role. Healthcare providers 
also told us, and many of these in

0:06:48.960,0:06:51.480
critical care units, they said that morally  

0:06:51.480,0:06:55.320
challenging situations were ones 
that involved decisions around

0:06:55.320,0:07:00.660
resuscitation or prolonged ventilation. 
In these situations healthcare

0:07:00.660,0:07:03.840
providers told us that they felt 
the care that they were actually  

0:07:03.840,0:07:07.020
delivering was denying the patient a peaceful and

0:07:07.020,0:07:12.780
dignified death. Also many healthcare 
providers told us that they experienced drastic

0:07:12.780,0:07:17.760
increases in their workload and this was across 
multiple care settings during the pandemic

0:07:18.300,0:07:23.760
and even more so during times when 
community transmission of COVID was high

0:07:23.760,0:07:28.620
resulting in increased hospital 
emissions. The moral challenges  

0:07:28.620,0:07:30.840
in this situation occurred when patients

0:07:30.840,0:07:34.140
suffered harm from healthcare 
providers’ inability to what  

0:07:34.140,0:07:38.100
they perceived was inadequate 
care or stresses on care from

0:07:38.100,0:07:45.000
high workload and low staffing. We were also told 
about multiple instances of bullying, harassment

0:07:45.000,0:07:49.140
by healthcare providers from 
colleagues or even leadership,  

0:07:49.140,0:07:52.980
and this really left them feeling 
incompetent and demoralized.

0:07:53.580,0:07:59.400
We were also told about an increase in 
violence coming from patients, visitors, and

0:07:59.400,0:08:03.060
families and this was mostly 
during times when there was  

0:08:03.060,0:08:06.240
visitor restrictions or changes in the patient’s

0:08:06.240,0:08:12.360
care. The last area we’ll cover today 
is that many healthcare providers talked

0:08:12.360,0:08:16.380
about moral challenges related 
to decisions made by healthcare  

0:08:16.380,0:08:19.320
organizations. They felt that some of

0:08:19.320,0:08:21.600
these decisions may have negatively impacted  

0:08:21.600,0:08:25.080
patient care when it came to bed 
or even equipment allocation.

0:08:26.040,0:08:28.020
Healthcare providers in these situations  

0:08:28.020,0:08:32.040
perceived a disconnect between the 
values of management and hospital

0:08:32.040,0:08:36.300
leadership, and those of frontline 
healthcare providers. This resulted  

0:08:36.300,0:08:38.700
in feelings of betrayal. Now we’ll turn

0:08:38.700,0:08:43.980
it over to Andrea, who will share some 
of our other results. Thank you, Kim.

0:08:44.880,0:08:48.240
In addition to interviewing 
healthcare workers throughout 2021,  

0:08:48.240,0:08:50.580
we also ask Canadian healthcare workers to

0:08:50.580,0:08:53.700
complete an anonymous survey online. On this slide  

0:08:53.700,0:08:56.640
here I’m showing you some of 
our data of a subset of our

0:08:56.640,0:09:00.000
healthcare workers, so among 
respiratory therapists. We wanted  

0:09:00.000,0:09:02.280
to understand if respiratory therapists were

0:09:02.280,0:09:06.660
considering leaving their positions 
during the COVID-19 pandemic. What  

0:09:06.660,0:09:09.660
we found was that in the spring of 2021 one in

0:09:09.660,0:09:12.720
four of the respiratory therapists 
that we surveyed were considering  

0:09:12.720,0:09:14.640
leaving their position due to moral distress.

0:09:15.240,0:09:17.820
Interestingly those who were considering leaving  

0:09:17.820,0:09:22.200
were characterized by greater adverse 
psychological outcomes. So those

0:09:22.200,0:09:26.220
considering leaving scored significantly 
higher in terms of symptoms of depression,  

0:09:26.220,0:09:28.440
anxiety, moral distress and

0:09:28.440,0:09:34.560
PTSD. Interestingly when we ran predictive 
models to understand factors that may

0:09:34.560,0:09:36.960
increase someone’s likelihood of considering  

0:09:36.960,0:09:40.980
leaving, we learned that having 
considered leaving a position in

0:09:40.980,0:09:43.260
the past and endorsing system-related  

0:09:43.260,0:09:46.740
sources of moral distress (so that’s 
distress coming from organizational

0:09:46.740,0:09:51.240
factors like low staffing or low 
resources) along with PTSD symptoms,  

0:09:51.240,0:09:54.000
these three predictors actually increase the

0:09:54.000,0:09:56.400
odds of current consideration to leave  

0:09:56.400,0:10:00.540
but what this analysis also revealed 
was that the contribution of the mental

0:10:00.540,0:10:03.600
health variables in predicting 
intention to leave was very,  

0:10:03.600,0:10:06.960
very low and actually past 
consideration was the driving

0:10:06.960,0:10:10.860
factor in terms of whether the respiratory 
therapist was currently considering leaving.  

0:10:11.760,0:10:13.560
These results tell us that although

0:10:13.560,0:10:15.540
the respiratory therapists who are considering  

0:10:15.540,0:10:19.500
leaving may be in need of even 
further psychological support

0:10:19.500,0:10:22.500
than their colleagues who are not 
considering leaving. This tells  

0:10:22.500,0:10:26.760
us that we perhaps need to look outside 
the individual level to understand why

0:10:26.760,0:10:29.640
respiratory therapists were 
considering leaving. We need  

0:10:29.640,0:10:32.040
to look to organizational factors: those factors

0:10:32.040,0:10:34.200
that may have been consistent between considering  

0:10:34.200,0:10:37.080
living in the past and also at 
the time of our data collection.

0:10:38.580,0:10:43.440
This work among respiratory therapists will be 
replicated among a broader sample of healthcare

0:10:43.440,0:10:46.980
workers to better understand the 
extent of turnover expected and  

0:10:46.980,0:10:49.380
to understand those factors related to turnover.

0:10:51.480,0:10:53.640
This will be a very timely work because the  

0:10:53.640,0:10:56.400
preliminary results that we’ve 
gathered in the latter half of

0:10:56.400,0:11:02.760
2021 tell us that almost half of the 216 
healthcare workers that we surveyed were

0:11:02.760,0:11:09.420
considering leaving their positions. 
As our results indicate the potential

0:11:09.420,0:11:12.540
role that an organization may play in assisting  

0:11:12.540,0:11:15.420
their healthcare workers in terms 
of their mental health and in

0:11:15.420,0:11:16.740
retaining these healthcare workers,  

0:11:16.740,0:11:20.640
we wanted to better understand healthcare 
workers’ perspectives on how their

0:11:20.640,0:11:22.680
organizations and leaders can best support them.  

0:11:23.640,0:11:27.780
In our interviews healthcare workers 
made many recommendations for how their

0:11:27.780,0:11:30.720
organizations and leaders 
can support them. Firstly,  

0:11:30.720,0:11:33.900
healthcare workers want to 
be listened to and validated.

0:11:33.900,0:11:36.240
Healthcare workers want their leaders to know  

0:11:36.240,0:11:39.660
about their experiences during the 
pandemic and the impact that the

0:11:39.660,0:11:44.640
pandemic has had in them and on their 
families as well. This could include arranging

0:11:44.640,0:11:45.900
reflective listening sessions,  

0:11:45.900,0:11:50.100
asking questions to really understand the 
impacts and then validating healthcare

0:11:50.100,0:11:55.440
workers experiences. Healthcare workers know that 
their leaders don’t have quick fixes for many

0:11:55.440,0:11:58.020
of the complex problems that 
they faced during the pandemic,  

0:11:58.020,0:12:01.440
but they need to be supported 
by being heard valued and

0:12:01.440,0:12:08.280
understood. Secondly our healthcare workers want 
to be questioned about what their needs are.

0:12:08.280,0:12:11.520
Healthcare workers are aware 
that they have stressful jobs  

0:12:11.520,0:12:14.580
and they want supports to be able to perform those

0:12:14.580,0:12:18.060
jobs well. During our interviews 
healthcare workers told us that  

0:12:18.060,0:12:20.220
having access to long-term mental health

0:12:20.220,0:12:22.620
supports was one of the most important tools  

0:12:22.620,0:12:26.040
that they believed could improve 
their mental health. Importantly

0:12:26.040,0:12:30.120
these supports need to be informed 
about their role as a healthcare worker;  

0:12:30.120,0:12:32.220
to understand the types of challenges that

0:12:32.220,0:12:33.780
may be unique to their line of work.  

0:12:35.340,0:12:39.060
Finally it’s important that 
healthcare workers are acknowledged in

0:12:39.060,0:12:41.580
terms of the inherent occupational moral  

0:12:41.580,0:12:44.700
stressors that they face daily and 
especially during the pandemic.

0:12:44.700,0:12:48.000
Difficult ethical situations 
are part of most healthcare  

0:12:48.000,0:12:51.720
occupations and can’t always 
be removed from the job, but

0:12:51.720,0:12:54.240
providing healthcare workers 
with adequate training for these  

0:12:54.240,0:12:58.560
situations will be important to prepare 
our healthcare workers. When morally or

0:12:58.560,0:13:00.300
ethically challenging situations arise,  

0:13:00.300,0:13:04.740
discussing them in an open way within 
teams will promote awareness and

0:13:04.740,0:13:07.920
connection among team members and 
remind them that they’re not alone.  

0:13:08.640,0:13:10.740
Now this list is by no means exhaustive

0:13:10.740,0:13:14.700
and further recommendations can be 
found in our moral injury infographic.

0:13:17.340,0:13:19.380
Altogether our research shows that healthcare  

0:13:19.380,0:13:22.980
workers have indeed faced a range 
of moral challenges related to

0:13:22.980,0:13:26.220
their occupation during the 
pandemic. Most of the events  

0:13:26.220,0:13:28.260
that have been described really centered around

0:13:28.260,0:13:32.880
situations that involved a risk or 
potential risk to harm to a patient.

0:13:33.540,0:13:35.220
This may indeed be the moral value that’s  

0:13:35.220,0:13:38.100
transgressed for healthcare 
workers in these situations.

0:13:38.100,0:13:41.880
Further research is needed 
to identify interventions  

0:13:41.880,0:13:45.240
for moral injury and distress 
and to understand the long-term

0:13:45.240,0:13:48.780
Impacts, both psychological and in 
terms of leaving one’s profession.  

0:13:49.320,0:13:51.420
Our research team is dedicated to

0:13:51.420,0:13:55.680
continuing this research and we will continue 
to advocate for our vital healthcare workers.

0:13:57.000,0:14:00.420
With that I’d like to thank you 
for your time today and also thank  

0:14:00.420,0:14:02.820
all of the healthcare workers who participated in

0:14:02.820,0:14:07.680
our study so far. We thank you for your service 
on the front lines of the pandemic. Thank you.

0:14:07.680,0:14:11.460
Thank you for sharing your research Kim 
and Andrea. I really appreciate having  

0:14:11.460,0:14:14.460
your perspective from what you’ve 
learned to this discussion today.

0:14:14.460,0:14:20.880
I’m approaching today’s topic of moral 
injury from a learner’s perspective. I’m

0:14:20.880,0:14:23.700
not a doctor and the topic 
is relatively new to me,  

0:14:23.700,0:14:26.640
so as a member of the public 
living through the pandemic

0:14:26.640,0:14:29.400
it’s hard to grasp just how 
much healthcare providers have  

0:14:29.400,0:14:34.380
given themselves to the care of our 
loved ones during the pandemic. In

0:14:34.380,0:14:40.860
this moment I’m finding myself overwhelmed 
with this feeling of intense gratitude. So if

0:14:40.860,0:14:45.060
you’re in the audience and you’re on the front 
lines, thank you so much for your service

0:14:47.280,0:14:51.240
We’re going to move into the live 
discussion portion of our event today.

0:14:51.240,0:14:54.180
This is a chance to get into the 
nitty-gritty and understand the  

0:14:54.180,0:14:58.320
complexities and nuances of moral injury 
through the lens of work during the

0:14:58.320,0:15:03.300
pandemic. I’d like to welcome Margaret 
McKinnon, Alex Heber, Kim Ritchie and

0:15:03.300,0:15:06.840
Andrea D’Alessandro. I was hoping 
each of you could take a moment  

0:15:06.840,0:15:08.400
to introduce yourselves and tell us a little about

0:15:08.400,0:15:12.540
your involvement in the project and I was 
thinking Margaret maybe we could start with you.  

0:15:13.320,0:15:15.660
Thank you so much Amy and again I just want to

0:15:15.660,0:15:21.180
echo your comments. This project is deliberately 
called “Healthcare Salute: Thank you for your

0:15:21.180,0:15:25.800
Service” and we are so appreciative of 
healthcare workers across the country

0:15:25.800,0:15:29.640
for the sacrifices that they and 
their families have made over the  

0:15:29.640,0:15:32.160
pandemic. We recognize they have been tremendous.

0:15:33.180,0:15:35.400
My name is Margaret McKinnon. 
I’m the Homewood Chair in Mental  

0:15:35.400,0:15:38.400
Health and Trauma and a professor in the 
Department of Psychiatry and Behavioural

0:15:38.400,0:15:41.520
Neurosciences at McMaster University. I’m also a  

0:15:41.520,0:15:44.340
clinical psychologist. I serve as the 
research lead for the mental health

0:15:44.340,0:15:49.500
and addictions research program at St Joseph 
Healthcare Hamilton and I’m a senior scientist at

0:15:49.500,0:15:53.580
Homewood Research Institute. I’ve 
had the privilege of being on the  

0:15:53.580,0:15:56.220
ICU units and COVID units over the course of

0:15:56.220,0:15:58.920
the pandemic to provide mental health supports and  

0:15:58.920,0:16:02.760
really much of that what we saw on 
those units was the motivation for

0:16:02.760,0:16:06.420
this work. To see the suffering of healthcare 
workers and also really wanting to help  

0:16:07.620,0:16:09.120
in these difficult situations.

0:16:14.340,0:16:21.720
Alex, would you like to go next? 
Sure, thanks Amy. My name is Alexandra

0:16:21.720,0:16:27.480
Heber and I am currently the Executive 
Director of the Canadian Institutes for

0:16:27.480,0:16:32.700
Pandemic Health Education and Response, 
which is a knowledge hub that we’re

0:16:32.700,0:16:39.060
creating to host and kind of bring 
together the information from

0:16:39.060,0:16:45.180
a number of projects that have been 
funded by the Public Health Agency of

0:16:45.180,0:16:51.720
Canada, as Amy described at the beginning. 
I’m doing that work and this is one

0:16:51.720,0:16:58.740
of those projects. I’m also currently on 
secondment for my regular job which is Chief

0:16:58.740,0:17:03.000
Psychiatrist at Veterans Affairs 
Canada and I’m also a veteran of  

0:17:03.000,0:17:06.000
the Canadian Armed Forces 
and an associate professor

0:17:06.000,0:17:10.200
at McMaster University. I’m very, 
very honored to be here today.

0:17:11.940,0:17:18.300
Thank you both so much for being here. Kim did you 
want to add a little bit of context too? I know I

0:17:18.300,0:17:22.320
introduced you, but you know it’s 
your time to introduce yourself.

0:17:24.300,0:17:30.780
Thank you so much Amy. My 
name is Kim Ritchie and I’ve

0:17:30.780,0:17:34.080
also had the pleasure of 
being part of this project,  

0:17:34.080,0:17:38.040
it’s really been such a 
privilege. I work as a Research

0:17:38.040,0:17:40.980
Associate in the Trauma and 
Recovery Lab at McMaster University.  

0:17:42.540,0:17:46.560
We really started this project
over a year ago.  

0:17:47.340,0:17:49.740
It’s been a just a wonderful journey

0:17:51.000,0:17:56.160
throughout the pandemic and we’ve really 
felt it as part of our role, part of

0:17:56.160,0:18:01.860
our service towards the pandemic to try 
to capture the stories of healthcare

0:18:01.860,0:18:08.580
providers. To try to understand enough to 
advocate for them throughout the pandemic and what

0:18:08.580,0:18:11.520
they have been going through. Ultimately to thank  

0:18:11.520,0:18:15.000
them for their service and to 
let them know we hear you and

0:18:15.000,0:18:20.340
we really just want to give you a lot 
of gratitude for what they’ve done

0:18:20.340,0:18:27.060
and the stories that we’ve heard throughout. 
Thank you, Kim, for being here. Andrea

0:18:27.060,0:18:27.960
would you like to introduce yourself?  

0:18:28.560,0:18:32.220
Yes, thank you Amy. My name is Andrea 
d’Alessandro and I’m a graduate student,

0:18:32.220,0:18:33.420
one of Margaret’s students,  

0:18:33.420,0:18:38.340
at McMaster. I’ll be starting in the Research 
and Clinical Training stream this fall for my

0:18:38.340,0:18:42.120
PhD. I’ve had the privilege to 
work with this wonderful team,  

0:18:42.660,0:18:44.880
Alex, Margaret, Kim and all the rest of our

0:18:44.880,0:18:48.840
amazing colleagues. Echoing what 
my colleagues have said today, it  

0:18:48.840,0:18:50.580
really has been a privilege to be a part of this

0:18:50.580,0:18:53.820
meaningful work and to get to know 
healthcare workers on the front lines,  

0:18:53.820,0:18:55.920
to hear their stories and to be able to

0:18:55.920,0:18:59.460
amplify their voices so we can 
ensure that they’re well supported.

0:19:00.720,0:19:05.160
Again, a huge thank you to our healthcare workers.

0:19:06.420,0:19:09.300
Wonderful. Well thank you all for being here. I’m  

0:19:09.300,0:19:12.600
really excited to get into the 
nuance and complexity of this

0:19:12.600,0:19:16.260
topic because I know you all have a wealth of 
knowledge to share with our audience today.  

0:19:17.160,0:19:18.360
I’d love to start the conversation

0:19:19.020,0:19:25.980
by defining moral injury, to situate it 
within the context of this project. Dr. Heber

0:19:25.980,0:19:27.360
I was wondering if you could start us off by  

0:19:27.360,0:19:31.140
helping define what moral injury 
is and where it comes from? Sure,

0:19:31.140,0:19:35.100
thanks Amy. And this is really 
going to add to what Kim and  

0:19:35.100,0:19:38.520
Andrea have already explained in their previous

0:19:38.520,0:19:45.060
remarks. I’m going to try and put it 
in a context, in a bit of a historical

0:19:45.060,0:19:51.060
context. This was a term that was first 
developed by those who were looking

0:19:51.060,0:19:58.080
after soldiers who were returning 
from war zones and combat zones. The

0:19:58.080,0:20:03.000
term itself was first used by 
those who were helping veterans

0:20:03.720,0:20:08.880
from the Vietnam war, so 
it’s been around for a long

0:20:08.880,0:20:14.700
time. It was used to describe

0:20:16.200,0:20:22.800
what soldiers were suffering from who found 
themselves involved in situations that

0:20:22.800,0:20:28.500
contravened their own moral codes or 
ethical beliefs. So in addition to any

0:20:28.500,0:20:30.840
other traumatic situations they may have found,  

0:20:31.380,0:20:35.160
there was something that was still 
haunting these folks when they

0:20:35.160,0:20:42.240
returned from war. It was often to do 
with either witnessing situations or being

0:20:42.240,0:20:49.680
in situations where they felt either they 
were powerless to intervene or they couldn’t

0:20:49.680,0:20:55.800
help when somebody else was injured 
or killed, or they saw abuse of other

0:20:55.800,0:21:00.540
people in the war zone. Sometimes it also involved

0:21:00.540,0:21:04.500
feelings of betrayal by their chain of command or  

0:21:04.500,0:21:07.980
leadership. The most striking 
thing about it is that these

0:21:07.980,0:21:13.140
were feelings that really stayed 
with the person and haunted them.

0:21:13.140,0:21:19.140
An example is to think about for those of you 
who know anything about the story of General

0:21:19.140,0:21:25.260
Romeo Dallaire who still suffers from 
moral injury after his experiences of

0:21:25.260,0:21:31.080
leadership in the 1990s in Rwanda where 
he was powerless to stop the slaughter of

0:21:31.080,0:21:37.860
thousands of the residents there. He still 
talks about this moral injury that he suffers

0:21:37.860,0:21:43.140
from. Now we’re seeing these 
same kinds of reactions in

0:21:43.140,0:21:47.100
healthcare workers who served 
on the front lines of COVID 19,  

0:21:47.100,0:21:50.520
often struggling with feelings of having

0:21:50.520,0:21:57.000
been powerless, feeling very distressed 
that they weren’t able to provide for their

0:21:57.000,0:22:01.980
patients what they felt they wanted 
to, for a number of reasons: often

0:22:01.980,0:22:04.080
because of the overwhelming number of patients,  

0:22:04.080,0:22:09.060
how ill the patients were, as 
well as that there just weren’t

0:22:09.060,0:22:14.700
enough of them. Again, that moral distress

0:22:14.700,0:22:20.280
and moral injury also often takes the 
form of feelings of anger and betrayal

0:22:20.280,0:22:27.000
towards their own leadership, who they feel let 
them down, or to their institutions. I think

0:22:27.000,0:22:32.280
Margaret, because of her work 
on the front lines providing

0:22:32.280,0:22:35.385
support to many of these healthcare workers,  

0:22:35.385,0:22:38.040
is going to talk a little 
bit about specific examples.

0:22:39.000,0:22:44.100
Thank you so much Alex. You know right 
from the very beginning of this pandemic,  

0:22:44.100,0:22:45.420
it’s been clear that healthcare

0:22:45.420,0:22:47.700
workers are essentially on war footing.  

0:22:48.540,0:22:51.720
We recognize that the levels of 
distress that many are experiencing are

0:22:51.720,0:22:54.900
very similar to what our military members see in  

0:22:54.900,0:22:58.200
the combat theatre. That’s 
been really an evocative

0:22:58.200,0:23:00.660
understanding of how difficult some of these  

0:23:00.660,0:23:04.380
situations have been. We have 
heard, for example, situations

0:23:04.380,0:23:07.440
Where, due to a shortage of 
personal protective equipment,  

0:23:07.440,0:23:10.200
some healthcare workers were 
asked to wear their masks

0:23:10.200,0:23:13.860
for two weeks and then turn them 
over when they became dirty.  

0:23:14.760,0:23:16.920
You could imagine when you’re risking the

0:23:16.920,0:23:19.380
safety of yourself and, for 
many healthcare workers,  

0:23:19.380,0:23:22.680
even more critically the safety 
of their families to come to

0:23:22.680,0:23:27.900
Work, many felt that they weren’t 
receiving the support or the duty of

0:23:27.900,0:23:31.260
care that that institution had to them. These have  

0:23:31.260,0:23:34.320
been really difficult stories 
to hear, but even more so to

0:23:34.320,0:23:39.540
experience for those on the front line. 
We also know that, as Kim had mentioned,

0:23:39.540,0:23:43.440
many healthcare workers were 
put in that role of becoming  

0:23:43.440,0:23:46.080
essentially family members 
for patients on the units.

0:23:46.860,0:23:50.580
So there were things that we had 
to do throughout the pandemic to  

0:23:50.580,0:23:53.340
protect the safety and the security of the health

0:23:53.340,0:23:55.500
care system and for the greater good,  

0:23:55.500,0:23:59.880
but these were incredibly difficult things 
and some of them did not feel morally

0:23:59.880,0:24:02.640
right to our health care workers. A good example  

0:24:02.640,0:24:06.420
of that would be having to 
turn away the parents of a

0:24:06.420,0:24:09.720
dying child because, at that 
early point in the pandemic,  

0:24:09.720,0:24:13.440
parents and visitors were 
not allowed into the room. We

0:24:13.440,0:24:20.160
certainly heard about these situations. During 
the time I spent on the front lines and also from

0:24:20.160,0:24:23.700
the stories we’ve heard, often 
healthcare workers perceived the  

0:24:23.700,0:24:26.640
care that was being offered as being futile and in

0:24:26.640,0:24:32.220
some cases it was. Healthcare workers were caught 
in that difficult position between families who

0:24:32.220,0:24:38.760
understandably want to hold on to hope for their 
loved ones and providing care that is invasive and

0:24:38.760,0:24:40.320
sometimes painful where, for example,  

0:24:40.320,0:24:46.260
it would take seven people to prone or turn 
over an elderly individual in an attempt

0:24:46.260,0:24:52.200
to help with their COVID illness. 
These were really difficult situations

0:24:52.200,0:24:55.200
for health care and in some cases healthcare  

0:24:55.200,0:24:58.500
workers really communicated to us that 
they felt that it was like torture,

0:24:58.500,0:25:03.240
and that is a very evocative 
term. It’s one that’s hard to hear

0:25:04.200,0:25:09.240
but it is the experience of healthcare workers 
and they’re left with this lingering distress.

0:25:09.240,0:25:14.700
In particular we found moral distress or moral 
injury surrounding some of these situations.

0:25:16.740,0:25:23.700
Thank you for that context Margaret and for the 
really concrete examples of what it was like in

0:25:23.700,0:25:30.840
in the units. Alex, my follow-up question 
is from a clinical perspective: how can

0:25:30.840,0:25:37.080
healthcare workers know if they’re experiencing 
moral injury? And Kim I’d love to learn

0:25:37.080,0:25:42.900
more about what you found in your research 
about this as well. Sure so let me begin.

0:25:44.280,0:25:51.120
I think some of the things that people 
feel are what we’ve been describing, so

0:25:55.200,0:25:57.120
most of us when we go through a

0:25:57.120,0:26:02.880
traumatic or difficult situation, we will 
have a few days, sometimes up to a few

0:26:02.880,0:26:07.860
Weeks, where we’re still very distressed 
by that situation. We may have nightmares,  

0:26:07.860,0:26:09.420
we may have difficulty sleeping,

0:26:09.420,0:26:16.200
we may find that we are reminded of the 
situation, it is popping back into our heads

0:26:16.200,0:26:20.640
at strange times. But generally

0:26:20.640,0:26:28.260
within a few weeks to a couple of months, 
that fades into the background for most

0:26:28.260,0:26:34.740
people. But for some people a lot of 
those experiences and the feelings that

0:26:34.740,0:26:39.840
went along with them, they just 
don’t fade. They linger on, and

0:26:40.680,0:26:46.440
especially people who felt they 
were in these morally compromising

0:26:46.440,0:26:53.880
situations that did not fit with their 
own ethical and moral beliefs and

0:26:53.880,0:26:58.260
Standards, they’re left struggling with that.

0:26:59.640,0:27:03.900
In a way we can compare it to 
an unresolved grief reaction

0:27:03.900,0:27:09.060
where people just can’t get over it 
and they continue to think about it.

0:27:10.920,0:27:15.180
They’re often feeling guilty for 
things they had no control over.

0:27:16.800,0:27:22.260
Then there’s another situation where they had 
faith that those they report to, that their

0:27:22.260,0:27:27.000
leadership would be there in these times 
to help out and take care and make sure

0:27:27.000,0:27:33.960
that they were protected. But what happens 
instead is they feel abandoned. That’s

0:27:33.960,0:27:40.860
another strong part of moral 
injury. When people have these

0:27:40.860,0:27:46.260
feelings at first and then they fade, we 
call it more moral distress. But when those

0:27:46.260,0:27:51.780
feelings last and we just can’t seem to 
get over them, then we will call that

0:27:51.780,0:27:57.360
moral injury. Sometimes what 
can be helpful for people is

0:27:57.360,0:28:02.760
having trusted colleagues. A good team of people,

0:28:02.760,0:28:11.160
that can be helpful. We created a 
project at the beginning of COVID-19 for

0:28:11.160,0:28:15.240
frontline workers. At that time, 
we wondered how are we going to  

0:28:15.240,0:28:19.740
help these people remain okay, ready to work

0:28:19.740,0:28:26.400
and not suffering from some of these aftereffects. 
It was really interesting: when we went and

0:28:26.400,0:28:32.700
asked them “what were the most important 
things for them to feel they’d be able to cope

0:28:32.700,0:28:37.980
through COVID and all the changes that 
were occurring?”, the number one thing we

0:28:37.980,0:28:41.820
were told was “that I feel my leader has my back”.

0:28:43.500,0:28:48.900
I think that’s why we’re coming back 
to that betrayal part of moral injury,  

0:28:48.900,0:28:51.600
that betrayal that people end up feeling.

0:28:52.620,0:28:56.520
Right at the beginning of COVID 
they were telling us that and

0:28:56.520,0:29:04.440
even now, a couple of years later, that they need 
leaders to be there, to step up, to support their

0:29:04.440,0:29:07.440
people. We know this can be helpful for them.  

0:29:07.440,0:29:11.760
I’m going to pass it over to Kim 
because I think she’s got a lot of good

0:29:11.760,0:29:16.560
examples to add to this. Thanks 
so much, Alex that was fantastic.

0:29:17.880,0:29:22.800
We’ve heard a lot in our 
interviews exactly what Alex was

0:29:22.800,0:29:27.900
describing. A lot of healthcare 
providers have talked about this

0:29:28.440,0:29:35.820
ruminating over what they have had to do 
or maybe what they’ve seen or what type

0:29:35.820,0:29:37.020
of situation they’ve been in,  

0:29:37.020,0:29:42.000
and that rumination just doesn’t seem to 
go away. It comes to the point where it’s

0:29:42.000,0:29:48.120
overwhelming and an emotional impact 
comes with it. We’ve heard a lot about

0:29:48.900,0:29:53.340
healthcare providers feeling very 
angry as well. Going back to what  

0:29:53.340,0:29:56.160
Alex mentioned about anger towards the system,

0:29:56.160,0:30:02.880
towards leadership, towards just 
COVID in in general and the types of

0:30:02.880,0:30:09.060
situations they’ve been faced with and feeling 
very let down by the healthcare system as a whole.

0:30:09.780,0:30:12.600
Keeping in mind that prior to the pandemic,  

0:30:12.600,0:30:16.200
healthcare providers were very 
used to making very difficult and

0:30:16.200,0:30:18.360
challenging and morally challenging decisions,  

0:30:18.360,0:30:23.520
but this is different. There’s 
a new added layer on top of

0:30:23.520,0:30:30.840
what was already a challenging situation, 
an under resourced situation. Those

0:30:30.840,0:30:37.080
situations have become worse, amplified. 
Healthcare providers told us COVID has

0:30:37.080,0:30:41.460
made what was there already even 
worse than it is than it was before.

0:30:47.040,0:30:48.540
The other thing that we’ve heard

0:30:48.540,0:30:53.520
a lot about is a sense of negative 
self-talk, negative beliefs about yourself,

0:30:54.900,0:30:59.640
where you might say to yourself 
“I’m a bad nurse” or “I’m a bad

0:30:59.640,0:31:05.280
physician” because of what I’ve done 
or what I’ve seen. It’s trying to

0:31:05.940,0:31:12.900
understand that it’s the situation that you’re 
placed in and trying to recognize that that’s

0:31:12.900,0:31:18.000
part of the talk. The only other 
thing I’ll just add to Alex’s comments

0:31:19.260,0:31:23.400
is that we’ve heard from healthcare providers 
that they feel like they’re living in two worlds:

0:31:26.280,0:31:31.140
they go to work and they’re in 
essentially, as Margaret said, almost in a

0:31:31.140,0:31:37.320
war zone and then they come home. 
They’re trying to function in these

0:31:37.320,0:31:42.420
two worlds. We hear a lot about these 
disruptions and functioning where

0:31:42.420,0:31:45.540
they feel they can no longer 
parent or they can no longer  

0:31:45.540,0:31:49.140
be a spouse or the family member they were before.

0:31:49.140,0:31:52.920
It really shakes your sense of 
self in trying to navigate back  

0:31:52.920,0:31:55.800
and forth between these two worlds that are so

0:31:55.800,0:32:03.120
drastically different. You don’t have a way to 
kind of reconcile them. Kim and maybe Andrea

0:32:03.120,0:32:06.960
as well, I’d love to hear 
your perspective on what are

0:32:08.040,0:32:14.940
healthcare workers saying is helpful once they 
acknowledge that this is this is the way they’re

0:32:14.940,0:32:15.440
feeling?

0:32:20.700,0:32:25.620
Healthcare providers have a 
very strong sense of caring for

0:32:25.620,0:32:31.440
others and they want to serve 
others. They prioritize the needs of

0:32:31.440,0:32:35.880
of the people they care for, the 
families and the patients they care for,  

0:32:36.720,0:32:38.520
especially during the pandemic. As we’ve

0:32:38.520,0:32:46.020
said, they were living in this world that was so 
different, working days and hours and weeks on

0:32:46.020,0:32:51.180
end without breaks, without vacation. Many 
more hours than they may have done before.

0:32:52.560,0:32:56.760
One of the first things is a 
sense of self-compassion. We  

0:32:56.760,0:32:59.340
talk a lot about self-compassion in our

0:32:59.340,0:33:06.540
work. Self-compassion is a term that 
has been around for many years and is

0:33:06.540,0:33:11.940
now being applied to healthcare workers more 
and more, as we’re starting to realize this  

0:33:12.540,0:33:14.400
sense of serving others

0:33:14.400,0:33:19.800
and the need to prioritize your own

0:33:19.800,0:33:25.860
needs too. Self-compassion is about 
being compassionate towards yourself, the

0:33:25.860,0:33:28.020
same way you would be towards someone else. Giving  

0:33:28.020,0:33:31.980
yourself that sense of empathy and 
humanity that you would to your

0:33:31.980,0:33:36.960
patients or your families or your 
friends. That’s one of the first things.

0:33:42.120,0:33:44.820
Many, many times during the interviews,

0:33:44.820,0:33:50.940
healthcare providers said that when they 
completed some of our surveys on moral

0:33:50.940,0:33:56.160
injury, that’s when they first understood 
what they were feeling, which gave them

0:33:56.160,0:34:02.700
a way to understand it. I think that as 
we become more familiar with the term

0:34:02.700,0:34:09.300
“moral injury,” as we talk about it in in 
our healthcare organizations and amongst our

0:34:09.300,0:34:12.900
leadership, then it gives a way to frame what the  

0:34:12.900,0:34:16.800
experience is. I think that’s 
really helpful. It gives us

0:34:16.800,0:34:19.920
a way to understand what 
you’re feeling. Healthcare  

0:34:19.920,0:34:22.020
workers have said that is really helpful for

0:34:22.020,0:34:26.940
them. Andrea, I know, has lots to share with you.

0:34:26.940,0:34:30.120
Yes thank you Kim. I think you said that so well,  

0:34:30.120,0:34:33.780
really giving yourself permission 
as a healthcare worker to

0:34:33.780,0:34:37.740
take care of yourself. It’s so easy 
to be focused on caring for others:  

0:34:37.740,0:34:40.140
that’s part of the heart 
and the humanity for a lot

0:34:40.140,0:34:40.860
of our health care workers,  

0:34:40.860,0:34:46.320
that’s why they got into the field. But in 
these times, recognizing when you may be

0:34:46.320,0:34:48.780
in moral distress or experiencing a moral injury,  

0:34:48.780,0:34:53.040
recognizing that you need to take care 
of yourself and doing that. Something

0:34:53.040,0:34:55.860
we’ve heard a lot about from 
our healthcare workers in our  

0:34:55.860,0:34:58.560
interviews was coping strategies or just self-care

0:34:58.560,0:35:01.500
strategies. Not surprisingly,  

0:35:01.500,0:35:05.100
a lot of health care workers found this 
very difficult to do during the pandemic.

0:35:05.100,0:35:08.280
As Kim mentioned, healthcare workers are often  

0:35:08.280,0:35:10.800
working through stressful 
situations in their field.

0:35:10.800,0:35:16.500
That’s not new, but what was new 
were the barriers: maybe someone

0:35:16.500,0:35:20.220
typically would go to the gym or would 
go out for social time with friends,  

0:35:20.220,0:35:22.500
but with lockdown periods that wasn’t

0:35:22.500,0:35:25.260
Possible in many cases. Additionally,  

0:35:25.260,0:35:28.560
with the added stress and the 
amplified nature of the stress

0:35:28.560,0:35:30.900
during the pandemic, a lot of 
our healthcare workers said  

0:35:30.900,0:35:33.840
that they couldn’t even find the bandwidth or the

0:35:33.840,0:35:35.640
energy to take care of themselves even if  

0:35:35.640,0:35:39.600
perhaps they had done it prior 
to the pandemic. We really see

0:35:39.600,0:35:43.680
in these conversations the need 
to help our healthcare workers  

0:35:43.680,0:35:46.320
create a plan say “What can I do? What can I turn

0:35:46.320,0:35:50.700
to? Who can I call? How can I 
check in with myself?” In our  

0:35:50.700,0:35:52.920
group and in our project we’re developing tools,

0:35:53.940,0:35:55.620
such as the mental health continuum,  

0:35:55.620,0:36:00.060
to allow healthcare workers to read 
common signs of different levels

0:36:00.060,0:36:03.420
of stress, to see where they fit in 
and provide them with supports that  

0:36:03.420,0:36:05.820
would work best for them, to help them to get the

0:36:05.820,0:36:09.480
help that they need. There are 
many tools and we’ll continue  

0:36:09.480,0:36:11.460
to work to make those readily available for our

0:36:11.460,0:36:15.780
healthcare workers. Wonderful 
thank you both. Yes, Alex go ahead.

0:36:18.060,0:36:20.040
Sorry, I’m just reading some of the comments,  

0:36:20.040,0:36:23.340
which made me think of a few more 
things to add if you don’t mind.

0:36:25.500,0:36:29.820
One of the things, Kim mentioned this 
certainly when we were talking earlier, is

0:36:29.820,0:36:33.780
acknowledgement. First of 
all, I think the fact that  

0:36:33.780,0:36:37.080
we are acknowledging this and we are now looking

0:36:37.080,0:36:42.420
at it and saying this exists, there is 
an issue here for healthcare workers.

0:36:42.420,0:36:44.760
It’s for good reason that 
they’re feeling this way.  

0:36:44.760,0:36:48.780
This acknowledgement is the first step to people

0:36:48.780,0:36:53.400
starting to feel better and to also 
get help with how they’re feeling.

0:36:54.000,0:36:59.940
Reframing or, as Kim mentioned, 
self-compassion is really

0:36:59.940,0:37:06.120
important. Why do people suffer from 
moral injury? It’s because they are

0:37:06.120,0:37:11.700
people who care. That’s why they’re struggling 
with these things. These are people who care

0:37:11.700,0:37:14.400
so much about other people and that’s that is a  

0:37:14.400,0:37:19.140
good thing, but it’s not good when 
you suffer. They’re basically very

0:37:19.140,0:37:25.980
good people. Also, and this was commented 
on two times in the chat, having

0:37:25.980,0:37:32.040
supportive and present leadership, that 
your leaders are there with you telling

0:37:32.040,0:37:34.500
you you’re doing a good job and supporting  

0:37:34.500,0:37:38.760
you when things don’t go well, 
that’s incredibly important for

0:37:38.760,0:37:46.260
people. And social support, having people 
who are able to work in teams that get

0:37:46.260,0:37:49.380
to know each other, who can support each other, is

0:37:52.020,0:37:57.120
certainly a way to help prevent 
some of this from happening.

0:37:57.120,0:38:04.260
I know in healthcare that often it just wasn’t 
possible, that sometimes the fracturing of

0:38:04.260,0:38:11.160
that ability to be working in a consistent team 
over time also contributed to these problems.

0:38:11.160,0:38:18.000
Of course, for some people, sometimes getting some 
professional help, some support, some guidance

0:38:18.000,0:38:23.520
some counselling, is very, very 
helpful. Margaret go ahead.

0:38:23.520,0:38:24.660
Thank you so much.  

0:38:25.380,0:38:30.360
You know one thing I just wanted to comment on is 
that this is happening for our front line and it’s

0:38:30.360,0:38:35.940
happening for our leaders too. Just to acknowledge 
the pain and suffering as well of leaders who are

0:38:35.940,0:38:41.580
often put in difficult situations, having 
to make impossible, truly impossible

0:38:41.580,0:38:45.240
choices. We want to acknowledge 
the suffering of everyone,  

0:38:45.240,0:38:48.180
recognizing that moral 
distress and moral injury has

0:38:48.180,0:38:53.940
been a big part of the picture for our leaders 
too. I often think of healthcare as a family and I

0:38:53.940,0:38:55.740
think one of the big challenges we’re facing right  

0:38:55.740,0:38:58.260
now is “how do we put our 
family back together again?”

0:39:01.200,0:39:07.500
Absolutely and I think that’s sort of 
the perfect segue to zoom out for a

0:39:07.500,0:39:13.260
moment and talk about the healthcare system 
in general. Self-care and compassion for

0:39:13.260,0:39:15.900
yourself as a healthcare 
worker is of course important,  

0:39:15.900,0:39:18.720
but also you need to be working 
within a supportive system

0:39:20.880,0:39:25.080
to really truly thrive in in the 
environment you’ve chosen to work in.

0:39:27.060,0:39:31.860
I’ve actually seen this in the comments as well, 
I think Stephen commented that you know all these

0:39:31.860,0:39:34.440
factors that we’re discussing today were important  

0:39:34.440,0:39:38.040
pre-pandemic but they’re 
essential now. I’m wondering

0:39:38.700,0:39:44.220
Margaret what do you think 
these stressors, like turnover,

0:39:44.220,0:39:49.380
short staffing effects of moral injury, 
what does this mean for the healthcare

0:39:49.380,0:39:56.220
industry moving forward? Thank you. I think part 
of the moral distress that is a rising right

0:39:56.220,0:40:00.360
now is around our inability in 
some cases to provide adequate  

0:40:00.360,0:40:03.300
care. We know that many units are running

0:40:03.300,0:40:04.740
short-staffed right now.  

0:40:05.700,0:40:09.240
We’re seeing that many people who are 
very junior to the field are being put

0:40:09.240,0:40:15.240
in positions that would typically be reserved for 
more senior healthcare workers. If we think about

0:40:15.240,0:40:17.160
the continuity of our healthcare system,  

0:40:17.160,0:40:21.240
we know that when we did our initial 
survey of all healthcare workers,

0:40:21.240,0:40:25.620
so all professions across Canada, we 
saw during the delta wave that about

0:40:26.340,0:40:28.260
one in four were considering leaving their  

0:40:28.260,0:40:32.760
clinical position. When we repeated 
this survey during Omicron, what we

0:40:32.760,0:40:37.560
found was in fact one in two healthcare workers 
were considering leaving their positions.

0:40:38.100,0:40:42.000
Past evidence suggests that among those 
who considered leaving their positions,  

0:40:42.000,0:40:43.320
about one-third did leave.

0:40:44.520,0:40:50.700
We cannot afford at this point to lose 
any of our health care workers, let

0:40:50.700,0:40:55.560
alone those who are experiencing this moral 
distress and this moral injury right now.

0:40:56.340,0:41:01.500
Andrea’s work and other work shows that this is 
really driving a lot of what is making people

0:41:01.500,0:41:06.060
consider leaving their profession. I 
think addressing, as Alex was saying,

0:41:07.740,0:41:13.500
giving people words for their experiences, 
providing supports, it’s a way of helping

0:41:13.500,0:41:16.680
individual healthcare workers 
and leaders. It’s also a way  

0:41:16.680,0:41:19.680
of ensuring continuity essentially of our

0:41:19.680,0:41:22.260
health care system, which really is in a perilous  

0:41:22.260,0:41:26.280
situation right now. Again we 
want to say you know we’re so

0:41:26.280,0:41:31.440
grateful to everyone who served. We 
understand those who left positions

0:41:31.440,0:41:33.540
because this was incredible suffering.  

0:41:34.080,0:41:37.740
We really want to support those who 
remain on the front line and in the

0:41:37.740,0:41:41.700
leadership positions because they are 
such a precious resource to Canada.

0:41:48.720,0:41:54.060
In your presentation earlier, Kim, 
we heard a bit from healthcare

0:41:54.060,0:41:57.900
workers about how their employers 
can support them. I’m wondering  

0:41:57.900,0:42:00.060
what other strategies healthcare providers

0:42:00.060,0:42:03.480
suggested could be done at that 
organizational level to support them.

0:42:05.880,0:42:11.220
Thank you. Just adding on to 
the comments that Margaret

0:42:11.220,0:42:18.360
made and that Alex made earlier, we’ve heard from 
healthcare providers that many of them really do

0:42:18.360,0:42:24.480
want to get mental health supports. 
They understand that their job is

0:42:24.480,0:42:29.220
stressful normally and they 
understand that during COVID it has

0:42:29.220,0:42:35.040
just become so much more stressful. 
They find that there’s so many

0:42:35.040,0:42:41.220
barriers in place to getting the types 
of supports that they need. One thing

0:42:41.220,0:42:46.800
that would be really important to look 
at is how do we get really accessible

0:42:47.940,0:42:51.180
supports that can get through 
some of these barriers. Some  

0:42:51.180,0:42:53.220
of the barriers we’ve heard about are that

0:42:53.220,0:43:00.180
healthcare providers, especially those who work 
part-time or casual, don’t have a lot of benefits

0:43:00.180,0:43:05.160
or they don’t have a lot of ability to 
get these types of healthcare support,  

0:43:05.160,0:43:06.540
so they want them to be

0:43:06.540,0:43:11.760
accessible and available. The 
other thing we’ve heard about is

0:43:11.760,0:43:16.860
that they really want the types of 
supports that they get to be tailored.

0:43:23.160,0:43:24.240
We’ve asked the healthcare providers 
that we’ve interviewed “what

0:43:24.240,0:43:27.720
is the most important thing for you to get mental  

0:43:27.720,0:43:30.180
health support?” “If you were to 
get mental support, “What would be

0:43:30.180,0:43:34.140
what would be the most important part 
of that?” and almost everybody has  

0:43:34.140,0:43:37.140
said you have to know the type of work I do and

0:43:37.140,0:43:39.480
the types of situations that I’ve been in during  

0:43:39.480,0:43:43.380
the pandemic. I think that’s 
an added component in terms of

0:43:43.380,0:43:49.920
mental health supports: that we have to 
educate those who provide mental health support

0:43:49.920,0:43:55.620
to understand these things about COVID 
and about the type of work they do in

0:43:55.620,0:43:59.160
order for healthcare providers to feel 
that they’re heard and understood,  

0:43:59.160,0:44:02.100
and not having to repeat things

0:44:02.820,0:44:08.700
over and over. The last thing is having 
long-term mental health supports.

0:44:12.360,0:44:15.000
Something I’ve really learned during this study

0:44:15.000,0:44:21.780
is that that there is a need for 
long-term support for many healthcare

0:44:21.780,0:44:27.300
providers because of the stressful nature of 
their jobs. Many healthcare providers have

0:44:27.300,0:44:30.240
said you know I want to be 
able to do my job better,  

0:44:30.240,0:44:33.240
or not I guess not so much 
better, but to be able to

0:44:34.920,0:44:40.200
also manage my stress and the 
types of mental health strain

0:44:40.200,0:44:44.100
that the work causes even outside 
of the pandemic. I think we really,  

0:44:44.640,0:44:46.560
as a healthcare system, have to look

0:44:46.560,0:44:51.480
at that now too. How can we better support 
our healthcare providers’ mental health?

0:44:54.480,0:44:58.980
Absolutely, thank you. I’m so 
sorry I have a fire alarm going off

0:44:58.980,0:45:04.680
in the background. I don’t know if you can hear 
it. Can you? I’m so sorry, I don’t know what’s

0:45:04.680,0:45:11.700
happening. I’m just going to keep moving here, but 
I really apologize if it’s loud. I think that’s

0:45:11.700,0:45:16.920
a that’s a perfect observation 
to end this fireside chat on.

0:45:17.640,0:45:23.760
Oh, Margaret’s got some things. I just 
wanted to add with respect to mental health

0:45:23.760,0:45:25.680
supports for healthcare workers,  

0:45:25.680,0:45:31.020
one thing in the St. Joseph’s Healthcare 
system in Hamilton and at St. Mary’s in

0:45:31.020,0:45:32.640
Waterloo and also at Homewood Health,  

0:45:32.640,0:45:37.320
we’ve been providing on unit supports 
to healthcare workers. I think this is

0:45:37.320,0:45:44.100
really important. The first time I 
was on a COVID unit, I was actually in

0:45:44.100,0:45:47.340
the storage closet, so I had 
about 36 hours at the hospital,  

0:45:47.340,0:45:50.700
much of that was spent in 
the closet on the unit. When

0:45:50.700,0:45:53.040
nurses and staff came in to change their masks,  

0:45:53.040,0:45:57.600
that was the only time that they 
had for mental health supports.

0:45:58.380,0:46:03.240
That wasn’t the fault of an organization, it’s 
just the way that it was. Things are so hectic.

0:46:03.960,0:46:07.200
There’s really no substitute for 
sitting down on a nursing station,  

0:46:07.200,0:46:10.560
being present, allowing people to come to

0:46:10.560,0:46:14.700
speak to you. One of the most powerful things 
that we could say, as Kim was mentioning, was

0:46:15.480,0:46:17.520
“I recognize that you’re living in a different  

0:46:17.520,0:46:20.580
world right now from people who 
are not involved in health care

0:46:21.660,0:46:27.300
and that your experience is very different when 
you go home. It may be hard to talk about, others

0:46:27.300,0:46:30.840
can’t appreciate or understand 
the circumstances that you face”,  

0:46:30.840,0:46:33.420
and I think for our healthcare workers many don’t

0:46:33.420,0:46:35.820
have time to go to the library or to go to other  

0:46:35.820,0:46:39.960
parts of the hospital. We need to be 
with them and be present on the units

0:46:39.960,0:46:42.720
to provide those supports. 
That’s a really important  

0:46:42.720,0:46:45.360
thing that we’ve learned in Hamilton and Guelph on

0:46:45.360,0:46:51.600
providing supports for healthcare 
workers. Absolutely and I think

0:46:53.040,0:46:59.100
that is also the perfect segue 
into the Q&A session. I see that 

0:46:59.100,0:47:01.980
we have some questions from 
healthcare workers themselves that  

0:47:01.980,0:47:06.060
we’re going to address today. That’s
kind of it for me, I’m going to pass  

0:47:06.060,0:47:10.260
to Teresa, but I wanted to thank you all 
so much for chatting with me and helping 

0:47:10.260,0:47:15.120
me learn about moral injury today. 
I will pass it to you, Teresa. 

0:47:15.780,0:47:20.100
Well thank you very much Amy for your time 
and excellent skills. I’m going to have to 

0:47:20.760,0:47:26.340
recruit you to be a webinar host; 
you’ve got some superpowers there. 

0:47:28.020,0:47:33.060
Amy, I’ll keep you on the stage for now 
to round out the number of people here. 

0:47:36.060,0:47:45.240
If everyone could maybe share in the chat and
and also out loud where can learn more about your  

0:47:45.240,0:47:47.160
research and the data that’s been
presented here. 

0:47:54.900,0:47:59.040
I could start if that’s all right. 
Through our funding from the 

0:47:59.040,0:48:04.920
Public Health Agency of Canada, we are mounting 
a website called Healthcare Salute: Thank you for 

0:48:04.920,0:48:08.220
your service. This will include 
information available in both French  

0:48:08.220,0:48:13.380
and English about the research study,
about resources for healthcare workers,  

0:48:13.380,0:48:18.060
and provide more education around 
moral injury and post traumatic stress 

0:48:18.060,0:48:23.100
injuries. We’ll also have a 
trauma-informed training course 

0:48:23.100,0:48:27.840
for people who wish to support healthcare 
workers or for healthcare workers themselves.  

0:48:28.680,0:48:30.120
We’re going to be
working to enhance  

0:48:30.120,0:48:34.560
cultural sensitivity around 
these issues, seeking to 

0:48:34.560,0:48:38.490
understand the experiences of healthcare 
workers through their own words. We  

0:48:38.490,0:48:42.240
will have video recordings of healthcare
workers speaking about their experiences  

0:48:42.240,0:48:46.980
and in-depth reflection exercises for 
those who are watching the videos to 

0:48:46.980,0:48:51.420
relate it to their own experiences. 
To teach about terms using plain  

0:48:51.420,0:48:54.660
language because we recognize that a
healthcare worker at five o’clock or  

0:48:54.660,0:48:58.440
three o’clock in the morning may be 
Googling “moral injury” and “COVID 19 

0:48:58.440,0:49:03.600
Pandemic” and we don’t want a long description. 
What we want is something that’s accessible 

0:49:04.680,0:49:07.800
and easy to use. This website 
will provide a lot of information  

0:49:07.800,0:49:12.360
about this. We’ve also been publishing our
work and we could send out links to that that work  

0:49:12.360,0:49:17.640
as well. Finally we did prepare a briefing note
for the Canadian government that summarizes these  

0:49:17.640,0:49:22.380
findings and we’ll be able to share that with
participants. There are also some  

0:49:22.380,0:49:26.700
recommendations surrounding these 
findings. That’s very exciting, I 

0:49:26.700,0:49:31.680
think the website is going to be huge. 
Do let us know and I’ll help boost it and 

0:49:31.680,0:49:36.900
promote it with my social media 
presence. Alex, please go ahead. 

0:49:37.740,0:49:45.240
Just to add to that, as I mentioned earlier, I’m 
going to be creating also a web presence that is 

0:49:45.240,0:49:53.460
going to have a host as well and link to
what’s being created in this project,  

0:49:53.460,0:49:57.780
as well as to a number of other 
projects that have been funded by Public 

0:49:57.780,0:50:04.380
Health Agency of Canada. Our website is not up 
yet; it’s probably going to be about another month 

0:50:04.380,0:50:10.260
but it will have this whole host of 
resources as well. The name of it is, 

0:50:10.260,0:50:16.380
the easiest way is to remember the 
acronym which is cipher c i p h e r. This 

0:50:16.380,0:50:21.720
will be the acronym for that website 
and we will link to all of Margaret’s  

0:50:21.720,0:50:24.660
resources as well. Excellent,
this is great. I’m going move on to  

0:50:24.660,0:50:29.520
the next question. An anonymous 
attendee asks “you noted that 

0:50:29.520,0:50:34.080
participants needed to feel their leaders 
at their back. What is the impact of  

0:50:34.080,0:50:36.900
leaders working from home and
not being visible alongside  

0:50:36.900,0:50:41.640
their frontline staff? I found that staff 
feel resentful and more disconnected from 

0:50:41.640,0:50:45.300
Leadership, especially higher-level leadership 
because the leaders are working from home.”  

0:50:45.840,0:50:50.580
Any thoughts on that dilemma?
I’ll go to Andrea, she was nodding.  

0:50:52.740,0:50:54.960
Yes,I think what was said in that 

0:50:54.960,0:50:58.200
comment is exactly what we heard from 
healthcare workers in our interviews,  

0:50:58.200,0:51:02.400
that that was a key source of some of
that betrayal, that part of moral  

0:51:02.400,0:51:06.540
injury where a lot of workers on the front 
lines. Respiratory therapists, physicians, 

0:51:06.540,0:51:09.780
nurses, they’re telling us that they 
have certain needs and experiences,  

0:51:09.780,0:51:14.580
yet decisions are coming from higher up from
people who aren’t there. They’re not  

0:51:14.580,0:51:18.060
seeing exactly what they’re seeing, 
they’re not made fully aware of the 

0:51:18.060,0:51:22.080
concerns and maybe why a certain policy 
or procedure doesn’t make any sense or is  

0:51:23.160,0:51:24.960
elevating stress or
putting the workers  

0:51:24.960,0:51:29.460
out further risk. I think that comes back 
to what we were discussing earlier about 

0:51:29.460,0:51:34.620
the need to listen to the healthcare 
worker. Organization leaders need  

0:51:34.620,0:51:38.820
to simply ask “what can I do to
support you? How can I help you?”  

0:51:39.360,0:51:43.920
and facilitate those discussions about 
creating a space for the frontline 

0:51:43.920,0:51:48.300
workers to share their concerns, to have 
the time to question these different  

0:51:48.300,0:51:51.240
policies/procedures coming up
that maybe they disagree with.  

0:51:51.780,0:51:55.440
If I could comment a bit further in that 
Andrea. Thank you for that great answer. 

0:51:56.220,0:52:00.540
We know that the risks of COVID 
19 were not evenly distributed and  

0:52:00.540,0:52:04.200
that’s a really important thing for
organizations and individuals to  

0:52:04.200,0:52:08.040
acknowledge. There were those who served 
at the very front line who took on the 

0:52:08.040,0:52:12.600
greatest risk for their families and for 
themselves, and that’s an important piece  

0:52:12.600,0:52:16.200
that we can acknowledge. We also know
that for people who were at home,  

0:52:16.200,0:52:20.100
many of them also suffered in the sense 
that they felt guilty that they weren’t 

0:52:20.100,0:52:25.740
there. When we talk about putting 
our family back together again, I 

0:52:25.740,0:52:28.500
think there are some things that we 
just need to have in the open to talk  

0:52:28.500,0:52:34.920
about and help us to come back together.
I think there’s a lot of stress trying  

0:52:34.920,0:52:40.380
to manage things when you can’t
see, and I do think that that’s  

0:52:41.460,0:52:45.360
a challenge. I think that a lot of
people probably had some moral injury even  

0:52:46.860,0:52:49.500
just doing it over Zoom, knowing 
that they’d want to get in 

0:52:49.500,0:52:54.660
there but that’s probably not the best place 
for them. That disconnect can be really hard and 

0:52:54.660,0:53:00.240
even, as you point out, that sharing of 
those perspectives will be important. We  

0:53:00.240,0:53:04.260
have a couple more minutes. I’m
going to ask one more question 

0:53:08.640,0:53:10.380
and this one comes from an ICU nurse,  

0:53:11.040,0:53:19.200
Annie, who has been for the past 14
years a high senior and then she’s transitioned 

0:53:19.200,0:53:24.240
into being an RN psychotherapist. She 
finds that a lot of the co-workers prefer 

0:53:24.240,0:53:30.300
the support of other co-workers, more of a 
grassroots, someone that’s at your elbow, that 

0:53:30.300,0:53:34.200
understands you, that has been going 
through that, versus a third party.  

0:53:34.920,0:53:39.720
I think this probably goes along with
the lack of trust and fractured faith  

0:53:39.720,0:53:43.440
in individuals who don’t have the same 
similar lived experience. What are your 

0:53:43.440,0:53:49.080
thoughts on this and how do we, as 
bedside nurses or leaders, better support 

0:53:49.080,0:53:53.220
these kind of programs for healthcare 
practitioners and professionals?  

0:53:54.120,0:54:01.500
Thank you very much.
We’re going to go to Alex. 

0:54:03.600,0:54:08.340
Let me start out with that one. 
First of all, I think that that is 

0:54:08.340,0:54:15.780
such an important issue. Margaret and Kim 
touched on this earlier, that whole issue 

0:54:15.780,0:54:22.560
of what we call cultural competency. That 
when therapists, when helpers, are trying to 

0:54:22.560,0:54:26.340
help somebody in a particular 
profession, it’s really important  

0:54:26.340,0:54:36.960
that they have some sense of how a person’s work
life and home are affected by the work life. We 

0:54:36.960,0:54:42.000
found that, again if I go back to my military 
experience, that that was really critical. 

0:54:44.700,0:54:50.820
We had people working with our 
folks who really understood what it 

0:54:50.820,0:54:55.500
was like to be in the military. I think 
for healthcare workers this has become  

0:54:55.500,0:54:59.100
more and more of an issue,
especially with the crisis  

0:54:59.100,0:55:06.180
occurring. Yes, cultural competency and
Margaret mentioned that one of the parts  

0:55:06.180,0:55:12.900
of this project is going to be to create
some resources for therapists to help them  

0:55:12.900,0:55:16.380
become more culturally competent in
the world of healthcare workers.  

0:55:18.840,0:55:24.180
Alright, excellent, very snappy. I love
it. All of you should be on talk shows  

0:55:24.180,0:55:30.240
more often. I love it and I think that
there’s just a lot out there right now  

0:55:31.260,0:55:35.340
that we need to digest and it
sounds like there is an upcoming webinar,  

0:55:35.340,0:55:40.860
webinar number two, that all of you are 
invited back to come and interact with 

0:55:40.860,0:55:45.720
us more. Please watch out for that advertising 
for Healthcare Salute Town Hall number two,  

0:55:45.720,0:55:48.480
September 15th. You can
mark it in your calendar,  

0:55:48.480,0:55:54.360
10 to 11 a.m. “Family Interpersonal Impacts”. 
That’s going to be really important so please, 

0:55:54.360,0:55:59.280
please, please jump on in that one. 
It might be a good one to bring 

0:55:59.280,0:56:04.320
a family member or others who have 
been your supports because I think  

0:56:04.320,0:56:09.120
we need to salute all of them as well.
I think that this has been fantastic.  

0:56:09.120,0:56:11.640
We’re going to go to Margaret 
for some closing remarks and then 

0:56:11.640,0:56:16.920
maybe I will also ask Andrea – you have a slide 
with some information that you’re going to share  

0:56:16.920,0:56:21.720
as well so if you want to pop that
up. I really just wanted to conclude  

0:56:21.720,0:56:28.080
by saying thank you again to those who
serve. We really want to also acknowledge  

0:56:28.080,0:56:32.520
that what happened over the past two and a
half years has also occurred within a unique  

0:56:32.520,0:56:36.780
historical context where 
we’ve learned about issues 

0:56:36.780,0:56:40.440
surrounding residential schools and 
the discovery of the bodies of innocent  

0:56:40.440,0:56:44.100
children. We’ve had the murder of George
Floyd and there’s been a historic context  

0:56:44.100,0:56:47.400
that also surrounds this. I 
recognize that many healthcare 

0:56:47.400,0:56:52.980
workers from equity deserving groups went to 
work with not only the burden of the pandemic,  

0:56:52.980,0:56:55.980
but also the current social
Context. We want to really  

0:56:55.980,0:57:00.120
acknowledge that and we will be talking 
about that more as we go forward with 

0:57:00.120,0:57:06.600
this work. We want to also thank our funders who 
helped us to do this research: the Atlas Institute 

0:57:06.600,0:57:10.800
which was formerly known as the Center for 
Excellence on PTSD, Homewood health made an  

0:57:10.800,0:57:13.440
incredibly generous donation to the
Homewood Research Institute,  

0:57:13.440,0:57:18.120
CIHR has been a big supporter, and finally 
the Public Health Agency of Canada for their 

0:57:18.120,0:57:22.800
support to move this this work forward. 
And we just want to thank all of you 

0:57:22.800,0:57:27.300
for your service. That word is 
really meaningful to us here. 

0:57:27.840,0:57:30.960
We’ve worked with the Canadian military, 
we’ve had the privilege of working with  

0:57:30.960,0:57:34.980
the Canadian military, with veterans,
with public safety personnel, all who  

0:57:34.980,0:57:39.120
have also served selflessly throughout 
this pandemic. The word “service” means 

0:57:39.120,0:57:44.340
something to us. We just want to thank you for 
that service that you’ve given, both you and  

0:57:44.340,0:57:47.280
your families, throughout this
pandemic. Thank you.  

0:57:49.140,0:57:52.800
And thank you so much to all of you for
spending the time with us today.  

0:57:54.480,0:57:58.740
I’m just going to give a shout out again 
here to all of you for the great work 

0:57:58.740,0:58:02.640
that you’re doing and I’m hoping that 
people in the audience will feel their  

0:58:02.640,0:58:08.280
gratitude as well and express it and
participate in your research. For all  

0:58:08.280,0:58:11.070
of you who may not know what that 
little squiggle thing in the corner 

0:58:11.070,0:58:14.820
corner is. Probably you do know by now, 
but you can take your phone, open up the  

0:58:14.820,0:58:19.920
camera and you should just put that in the
middle of the shot and it should actually  

0:58:19.920,0:58:23.640
open a hyperlink to be able 
to go ahead and participate in 

0:58:23.640,0:58:29.640
this. We’ve also put a bunch of 
other information about how you can 

0:58:30.300,0:58:35.760
give us feedback about today. I’m going to 
pop that link in the chat as well. We’re 

0:58:35.760,0:58:40.980
really excited to have all of you join 
us. The webinar has been recorded, 

0:58:40.980,0:58:48.000
there’ll be some post-production, and then we’ll 
be putting it on the websites that we’re making. 

0:58:48.660,0:58:53.520
It’ll be shareable on YouTube. We’re 
just really excited to have all of you  

0:58:53.520,0:58:56.880
engaged in this way, so thank you so
much for all your time. Thank you,  

0:58:56.880,0:59:01.560
Teresa. We will also provide simultaneous 
French translation on the recording as 

0:59:01.560,0:59:07.080
well for anyone who would like to watch 
this video in French. Thank you, Teresa, 

0:59:07.080,0:59:09.540
for your support. And Amy: 
thank you to our wonderful host,  

0:59:09.540,0:59:15.780
thank you so much. Thank you for having me
The pre-registration, someone has asked,  

0:59:17.040,0:59:20.460
is not available yet but just hold the
time your calendar and keep an eye out  

0:59:20.460,0:59:24.660
for our social media. I’m sure you 
won’t miss it and we’ll be in touch.