 Hi everybody, this is Donna Cross, our Chief Clinical Officer at the Patient Safety Movement Foundation. We're here to bring you another COVID-19 update. Today we're going to talk about the effective management of mental health and stress during this COVID-19 pandemic. And I'm excited to be joined today by four panelists. We have Kita Franklin from Tennessee here in the United States, and Bernadette Wilson from California, same place as I am here in the United States. But we're also joined by Anka Sarbu from Switzerland, and Ariel Noble from the United Kingdom. So I'd love to go around and have our panelists introduce yourself. Let's start first with Kita. Hi, thank you so much for having me. Yes, I am the Chief Clinical Officer at SiteCub, which is an online education company. My background is in social work. My PhD is in social work where I have had a couple decades of work experience working with our nation's active duty military and veteran populations in the area of post-traumatic stress disorder and trauma and suicide prevention. So I'm happy to be with the panel today. Well, thanks. Welcome. Bernadette. Yes, good morning. I represent this group as an advocate for the patients and also the health care worker. I'm involved with the Patient Safety Movement on some committees, and I just love the organization. I have my masters in business, and I've been in the business environment for quite some time, and I am a practicing trainer and also a neural coach. So I use brain-based technologies to lower stress and really reduce a lot of the outputs that we get from all of the conditions around us. So I'm really excited to be here and kind of bring together the medical environment along with all of our backgrounds. So thank you. Thanks for joining Bernadette. Anka. Hi. Thank you for having me, Dana. It's a great pleasure to join you at the Patient Safety Movement Meeting on Mental Health. As you already know, I'm a Patient Safety Movement Foundation ambassador in Switzerland, in Austria, currently based in Zurich. I work at a mental health care facility only for women as the head of quality management and organizational development. And in the same time, I'm a healthcare innovator with EIT Health, which is a body of European Commission on projects on mental health development, developing tools, and digital strategies for improvement. Thank you. Great. Thanks for joining us, Anka. And Ariel. Hi. Hello. Thank you for having me, Dana. It really is lovely to join all of you. So yes, I'm Ariel Noble. I am the research psychologist and the clinical supervisor at Mental Health Innovations, which is a charity in London. And our first project has been to bring SHOUT, which is a 24-7 digital crisis text line for anyone in the UK, free anonymous to use. It's actually our one-year anniversary this year. We've had over 300,000 conversations. And I am a member of the data insights team, where we are able to effectively evaluate and consider some evidence-based improvements. Great. Well, thank you for joining us. So we have a great panel today, and I'm so excited to start talking about how, well, let's start talking first about what exactly is happening right now. We all know that this pandemic has created a new normal for us. We live in a virtual world with not a whole lot of physical contact. Those with existing mental health issues are finding it challenging to access the therapy and the services that they need. Those healthcare workers on the front line and other essential workers are quite stressed. And those who are dealing with economic hardships are also dealing with some mental health crises right now. So I'd love to just kind of go around. Let me start with Ariel. I'd love to understand what you're seeing in the UK and the general population. What are some of the mental health challenges that you're finding? Yes. So our service currently averages around 25,000 conversations a month. And by the end of March, we found that 25% of our conversations concerned COVID, around 60% of the COVID-related conversations also mention anxiety, which is twice the rate that we usually see. So we have found that anxiety appears to spike in response to major news announcements about the outbreak and have continued to track what concerns people most at different stages of this pandemic. So for example, the trend of conversations mentioning uncertainty has closely matched the trend of conversations mentioning the virus. We're struggling with uncertainty in relation to risk, time and duration, whether we will ever return to a familiar state. And interestingly, these concerns have gradually decreased as we have settled more and more into lockdown. Now in lockdown, we're finding that people struggle more with maintaining a routine. This highlights our challenges with change and evolving to a new normal. This also highlights boredom and our need for distraction. People are feeling trapped with themselves. Distress has become inescapable. We're spending more and more time with ourselves, have less distraction and escape, feel more vulnerable and exposed and suffer from the illusion that this is a bad thing. With limited distraction, we face aspects of ourselves and of our lives that have been buried away unconsciously. Just because we didn't notice before doesn't mean that it wasn't there. And so this can be an opportunity to understand and work through it. However, what we do need is a safe structure to do this well. What we need now is a new structure to self-regulate our distress and developing a healthy routine and lockdown is not only a great way to self-regulate emotionally, but also to regulate our sleep, which has also been impacted. It helps us to reset and is essential to our mental health. I think that's probably true across the world. Anka, your thoughts from Switzerland and the other German speaking countries that you represent. What are you seeing over there? Well, I'm involved mostly at the organizational level and the healthcare administration, which is also a focus area of patient safety movement foundation. And what I can tell you is that since the beginning, lots of measures have been in place in order to ensure the continuous provision of care for inpatients in mental health care facilities. And that was a big focus also in my clinic, in my hospital, where we actually had to reduce drastically the number of beds because of the safety measures, of course, of the patients as well as of the employees. So it was quite challenging at some point. Of course, the pitfall was that the number of beds was reduced and the mental health care patients in need of care was the same or even higher. So we were really struggling for a period of time. But at this point, fortunately, the state measurements have become a little bit more light here in Europe, in the Poldach region. Austria started to open lots of businesses, actually, which is somehow related, of course, also with the mental health status of people. So they can come get back to to normality faster. In Switzerland, we started this enlightening of measurements two weeks ago. In Austria, they started already three weeks ago. So we are actually now recording the developments and we are monitoring closely what is happening in each facility, as well as we have to report to the authorities and, you know, in the German speaking countries, there are these regional health care administrations. So we are actually binding to report to them everything that happens in terms of patient safety in our hospitals in order to be able to decide at regional level if we are keeping our beds at the minimum capacity or we can get back to work for better efficiency. So this would be something that we had to comply with for almost two months. And the worries in my area in clinical risk management and quality management was exactly what is happening with the people in need of inpatient care that were not able to check into any hospital or had to be discharged earlier. Because this was also a measure that was implemented in many of the hospitals in order to reduce the number of beds. So, yes. And until now, the question has been how can we really provide the services we want to do all the patients in need. And thank God, in my hospital, we have been coronavirus free until now. But there have been other cases in long term care facilities, which have been really under critical conditions. And, yes, now I think it's more of a matter of how are we going to be prepared for what is coming next. So that's actually what we're working on right now, more on the preparedness and what Ariel was actually mentioning what is happening with everything that had an impact on the population that was not an inpatient already. And if they are going to come to us now, and how are we going to be able to provide them with needed care? And how have you done that over the last two months that you've had to decrease your inpatient beds? How have you dealt with, how have you treated the patients who typically would have been in an inpatient bed? It was mostly, I think, a very challenging time. But in the same time, it was a very good opportunity for the hospitals, for the mental health facilities to discover so many digital health solutions that were already available on the market, but were not used at their full potential. So what we actually did, it was starting with the triage process. So we actually adapted our triage of patients when we selected them to come to us on a coronavirus basis. So we were actually testing all of them after doing the triage form. And afterwards, we were trying to optimize our services in terms of providing, I'm sorry, in terms of providing monitoring, remote monitoring of patients and teleconferences and telepsychiatric therapy via digital means. So that was mostly, they played a very big role in the care that we provided in the last month. The good thing is, and I can say this from a healthcare innovation perspective, is that we keep going on in this way. And it's so good to see that so many long-term care facilities and mental health care facilities under these circumstances feel obliged, but also more friendly with innovation in healthcare. So these measurements that they implemented during the coronavirus crisis are still in place in the Dach region. In Germany, for example, the use of mobile apps has become a thing, has become reimbursed by the government. And now family doctors are really prescribing these. Whereas in Switzerland, for example, we did not actually the patient pathway once they have symptoms was all digitalized. So everything was happening via phone or video call. They were not going to the hospital unless it was critically bad. So they couldn't even go to the emergency room if they didn't call before. So that was really, really good implemented. Yes, we are really preparing now for the for the second wave and we are all skeptical to see what is coming. And as I told you in terms of the perspective of healthcare administration, as well as healthcare professionals and patients, we are trying to work a lot on the preparedness of our services to be able to cover all the numbers and the wave that is going to come probably after the pandemic, not the second wave of the of the crisis, to be able to allocate all the patients. And we're working hand in hand with the ministries and with the local governments to see how we can actually facilitate the needed care for people who are going to need us. Great. Kita, you know, you talk a lot about what we're doing to help patients at this time. But what are you seeing right now among healthcare workers, whether mental health practitioners or other frontline healthcare workers? How are they, how is the stress manifesting in them right now? Such a good question. I think this is going to be the future here in the US where we've started to see phased opening. You know, the brunt of the first responder sort of trauma related work has largely been on the hands of healthcare workers. And, you know, we have healthcare workers across the spectrum from from new nurses, like my daughter, who's a brand new nurse and who is, you know, working in the emergency room here locally, all the way up to very seasoned nurses who have, you know, who are themselves potentially vulnerable, based on their own, you know, healthcare and family circumstances. And so I think that these are the folks that we're going to be caring for as mental health clinicians and the way forward over the long haul in part, you know, exposure to trauma, also the all the work that's happened. You see a lot of it on the news in the US where frontline workers, hospital staff are, you know, performing in the roles of family members as they've, you know, stood by the bedside of people that are dying by COVID related symptoms and they're using creative IT technology to help them say goodbye to their loved ones when loved ones are not able to be by the bedside. And while that's certainly commendable and heroic and needed and all good, it's also, you know, something that's going to have to get processed by those healthcare professionals in the context of trauma exposure. And, you know, even the best, the best hospital staff out there are, you know, are vulnerable to trauma and to stress issues, stress related mental health conditions. And I just, I feel for that group, I think we're going to be taking care of them for the long haul here in the US. And Bernadette, what about patients and families, folks who are currently having to deal with the hospital system, what are you hearing from folks? Well, I just, one I wanted to say, thank you all of you for your contributions. And Ariel, I wanted to bring forward also that American Suicide Foundation has an app as well that people can text. So maybe after when this is posted, we could put those numbers in there. And it's really, it's really helpful. Sorry, I just wanted, so sorry, I just wanted to actually say thank you, Bernadette, that we have been powered by Crisis Text Line from the US. So that would all certainly be very helpful to share. Thank you for bringing that up. You're welcome. You're welcome. What I think you also highlighted the fact of the unknown, and we know when we don't know and there's change, that puts a lot of stress. That's just our primary instinct. We like to control our environment. So what we're seeing more here on the West Coast versus, I think that was your original question, then versus the, you know, the East Coast of the United States is here in Southern California, we're fortunate when we have the weather. And by nature, we're more outdoor people. So, you know, people have to actually walk around each other to take walks. So they are really following those guidelines for mental health, which is get out, take breaks, you know, have, take a walk, you know, you'll see families riding their bikes together. Everybody's, you know, especially on Mother's Day. We just had Mother's Day. There was a lot of families out, but they're really very, very respectful. I think people have fear. I was speaking to a client yesterday, they have fear going into the grocery store. They have their primary basic needs, people have anxiety around that. And then they're also overburdened with having their children at home and time management and how are they going to do their job and also raise their children that are home and keep them entertained and giving them the best advice as well. So I see this as an extremely complex issue. Then you, and it's also a demographic issue. So we're getting clusters where people are more in a closer confined areas. And then also we all know it's also for the aging population. And one of the things that we were thinking of remedies of, you know, how we're talking right now in the virtual world, there are a few organizations that we can post later also that help seniors with learning how to use technology. I think of my 91 year old, 92 year old father who's served in both of our wars and is just a wonderful man. But, you know, he loves to get out. I mean, he still works on cars, but he could not work a computer for the life of them. So, you know, how are those types of demographics also getting involved? And then I also think about our senior population is many of them have illnesses and they have not been able to see the primary doctor. A lot of them schedule their whole day around going to the physician. I mean, that is a whole ordeal. You know, how long you're going to be there? What are you going to do? It's a social engagement. So they're really not getting that either. So there's so many layers to this and I think just bringing that awareness to it is really helpful. And the other side of it, I also have clients that maybe feel that they can't contribute. And there's a lot of good ways, a lot of positive ways such as if you wanted to volunteer online to help senior citizen studios technology, you're able to do that. And then just one thing, backing it up, when we're just starting now to open up to see patients in the office. There also, we had stopped all of the surgeries, unnecessary surgeries. So now they're doing testing beforehand for the patients. And what limited part about if you go in for a day surgery, bringing in a family or friend, that person will definitely bring a mask. You'll need to have a mask. They're going to be, we're using release forms now. So there's a whole new protocol and that will lead us later on, you know, when we talk a little bit more about a patient's bill of rights and really assuming there's now more an assumption of, you know, taking responsibility for your own personal health. Before the epidemic, we were in a phase of wellness. It was all about wellness and I, you know, stopping anything from happening. Now we're more in a crisis mode and taking, now the individual person really has to assume their own responsibility. And I recommend to them to keep binders and folders and just all the information they have. So if I'm talking to you as a medical physician online, I have my questions out. I know what to ask you. I'm, you know, I take responsibility as the patient as well. And I think that allows coming back full circle here. There's things that we can do to implement in our life to feel like we have more control and more power. Because as we all know, this is, medicine is moving this way, more online and more virtual. And it may be possibly a good thing to alleviate a lot of long lines and impacted EDs. So there's some real positive benefits as well. Those are great points, Bernadette. Thanks. Aria, what are you seeing there in the UK? Are you seeing the same kinds of issues that Bernadette was describing here in the UK? Yes, I mean, there's certainly overlaps and great points. I suppose, I suppose, like Bernadette said, you know, there's a lot now about how we can cope or find ways of coping in this virtually. So technology has become an essential tool and has been for a while for connecting, offering us ways to be listened to, to be understood, to meet our true need, to be cared for and connected with others. Coming prepared for that, seeking that out is very important. And we can use it in many ways. We just need to satisfy those needs. So whether it be through exercise, therapy, a doctor's appointment, new skills, hobbies, entertainment, you know, whatever it is that supports your sense of connection and feeling cared for for yourself and for others. What's interesting, though, is that what I find in the virtual world, just in general, you know, there's lots of opportunities for connections, but that they can be both authentic and inauthentic. And so something that comes up for me, it makes me think of Gabor Matei suggests we have two needs, attachment and authenticity, and that we strongly gravitate towards being connected so much so that we might sacrifice our authenticity for that connection, not on purpose. And we sometimes don't even realize it, but we might know when this happens because we end up leaving a social activity or some sort of social connection feeling disconnected from ourselves, not feeling heard, not feeling cared for. And so it's important to consider which virtual activities promote your sense of connection and authenticity, because it's only when we are being authentic that we can truly feel cared for and be connected. So again, what we're hearing a shout is that this is the first point of meaningful contact for many. It's important that you try and find that meaningful contact in any way that you can. Almost half of people who text us say that they feel that they have no one else to talk to or that they've never asked for help elsewhere. So it seems like, again, there's a lot of connection happening, but perhaps a little bit less of sharing something meaningful with someone, which is really important. People most appreciate being listened to and feeling understood. And so it's really important that collectively, whether we're coming from a position of a provider or if we're seeking any sort of support that we continue to develop, encourage and find for ourselves authentic avenues of connecting. Excellent. So to me, then, like every country is really dealing with the same issues. Is that a fair statement? Yes, I truly believe that. And I would also like to point out in connection with Ariel, what Ariel said, the meaning of health literacy here and the big role the health literacy plays in the burnout of healthcare workforce in the stress level and the mental health issues that might cause to general population as well to the normal patients. Because we have been seeing, yeah, we have seen in the last months lots of misinformation on lots of channels online and most of it also on TV. And when we're talking here about the isolated elders, for example, and we worry about their mental health, then we have to connect it directly or link it with what is actually published on TV and on radio as they are not as much on Facebook and other social channels. But health literacy in my opinion plays here an important role. And regarding these points, I wanted also to mention that I recently launched a project here in Europe, but we actually gather also lots of people from around the world from Australia, Asia and Russia and the U.S. Actually, we have advisory board members from the U.S. It's called the Digital Aid Project. It's a pro bono initiative and two actually of the pain points that we are trying to tackle are related with mental health. One of them is called patient distress to avoid patient distress and the other one is employee burnout and stress level. So that's actually directly related with the healthcare workforce. What we're trying to do here, it's actually, it's a tailor made health innovation tool set and is responding to the most common and pressing pain points in long-term care facilities in general. But as I said, two of these are directly related with mental health and we are actually validated recommendations and we tailored a guideline based on the need, based, goal-oriented criteria and we compile a catalogue of ready to implement digital health solutions that are able to tackle these pain points and support the long-term care facilities overcome this difficult time. So we actually focused a lot on the elders here and on inpatients also in mental health facilities and we actually approached the topic of remote monitoring of telecommunication, how we can actually talk with the people who are in isolation and how we can bind them closer to the society whereas we are implementing social distancing everywhere. So that's a very nice, we actually launched it last week in English and we are preparing it in 10 additional languages in the weeks to come and I'm very happy to share this with you and with our followers afterwards because as I said, it's free to download for everyone and it can help any healthcare organization, patient, family and professional in need. So yes, that could be the input the digital has. Yes, we will share that at the end and make sure everybody has that website. Thank you. Kita, recommendations from your standpoint on what can we do moving forward in this new world that we're in and I think from your standpoint what I'd be interested in is specifically what about healthcare workers? What can clinicians do and other essential workers that are on the front lines that have to go to work every day while the rest of us are home, how can they better manage this? It's such a good question and I picking up also on my colleague here on the panel, Annika's comments about the importance of getting the right information on this healthcare literacy movement in a post-COVID era is going to be critically important for universal populations across the nation but also subpopulations that might be at distinct risk because of exposure or other pre-existing vulnerabilities and so at PsyCov we also have some good resources I'd like to push out at the end too that are also free related to video-based content on things like anxiety and depression and post-traumatic stress and even suicide risk and also targeted towards tele-mental health so we pushed out a free course too to help teach providers how to effectively do tele-mental health in their practice in a post-COVID time when you've had to sort of switch to tele-mental health rather quickly and might need to prepare your practice and maybe that wasn't in your game plan early on as a clinician so that all free resources but also to get after your question about sort of what do we do? Like what do healthcare workers do or what can we expect moving forward? I don't know if your listeners would be surprised or not but I really think a lot of what we do is very basic in that we're expecting folks to try their best to despite the fact that they're working in a telework environment to you know stay on a routine and also putting back on my hat with regard to your question for what do healthcare workers do also we're wanting them to rely on each other for peer support you know when you've been through trauma one of the best resources is someone else who's been there and sort of done that as well and so nurse to nurse medic to medic doctor to doctor support each other peer support is critically important during this time and reach out to somebody every day don't let isolation get the best of you don't withdraw when you might want to certainly a fair amount of quiet time might be necessary as you're you know leaving your shift but it's also important to stay connected and so keep a good predictable routine stay connected follow any and all guidance with regard to the CDC guidelines on you know isolating yourself in terms of after your shift you know being careful with exposure in that regard I know all of the healthcare professionals are are sort of top notch and following that so it's probably you know not necessary for me to say but the other things I can think of are you know just your basic principles of sleep hygiene nutrition and not forgetting to take care of yourself and I know they sound so basic but sometimes they're good reminders particularly during times of crisis like what we're experiencing right now with the pandemic yeah but we'll be sure to to share your site videos that you that you spoke of on at the end of this as well so so our viewers are going to get lots of information that good good resources yeah thank you great Bernadette you talked a bit about the American American Suicide Foundation hotline we'll be sure to share that but you also alluded to patient rights can you talk a little bit about what you what your recommendations might be for patients and families right now in this crazy time well it's interesting pre-covid we had been working on actually publicizing even larger a patient right that you have a right to safe care good care safe medication and just and access to your knowledge of your your healthcare information so that really hasn't changed it's just how we're going to go about and getting that so when you go into a hospital now as I alluded to before or stated before that you should wear a mask and you really have to look at your healthcare worker as well and seeing if they're taking the correct precautions and you can do that just by little investigation I know here locally at UCI they're definitely implementing a lot a lot of protocols to make sure the healthcare workers safe and also the patient safe and we've heard already here on the panel about gradually easing into face-to-face with the healthcare worker I think what we should know too is that giving kudos and respect to our healthcare workers because we do have fear of going into a healthcare office but I am going to lay probably a little bit more trust that they are doing the right thing and I think just again by some of these guidelines and they are just they want to keep themselves safe and what I'm seeing in hearing is they're actually even more over protective than need be to get the virus themselves which is a great thing and is a good thing and just make sure you know if a healthcare worker is going to do an exam on you make sure they wash their hands make sure they are masked make sure you wash your hands afterwards or before they enter in an extra room because we know this virus is very contaminant through touch so again your basic rights are just that you have a right to be healthy you have a right to your information and again it goes back to being responsible for your health so if there's a different point of view if I show up to an appointment with my binder follow my healthcare with some of my records and dates of when I've had my examinations and I know what medications I have you can then you have more you're more empowered as a patient to ask good questions and you can tell when you are not being spoken to with in the right way or also if your questions are not being answered that's very empowering yeah and we actually at the patient safety movement foundation one other resource that we can we can share with everybody is we have developed a plan of care for folks that they can it's a it's a virtual form but they can fill it out print it out and fill it out they can fill it out electronically and start exactly that binder that you were you were talking about so that's a great point thank you I'd love to hear from the rest of our panelists any other recommendations for what we can do to live in this new virtual world that we are living in with not so much physical contact I'm happy to start yeah so I feel I mean it's just been such an inspiring conversation actually in such amazing points have been raised I think from you know particularly the mental health perspective there is increasing demand across the world for mental health services very little has prepared us for how to provide support in times of global crisis when uncertainty and isolation become a shared experience and that's both for the mental and medical fields as a digital service our volunteers are based at home so we've been able to continue to offer support 24-7 throughout the lockdown this has been one lead one leading form of support and continues to offer a way to virtually connect in moments of distress and crisis and also I feel really inspired hearing in the conversation there's been also so many other new initiatives that have launched at this time so our national health service has developed a suite of options to support their frontline staff so extra mental health provision is being provided to NHS staff and then to offer extra mental health provisions to all UK frontline workers we've collaborated with other partners mine Samaritans Hospice UK the Royal Foundation to run a new campaign called our frontline we have our leading psychological associations our teaming together to create virtual guidance for mental health professionals to help keep mental health services open many organizations for vulnerable adults and young people are developing their virtual and digital access domestic abuse for one has risen by 25% in the UK since lockdown and an urgent cross-government intervention plan is currently in progress there has been lots of collaboration and we see that it is essential to offer virtual support when human connection is needed especially at uncertain times of physical absence high insecurity and we also realize that our need for virtual care extends beyond the current crisis so it is and has been necessary for a while and evidence of its current effectiveness and all this new innovation will serve to extend beyond this crisis we feel very excited about that in our conversation today it is exciting it is exciting I think you know what what we ever knew before about zoom is completely changing I think for all of us so um Anka um any do you have any recommendations or tips outside of the virtual world just basic things that that that maybe people can do to help make make themselves more mindful um you just mentioned a beside from the from the digital tools that's everything I've been trying to do in the last month it was just like trying to to find the best way to to implement digital tools in risk in risk management in in crisis management which was incredibly difficult as I'm dealing with change management myself on a daily basis in hospital settings and that takes years you know to implement projects now it has been really really a challenge I think a big question mark is here that is here is actually how to maintain social connect connectness how while we are actually maintaining social distancing but this brings us of course back to the to the technology right which I think it's it's just an added value to what our society is giving us right now and it's it's gonna make the situation or it could make the situation much better and and easier as it has been for for influenza for example back in the in the years um on in on another hand um I think mindfulness it's it's a very important thing and this doesn't have to be necessarily via technology because there are techniques that we can actually use to to improve our mental status and we can do that on an individual basis um from practicing yoga and meditation until reading and being again health literate I think this would actually reduce a lot of our stress levels and this would be key probably to to overcome the difficult situation we are facing all over the world if I could jump in here real quick I am a unified mindfulness coach and I use it a lot with my practicing and techniques what one of the easiest things we talked about walking we all know walking you can be very mindful with it but it is so important to take a lot of breaks especially today even I mean in this world and even if you have children running around you know just go to the bathroom and deep breathe and take a break and one of the techniques that I really love is it's called hear out and um I lost a child 12 years ago to suicide and my path through mental health was very long and but the meditation was one of the things that really helped me and understanding how calming the brain through any stress or trauma can really help you start to see other things and bring more clarity to the situation and this technique you could do it anywhere anytime is if you just sit here and you focus and you listen to out of your right ear first for a few moments then you listen to your left ear out of a few moments and you just listen to the sounds and then we call that hear out you can actually start turning it in but that's more you know after you practice for a little bit it is the easiest technique because sometimes our thoughts go we get on our random thoughts and we start ruminating and it does not make things any better for us and it really increases our stress level so this one technique even to try it just go out on a walk or you could do it after this call or after this video and just sit there and just listen and it's amazing how much it will reduce your stress so that you would ask for you know just something that we can implement right now um anytime nobody knows you're doing it you could do it one of you could be doing it right now and I would never know because the best place to listen is actually being in an unmindful state so even if your children are coming at you and at home or or you're in an awful situation at home with somebody that's abusive you know take some time to really really calm calm your thoughts that's how often I have a question thank you very much this is really insightful actually as I'm working two days per week in the hospital and the rest of the time I'm actually dealing with thousands of things from home office which is really challenging for a healthcare professional um but we're reducing the number of stuff in the hospital so I kind of need this kind of technique myself and I wanted to ask you how often should one do it per day or per week and how long does it have to take with an interval that you would suggest us every 20 minutes if you're working at your computer and you can even put it you know recommend putting a mindful clock on your computer and it can go ding you know I have a little bell back here but it's just that what happens with the bell is your mind will start listening to it and it's a reminder we also have apps on our Apple phone on our iWatch is that can calm you but it's just getting into the habit and not blabbering over it not making that taking a break as being a problem it's just something you just start doing you know you just feel your level and I love you know and I know you guys are mental health professionals but I love the technique that I learned through cognitive behavioral therapy it's also you know scale things from a I use the one to ten scale if I'm over a four I back off and this really really helped me a lot I started me to start feeling how I was feeling inside and you if it gets too high a stressful situation you don't know and healthcare workers don't have that luxury they really don't at times they really have to be on site and so a lot hospitals have implemented things called cold cold lilac or cold violet where after there has been an incident they can they regroup they you know nursing chief nursing officers have put this into hospitals so they can regroup and they really address the mental health concerns of the healthcare worker and they acknowledge it and I think finally what I'd like to say is as I know in the United States just from my own path that nobody talked about suicide 12 years ago it just it wasn't a conversation I had with my child we just didn't talk about it I am so grateful that within the last five years we have begun talking about it and and with every hardship such as we're going through right now with COVID there are these silver linings and this is one of the most amazing things is like you said that we're all coming together and there are so much out there and it's going to actually accelerate even though it's increasing and I think one of the comment that was said about as the news comes out the negative news comes out the incidents rise they have proven that also I think that was a study in the UK about suicide that if they report it in a negative manner the rate of suicide actually increases so reporting incidents and really you know overriding it with positives in our brain and also in our conversations does help it's not glossing over it it's acknowledging it and then really focusing on the positive aspects of what we can control and what we can change very well said Bernadette thank you any last thoughts from our panelists before we conclude all right well thank you all so very much for being here today I very much appreciate your participation this has been a fabulous discussion I imagine there's much more to come we may be asking you to do this again in a couple of months thank you very much Donna back to honor all right well everybody have a wonderful day bye have a good day