Evaluation of the use of a Whatsapp Forum for the Daily Clinical Case Review in Obstetrics and Gynaecology at a Teaching Hospital during the COVID-19 Pandemic

Abstract

Background

This study aimed to evaluate the use of a Whatsapp forum for a daily clinical case review in Obstetrics and Gynaecology.

Methodology

We used a Qualitative Action Research methodology, as the study involved an intervention; the introduction of a WhatsApp platform for daily morning case review; and exploration of what happened following the intervention using a feedback questionnaire. The 21 resident doctors and consultants who completed and returned the feedback questionnaire were the subjects of the study.

Results

Twenty-one out of the 29 doctors in the department (72.4%) participated in the study. Of the participants, 66.7% agreed or strongly agreed that the Whatsapp forum was an appropriate way of conducting the daily morning case review. Also, 76.2% of participants said that the learning via WhatsApp platform was different and created a forum for everyone to be in attendance and participate at their convenience. Hence, the vast majority of participants (81%) said that they would recommend Whatsapp morning review to other departments. Eighty-one per cent agreed or strongly agreed that the WhatsApp morning review motivated them to learn but what the Registrars liked the least about the WhatsApp review was 'the stress of typing and responding to long questions'. However, the Registrars felt safe and relaxed and said the Whatsapp approach 'reduced harassment and abuse of the junior doctors'.

Conclusion

The WhatsApp forum is an appropriate and safe method of conducting the obstetrics and gynaecology daily medical case review especially during a Pandemic. It may be worth looking at using the WhatsApp forum as an additional learning tool in the department even after the COVID-19 pandemic.

Introduction

Daily morning reviews have taken place in the department of obstetrics and gynaecology since the inception of the hospital and accreditation of the department in 2010. It is a review of the clinical management of all the patients that were admitted in the previous 24 hours. It was also an opportunity to plan the subsequent management and review the theoretical bases of the care provided to the patients. The Registrar I (second-year resident doctor) who was on call presents all the cases, and this is followed by those present seeking clarifications, asking questions and making comments; starting with medical students and ending with consultants. This was the situation until the Coronavirus disease 2019 (COVID-19) pandemic broke out.

COVID-19 was first reported in Wuhan, China in December 2019 and declared a pandemic by the World Health Organization on the 11th of March, 2020. The first case in Nigeria was reported in Lagos on 26 February 2020 in an Italian returnee, and since then cases have been reported in all the states of the federation. But it was not until the 6th of April 2020 that the first case was diagnosed in Delta State.

A lot of changes were brought nationally to minimise the spread of this very contagious disease including stay at home directives, regular and frequent hand washing, social/physical distancing, respiratory hygiene and the use of face masks. Schools including universities were closed, so there were no medical students at the hospital. The hospital was also keen to minimise the exposure of health care workers to the contagion so that they will stay healthy and be available to treat patients in the event of an explosion in numbers. Hence, all elective surgeries and high-risk outpatient clinics such as dental, pulmonology and otorhinolaryngology clinics were stopped. Also, all meetings including the daily departmental morning review meetings were cancelled so that there was very little opportunity for teaching and learning in the department. On the 13th of May 2020, the consultants in the department met to look at ways of having academic activities in the advent of the COVID-19 pandemic, and it was agreed that the daily departmental morning review should resume but be conducted remotely. After due consideration of the challenges and benefits of the various electronic platforms for communicating, the Whatsapp forum was chosen for the morning review.

Therefore, this study aimed to evaluate the use of a Whatsapp forum for a daily clinical case review in Obstetrics and Gynaecology.

Methodology

We used a Qualitative Action Research methodology, as the study involved an intervention; the introduction of Whatsapp daily morning case review; and exploration of what happened following the intervention.

Whatsapp morning review

A WhatsApp forum for consultants and resident doctors was created on 13 May 2020 and called morning REVIEW'. The summary of cases for the morning review is posted daily between 8.30 am and 9 am by the second year resident doctor that was on duty in the previous 24 hours. Thereafter, questions are posted by resident doctors and consultants till 4 pm, and the presenting resident doctor answers all the questions no later than 8 pm on the same day.

Feedback Questionnaire

On 23 June 2020, a post on the morning REVIEW' Whatsapp forum introduced the research and asked the participants to kindly complete a feedback questionnaire (Appendix 1) that was left in a box in the departmental office. The questionnaires were anonymised (no name required), and participants were given a week to complete the process. Twenty-one (21) doctors completed and returned the feedback questionnaire, and hence formed the subjects of the study.

The questionnaire used for this research had a mix of open and closed questions and open questions can provide responses that can be diverse and rich in ideas3. The questionnaire was analysed thematically and the response to the closed questions was presented as proportions.

Results

There were 29 doctors in the department, and 21 (72.4%)participated in the study (Table 1). Of the participants, only two were Registrar I who posted the case summaries and answered the questions (Table 1). All the resident doctors and consultants, including the Registrar I that were not presenting, posed the questions and made comments and contributions about all aspects of the presentations including the proffered answers to questions. The two authors who were consultants in the department did not participate in the feedback questionnaire.

Table 1:

Distribution of participants

	Participants	Total Staff	% participation
Registrar II	2	3	66.7%
Registrar I	2	3	66.7%
Sen Registrar	12	14	85.7%
Consultant	5	9	55.6%
Total	21	29	72.4%

Is WhatsApp an appropriate forum for conducting the daily morning review?

Of the participants, 14 (66.7%) agreed or strongly agreed that WhatsApp was an appropriate way of conducting the daily morning case review. However, three participants (14.3%) disagreed or strongly disagreed that WhatsApp was an appropriate way of conducting the morning review. One of them said 'it is not comparable to a physical meeting where we also have demonstrations'. Also, 'training of one's confidence and composure is lacking', and 'detailed discussion cannot be had because we have to type'. Indeed, 16 (76.2%) of participants said that the learning via WhatsApp was different from the physical morning review. Conducting the morning review by WhatsApp created a forum for everyone to be in attendance, 'it increases participation and 'all consultants are present and able to contribute'. It is convenient and 'allows everybody in the department to participate wherever they are.

Hence, the vast majority of participants, 17(81%) said that they would recommend Whatsapp morning review to other departments. The two participants who would not recommend it were consultants; one stated that 'it makes one feel detached from the clinical care discussed', and the other was indifferent about it, and felt that the WhatsApp morning review did not stimulate learning or deepen understanding of medical topics.

Did learning take place at the morning review conducted by the WhatsApp forum?

Participants were excited that learning and academic activity was going on despite the pandemic. They felt that it was a significant learning tool with 'detailed discussions of topic matter'. A Registrar II said 'it keeps me abreast with vital study tools necessary for my training'. They felt that they were still in an academic setting, and 'it helps to stimulate revision points…' It also 'broadens my understanding'. A Senior Registrar posited that '…makes me feel committed to learning and reading for more knowledge', 'it ignites the desire to study'. A Registrar I said '… allows for research to questions before the answers are provided'. 'The presenter has to search for the answers thereby enhancing learning'. Seventeen (81%) agreed or strongly agreed that the WhatsApp morning review motivated them to learn. This learning may have led to an improvement in patient care, as only two (9.5%)participants disagreed with this assertion (Table 2).

Table 2:

Feedback on Whatsapp Morning Review

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Appropriate	1	2	4	12	2
Stimulates learning	0	2	2	12	5
Deepens understanding	0	3	6	11	0
Improves patients' care	0	2	2	16	1
Different learning	2	0	3	6	10
Recommend	0	2	2	10	7

The learning environment of the WhatsApp forum

Typing and answering the questions alone may be stressful for the Registrars. One of them said what they liked the least about the WhatsApp review was 'the stress of typing and responding to long questions'. They also did not like the consumption of their data from typing. However, the Registrars felt safe and relaxed and said the WhatsApp approach 'reduced harassment and abuse of the junior doctors'. It takes the pressure off the person presenting the cases, and a Senior Registrar confirmed that 'it eliminates stage fright from the presenter'.

Discussion

In a scoping review of WhatsApp use in medical education, Coleman and O'Connor (2019) found that the most cited benefit of WhatsApp was its ability to create new learning opportunities when a physical meeting of teacher(s) and learners is not possible⁴. The physical meeting may not be possible because of time or geographical constraints, or as in our case because of the pandemic. The COVID-19 pandemic and its requirement for social or physical distancing to prevent being infected meant that we could not continue with the physical daily morning review meetings. This presented us with a new learning opportunity, the introduction of the WhatsApp forum; and it was quite apparent that the majority of the learners were excited about being able to continue some academic activity during the pandemic especially in the early days when there was a lot of anxiety about COVID-19. Even those who had reservations felt that WhatsApp was better than nothing, and would recommend it in a pandemic.

The WhatsApp morning review forum was very interactive and active learning took place as evidenced by Registrars researching questions, and searching for answers. They appeared to use questioning as a tool for collective thinking and sharing and jointly developing their knowledge. Collective thinking is a vital aspect of human development, and questioning can be used to 'scaffold' learning, and make implicit knowledge explicit, and build on and extend pre-existing knowledge⁵. However, emotional involvement in learning and effective communication, both verbal and non-verbal are vital in learning effectively⁶. Emotional involvement and in particular non-verbal communication was not possible with the WhatsApp forum. This may potentially have affected the quality of learning, but in general, there is an improvement in learner knowledge or confidence following WhatsApp learning⁴.

The strong asymmetry of power in interactions between teachers and learners creates a powerful barrier to the achievement of interactions in which learners display initiative, curiosity and negotiation⁷. This is likely to be true in the physical morning review as the participants said they felt safe and more relaxed with the WhatsApp forum, and that the WhatsApp approach 'reduced harassment and abuse of the junior doctors'. This is similar to the findings of Willemse 2015 who investigated the experience of 21 undergraduate nursing students' experience of using WhatsApp to integrate theory and practice of health assessment. The students liked the anonymity and felt able to ask any question without fear of being criticised⁸. This safe learning environment created by the WhatsApp platform may potentially give the learners more freedom to explore and enhance their learning.

Conclusion

In conclusion, the WhatsApp forum is an appropriate and safe method of conducting the obstetrics and gynaecology daily medical case review, especially during a Pandemic. Even after the COVID-19 pandemic, it may be worth looking at using the WhatsApp forum as an additional learning tool in the department. Future studies should look at directly comparing the learning that occurs using a WhatsApp forum to that of a physical meeting.