On information, safety and emotion

The year 2020 marked a turning point in human history: the COVID-19 pandemic transformed social practices and accelerated organizational and technological processes. The outbreak of COVID-19 compelled institutions and government health authorities to suspend face-to-face activities to maintain social distancing and reduce disease transmission.

Technological developments in the 21st century accelerated at an unprecedented rate. The Internet became indispensable and mobile devices, with all their numerous applications, facilitated grouping and interpersonal bonding processes. One of the most widely used communication applications was, and remains, WhatsApp, which emerged in 2009 ¹ as an instant messaging application for sending and receiving images, videos, audios, documents, among other functions.

Social networks, in general, and social software, in particular, have mediated learning and knowledge development ². However, while WhatsApp facilitates communication, its use can also complicate interpersonal relationships and communication flow within groups. Some disadvantages include loss of information in large groups ³, simultaneous discussions on multiple topics, group conflicts for various reasons ⁴ and transmission of irrelevant content ⁵. Additionally, the application’s limited capacity to convey body language and context are some of its major drawbacks ⁶. The communication exchange in the application is part of larger networks whose dynamics operate on virtual nodes ⁷. Within this activity, content consumption occurs in population sets with specific characteristics, where both the quantity and quality of data acquire particular features.

The WhatsApp chat of intensivists reached a pivotal moment with the emergence of COVID-19. Physicians in ICUs anticipated the arrival of critically ill patients needing intubation, necessitating a reorganization of medical care processes. This situation can be interpreted through Goffman’s notion of social interaction ⁸, wherein events occur within specific environments. In other words, in a situational framework, participants assume roles and premises based on rules that allow interactions to develop with a degree of normality. The hospital transformations prompted by COVID-19 triggered events among health unit participants. The sequence of these events and the organization of statements on WhatsApp defined spaces of meaning and intersubjectivity ⁹. There were continuities and discontinuities, changes, ruptures, shifts from one field to another, dislocations, displacements and transformations. The link between a singular experience and language was the meaning-enabling understanding on an immanent level by condensing the past, present and imagined future-expressed in a shared language ¹⁰.

In addition to the exchange of information, the feelings of the participants were expressed in this WhatsApp group. During the pandemic, when building and maintaining social ties were challenging, cognitive, interactional and emotional adjustments were key elements in considering affectivity in the field of health. Individual behaviors were approached within a social matrix where institutional conditioning and daily interactions were interwoven ¹¹. Affective discomfort was transmuted despite the emotional regulation inherent to the medical profession, as reflected in the participants’ testimonies.

The WhatsApp group messages allowed for characterization and signification of, for example, the existing relationships between the material conditions in which intensivists worked in their hospitals and the social construction of the fear of death during the pandemic. Goudsblom ¹² and Wouters ¹³, in their studies of contemporary fears, explained that emotional experiences are positioned in the social sphere. Constantly facing situations of uncertainty regarding life and death confronts physicians with the possibility of their own death ¹⁴. In human relationships during a pandemic, fears and feelings of vulnerability prevailed, where social worth was built on fragile foundations. There was a relationship between the subjects’ perceptions and the changes in social sensitivity thresholds ¹⁵.

How to analyze the contents of WhatsApp chats?

For intensivists, the WhatsApp group served as a node where the global, local and personal converged. The guiding question of the study was: what types of communicative exchanges took place in the WhatsApp communication platform of the Mexican intensivists’ group during the COVID-19 pandemic? The objectives aimed to describe and analyze: a) how intensivists incorporated globally circulating information and scientific knowledge about the COVID-19 pandemic into the WhatsApp group, b) the local situations referred to by the participants related to their positions in the hospital and ICU regarding institutional reorganization for the care of COVID-19 patients, as well as occupational safety, resources and supplies needed for medical care (diagnostics, treatments, medications, etc.), and c) how personal emotions were shared in the WhatsApp messages, creating an intersubjective space based on a collective professional ethic with values, beliefs, preferences and behavioral patterns specific to the group of intensivists.

Study design and population

Regarding the arrangement of the communicative exchanges within the WhatsApp group of intensivists, the study employed a qualitative methodology. A retrospective analysis of textual messages and other materials shared in the communicative exchanges of the WhatsApp group was performed. The "chat" was regulated by the main administrator, who frequently clarified what was permitted and prohibited in the group’s interactions. The 239 participants (155 males and 84 females), who participated voluntarily, worked in ICUs in secondand third-level hospitals. The physicians were from 40 cities across 26 states of the Mexican Republic, with 108 residing in Mexico City.

Variables and measurements

Becoming familiar with the dynamics of instant message exchanges required significant time and effort from the researchers, who analyzed these written messages. After reading and interpreting the contents, a scheme with the relevant dimensions (analysis of shared information, standards of social action in COVID-19 patient care and emotional expressions) was developed to code and classify the material (Table 1). The guiding questions in the scheme helped organize the data and give meaning to the messages.

Statistical analysis

The procedures followed in the virtual fieldwork ¹⁶ were as follows: first, the content from the WhatsApp communication platform was migrated to Word documents for text analysis. During this transfer, materials accessible only within the application were lost. A total of 24 weeks were analyzed, corresponding to the first stage of the pandemic in Mexico. Week one began on January 18 and week 24 concluded on July 12. Afterwards, the material was coded and classified. Two researchers (LHS and SAM) spent seven months classifying the material using the specified instrument. Once the content themes were clearer, the theories presented in the conceptual framework were employed to aid in the analysis and interpretation of the information. Finally, the theories, WhatsApp conversations and the researchers’ analysis were triangulated ¹⁷.

For the approach to communicative exchanges, it was assumed that individuals participated in events and constructed narratives to provide meaning and reinforce their identities and positions within the described situations. Human agency and imagination influenced what was included and excluded in the narratives ¹⁸. Therefore, the chat contents represented interpretable depictions of situations and experiences. Studying these narratives, grounded in place, time and interpersonal experience, allows for an exploration of the sociocultural contexts of the participants. Given the epistemological approach to the material analyzed from an interactional perspective, the analytical interpretations were partial, aiming for credibility (not absolute truth) and seeking to enhance understanding of the experiences and situations described in the communicative exchanges.

Ethical considerations

On May 23, 2020, the same WhatsApp chat was used to solicit informed consent from group participants for educational and research purposes. The group administrator communicated the study’s objective, "I am writing to the entire group to request your permission to use the data and conversations in this group for educational purposes. I have discussed this project with educational researchers at UNAM. Should any article or writing be produced, authorship will be shared as ‘On behalf of the group...’ Please let me know if you disagree. Once the study and the research question are complete, the results will be shared with you via this platform." Fourteen individuals responded affirmatively, 222 read the message but did not reply and three did not read it; there were no objections to the use of the contents. Participants’ anonymity was ensured by using their initials, and data protection confidentiality was

maintained to prevent misuse. The research protocol was approved by the Ethics and Research Committee of the School of Medicine at Universidad Autónoma de México (UNAM) and registered with the Research Division under number FM/DI/011/2021.

Elucidation of the communicative exchange

The first section of the fragment was informative, detailing the confirmation of the first positive case of COVID-19 in Mexico. From the messages, it was possible to interpret that the procedure for confirming suspected cases was as follows: the samples were sent to INER, where specific tests were performed to either confirm or refute the presence of COVID-19. If the initial tests were positive, they were retested to corroborate the result. Finally, a third confirmatory test was conducted at INDRE to eliminate any doubt. From this point on, the information could be considered "true information." In the group, reactions to the news were diverse; some inquired about the test at INER, asking whether it used specific COVID-19 reagents. Dr. EC emphasized the importance of the epidemiological relationship as a reliability criterion: "risk plus positive test." The second section was relevant because of two aspects: first, the center-margin geopolitical relationship, and second, the vulnerability of physicians to patients with COVID-19. The text raised issues of inequality in access to diagnostic resources and procedural guidelines for managing care of patients infected with the virus.

Finally, in the third section, the emotional overflow and the consequent regulation of behavior were made visible, alluding to the expected attitude of physicians in the face of the contingency. Expressions such as "I’m already scared" were shared, while Dr. ACh tried to encourage colleagues by recalling the experience of 2009 with the severe acute respiratory syndrome (SARS) caused by the influenza A H1N1 virus. The last intervention of the selected fragment was also revealing; Dr. SH wrote, "The second test is expected," perhaps as an attempt to stem the imminent avalanche of pandemic effects or to deflect the sense of fear gripping the participants’ consciousness.

Intensivists’ narratives: from reality to virtual textual representations

The communicative fragment analyzed allowed us to address the objectives set out in the three analytical dimensions. The first section, on the confirmation of the first patient with COVID-19, demonstrated how the event was co-constructed within frames of meaning common to the intensivists, who lent credibility to the information. Institutional referents such as INER, INDRE, WHO and CDC were synonymous with scientific reliability and assurance. In the initial communicative exchange of the presented fragment, representations of a socially shared fact emerged, which was considered a milestone. The "fact" was not isolated; it was interwoven with circulating social knowledge that was appropriated and recovered by constructing narrative plots imbued with subjective and objective meanings capable of being shared. The various communicative codes circulated inside and outside the WhatsApp group in different discursive registers- global, local and personal. When combined, they were reconfigured ¹⁹, allowing for innovation in knowledge and its application to unprecedented situations, although not without emotional adjustments.

In the second transcript, patterns of the practical implications mentioned in the second objective were shown. In an exercise that transitioned from deductive to inductive reasoning and vice versa, the physicians took the shared information to their local settings and questioned aspects of their own clinical environments. The physical site where concerns converged was the ICU. They discussed topics such as equipment for care, supplies for the protection of healthcare personnel, safety in the clinical environment, appropriate medical procedures, clinical cases, medications and more. The lack of guidelines increased uncertainty about the scope of hospital reorganization and resources for medical care.

Raising questions and discussing future scenarios on WhatsApp caused distress and led to confronting the most extreme unknown: death by infection. Conversations reflected a dialectic that fluctuated between the imaginary and the real, i.e., the manageable tasks of the ICU. The narrative structure of these dynamics was repetitive in the communicative exchanges: first, someone would present a chaotic and catastrophic scenario, followed by expressions of distress or panic. This was then mitigated by the intervention from someone who redirected the messages towards manageable aspects, emphasizing professional ethics. These statements showed how emotions entangled in the intersubjective virtual space of the WhatsApp group, with collective discomfort being shared. As indicated by García et al. ²⁰, the exchange of feelings can lead to emotional feedback cycles which, along with transmitted emotional contagion, can become a set of digital group emotions ²¹, accelerated by technology and social networks ²². The emotions spread during this crisis were predominantly negative, although positive feelings did occur and should be acknowledged ²¹. Blasi et al. ²³ observed that positive emotions decreased over time due to an increase in negative emotions as the outbreak impacted the healthcare system.

Instant messaging communication had the capacity not only to contain catastrophic scenarios but also to foster bonds of solidarity and empathy, enabling resilient coping with personal and social suffering. Physicians did not find the answer to the health crisis in a transcendent being but rather in professional ethics. They delimited the scope of their action to the ICU, promoting attitudes and values in their clinical performance such as order, preparation, logic, discipline and teamwork. By sustaining these principles in practice, the overwhelming uncertainty of the pandemic was confined within the symbolic boundaries of the ICU.

In conclusion, it was confirmed that what happened in the virtual space reflected human relationships and the deep concerns of people in crisis situations. The WhatsApp responded to the need for information, providing scientific and truthful data about the pandemic at global, local and personal levels, as well as the protocols to manage it ²⁴. The virtual group also served as a node in which different local hospital realities converged, where doubts, criticisms, shortages and other problems were raised and echoed in the responses of the chat colleagues. In that sense, the conversations recorded were a reflection of what was happening at the national level. Finally, intersubjectivity was also interwoven, albeit in a fragmented manner, in the instant messages exchanged. The social representation of fear was reconfigured repeatedly as events unfolded, moving from awareness of vulnerability to imminent death to the implementation of manageable professional guidelines and norms to contain the threat. Emotional maladjustments were manifested in the WhatsApp group and were an intrinsic part of the professional community studied.

Beyond the analyzed contents, it is possible to state that the WhatsApp instant messaging application was used as an important means of communication in the professional life and hospital environment by physicians to communicate and share data among peers ²⁵. Moreover, it constituted a useful and easy tool to quickly share information ²⁶. Intensivists shared scientific literature and clinical cases, requested and sent data as images or videos, and answered urgent questions about patients, among other things ²⁷. It was also evident that they benefited from cooperating in critical situations and sharing experiences within the context of an evolving health crisis ^28,29.