Social Media Assignment

Public Relations Review 41 (2015) 222–231 Contents lists available at ScienceDirect Public Relations Review Managing a health crisis on Facebook: How the response strategies of apology, sympathy, and information inﬂuence public relations Marcia W. DiStaso a,∗, Michail Vafeiadis b, Chelsea Amaral c aPennsylvania State University, 200 Carnegie Building, University Park, PA 16802, United States bPennsylvania State University, United States cSolomon McCown & Company, United States a r t i c l e i n f o Article history:

Received 2 August 2014 Received in revised form 18 November 2014 Accepted 20 November 2014 Keywords:

Healthcare Social media Trust Facebook Credibility Reputation a b s t r a c t Through an online survey with Internet users, this study evaluated the crisis response strategies communicated on Facebook and their impact on a hospital’s reputation, cred- ibility, as well as stakeholder trust and behavioral intentions. The ﬁndings indicate that public relations practitioners should avoid posting sympathetic Facebook posts during a health crisis since they might further damage the image of the affected organization. Con- versely, undertaking a proactive approach by posting informative messages can prove more advantageous. The practical implications of the results are discussed.

© 2014 Elsevier Inc. All rights reserved. 1. Introduction The explosive growth of social media and the subsequent rapid dissemination of information required by organizations have led to a strong need to examine the new rules of communication especially during a crisis. Previous studies have demonstrated that during a crisis social media use increases as stakeholders use them for immediate access to information as well as to share updates (Glik, 2007; Liu, Austin, & Jin, 2011; Veil, Buehner, & Palenchar, 2011 ). The plethora of social networks (SNS) breeds the rapid dissemination of misinformation that can distort events and eventually tarnish an organization’s image. In light of this, organizations utilize the Internet’s affordances to communicate with stakeholders (González-Herrero & Smith, 2008; Liu et al., 2011; Schultz, Utz, & Göritz, 2011; Taylor & Perry, 2005 ).

Amidst this evolving media ecosystem, there is an urgent need for public relations scholars and practitioners to study what type of crisis response strategy is appropriate during an unfolding crisis (Coombs & Holladay, 2008; Schultz et al., 2011 ) in an effort to mitigate potential damages to the reputation and credibility but also to safeguard stakeholder’s trust and behavioral intentions toward the organization.

Although past scholarship has examined crises events in various contexts (Coombs & Holladay, 2012; Coombs & Schmidt, 2000; Freberg, Palenchar, & Veil, 2013; Schwarz, 2012 ), there is lack of systematic research at the intersection of health-crisis ∗ Corresponding author. Tel.: +1 814 863 9874.

E-mail addresses: [email protected] (M.W. DiStaso), [email protected] (M. Vafeiadis), [email protected] (C. Amaral). http://dx.doi.org/10.1016/j.pubrev.2014.11.0140363-8111/© 2014 Elsevier Inc. All rights reserved. M.W. DiStaso et al. / Public Relations Review 41 (2015) 222–231 223 communication and social media around crisis situations. Effectively managing information and communication during a health crisis is crucial since stakeholders, who tend to react rationally when confronted with risk information, might show differing levels of rationality than the organization disseminating the information (Williams & Olaniran, 1998 ), since their risk perceptions are enhanced when the danger is man-made (Glik, 2007 ).

The purpose of this article is to address the gap in the literature by comparing the crisis response strategies of apology, sympathy and information a hospital in a crisis can employ on its Facebook page. This will have both practical and theoretical implications when the crisis response strategies are analyzed in relation to the perceptions of reputation, trust, credibility, and behavioral intentions. 2. Literature review 2.1. Crisis Crisis management has received renewed scholarly attention because of the abundance of social networks (SNS) and the fast manner information can reach large audiences (Coombs, 2014 ). Coombs (2007) deﬁned an organizational crisis as the “perception of an unpredictable event that threatens important expectancies of stakeholders and can seriously impact an organization’s performance and generate negative outcomes (p. 2)”. Although a crisis is temporally unpredictable it cannot be perceived as totally unexpected. Hence, a crisis management mechanism should exist to avert or mitigate damages on the affected organization and its stakeholders. This is critical in the Internet era since a crisis can rapidly unfold and proliferate due to the rich social media ecosystem which renders its management more challenging (Coombs, 2011b ).

Audiences are now fragmented and expect from companies to heed their informational exigencies and interact with them by providing swift and unambiguous responses, thus preventing negative situations from becoming organizational crises ( González-Herrero & Smith, 2008 ). It appears that stakeholder discontent or even a crisis can trigger a domino effect and tarnish the company’s image although an equivalent situation in the pre-Internet period could had inﬂicted less damage.

Successful public relations require establishing and maintaining enduring relationships between an organization and the publics, especially in volatile situations as in a crisis. Weick (1995) suggested that the real challenge for an organization is not determined by the magnitude of the crisis but by the type of the response it provides to audiences. Hence, an initial crisis response strategy should emphasize speed, accuracy, and consistency since uncertainty can result in extra pressure to stakeholders (Coombs, 2011a ). This is even more pressing these days as organizations increasingly rely on the Internet to communicate with stakeholders during a crisis ( Taylor & Perry, 2005 ). The literature suggests that offering a quick response is advantageous during an organization’s image repair efforts (Benoit, 1997 ). Moreover, it provides news media with critical real-time information and helps prevent the dissemination of false information or speculations due to the paucity of ofﬁcial updates (Middleberg, 2001 ). Past scholarship views quick responses as a characteristic of active organizations in control of crisis situations, a perception that can improve their credibility (Arpan & Roskos-Ewoldsen, 2005; Carney & Jorden, 1993; Hearit, 1994 ). 2.2. Reputation An organization’s reputation is one of the most important intangible assets a company possesses, but it is jeopar- dized during a crisis (Barton, 2001; Sturges, 1994 ). In general, reputation is the collective public perception stakeholders have over time toward an organization (Grunig & Hung, 2002 ). Reputation develops by interaction with an organiza- tion (Rindova & Fombrun, 1999 ). Organizational reputation is deﬁned as the “stock of perceptual and social assets – the quality of the relationship it has established with stakeholders and the regard in which the company and brand is held” ( Fombrun & Van Riel, 2004 , p. 32). Schreiber (2011) proposed a twofold deﬁnition of reputation; from an organizational standpoint, reputation gives a company the ﬂexibility to optimally handle the needs and expectations of its stakeholders, something that distinguishes it from its competitors. On the other hand, stakeholders assume an emotional, intellectual, and behavioral understanding of reputation that depends on the fulﬁllment of their desires and anticipations by the organization.

A good reputation reﬂects the company’s overall quality and services (Carmeli & Tishler, 2005 ) and epitomizes its care for customers (Brammer & Millington, 2005 ). Moreover, an enduring corporate reputation advances the long-term viability of an organization. Fombrun and Van Riel (2004) found that organizations with a good reputation perform better ﬁnancially than competitors with poor reputation. Past research also showed that reputation mediates the relationship between an organization’s qualities and consumer purchase intentions. In a study on reputation and airline companies, Graham and Bansal (2007) demonstrated that for every one-point increase in airline reputation consumers were willing to pay $18 more for airline tickets. However, a crisis undermines the reputation of a company since audiences can negatively evaluate the company based on its crisis response. Prior research suggests that negative word-of-mouth not only damages an organi- zation’s reputation (Tucker & Melewar, 2005 ) but can inﬂuence future purchases even after stakeholder anger dissipates because online comments remain and can inﬂuence others (Coombs & Holladay, 2007 ). Yet, Coombs (2007) suggested that an organization with a good reputation can make stakeholders discard unfavorable information since there is the tendency to perceive reputable organizations as less likely to be responsible for unfortunate events. 224 M.W. DiStaso et al. / Public Relations Review 41 (2015) 222–231 2.3. Credibility Credibility is the conﬁdence stakeholders have in the validity and veracity of the received message. Credibility is often associated with the construct of believability (Budd, 2000; Tseng & Fogg, 1999 ), that is, to what extent stakeholders are willing to accept the information of a corporate message. Johnson and Kaye (2004) deﬁne credibility as the worthiness of being believed, but identify that it should be measured as a multidimensional construct consisting of reliability, accuracy, and depth of information.

Usually, source credibility describes attributes of the communicator such as expertise, attractiveness, trustworthiness, or power, which, if present, enhance the believability of the transmitted information for message recipients (Ohanian, 1990 ).

In the crisis literature, the communicator is the organization and stakeholders are perceived as the message recipients. McGinnies (1973) argued that highly credible sources are more persuasive than less credible when message recipients ini- tially hold negative opinions toward the advocated message. Thus, organizational credibility is critical during an unfolding crisis as it can act as buffer against further damages. Additionally, the literature showed that information from credible sources can affect the beliefs, attitudes and/or behaviors via the method of internalization (Belch & Belch, 2003 ). Internal- ization takes place when recipients are keen in assuming an objective position toward an issue and thus, they embrace the perspective of the credible communicator as they consider the advocated information as true.

Strong corporate credibility is even more relevant when stakeholders have to assess antagonistic accounts of a crisis situation. Rumors, which are false and misleading reports about an organization, thrive when an ofﬁcial version of the situation is missing, particularly in the information-rich age of social media. To effectively address them, however, an organization should be perceived by stakeholders as a credible source of true and honest information (Coombs, 2007 ). Arpan and Roskos-Ewoldsen (2005) found that an organization that provides a timely response by disclosing negative information about itself has the opportunity to frame the message and situation accordingly, enhance its credibility, and, ultimately, inﬂuence how the crisis is evaluated. In sum, the literature underlines how crucial is for organizations to have appropriate crisis response strategies to quickly convey key information to stakeholders aimed at protecting their credibility. 2.4. Trust Another organizational characteristic that can inﬂuence the relationship between an organization and its stakeholders is trust. Trust is a multifaceted concept and affords multiple deﬁnitions. Rotter (1967) perceived it as an intrinsic attribute of individuals and deﬁned it as the group or individual expectation “that the word, promise, verbal or written statement of another individual or group can be relied upon” (p. 651). Other scholars viewed trust as an affective (emotions) or a cognitive (rationality) attribute, or both (McAllister, 1995; Rotter, 1967; Swan, Trawick, Rink, & Roberts, 1988 ). From an organization standpoint, trust is the shared group perception that the other party will be open, honest, fulﬁll its responsibilities, and refrain from exploiting others (Bradach & Eccles, 1989; Cummings & Bromiley, 1996; Hon & Grunig, 1999 ). Generally, trust signiﬁes a sense of predictability, that is, a consistent and anticipated behavior from the other group (Hosmer, 1995 ). Some of the dimensions it encompasses are: integrity, dependability, and competence (Hon & Grunig, 1999 ); openness and honesty, vulnerability, concern for employees, identiﬁcation, control mutuality, satisfaction, and commitment (Paine, 2003 ).

Trust is built gradually and matures based on the parties’ past interactions and mutual experiences. Developing trust between stakeholders improves the speed and effectiveness of business operations (Covey, 2006 ). Overall, trust is con- ducive in establishing stronger relationships with stakeholders and entails ﬁnancial beneﬁts as it can reduce the expenses of potential lawsuits, regulations, lawmaking, or negative publicity (Paine, 2003 ). Conversely, distrust can have deleteri- ous and lasting effects on the image of an organization. It is found that distrust generates uncertainty and distress and makes individuals feel uncomfortable, thus leading them to closely monitor the behavior and intentions of the other party ( Govier, 1992 ). Once stakeholder trust is breached, it is difﬁcult to restore it since it triggers a cycle of suspicion (Tschannen- Moran & Hoy, 2000 ). In a study about the deteriorating relationship between a local community in Alberta, Canada and the petroleum company operating in the region, Jahansoozi (2007) found that trust could only be restored incrementally and after the organization was willing to take small but concrete steps as evidence of its commitment in meeting the community’s expectations. 2.5. Social media and crisis management In the foregoing sections, we described how a crisis can create ambiguity, uncertainty, and eventually rumors which undermine the credibility, trust and reputation of an organization. Online crisis management is an arduous task as the swift profusion of (mis)information requires organizations to launch a dynamic social media presence to present their version of the story. Lariscy, Avery, Sweetser, and Howes (2009) deﬁned social media as “online practices that utilize technology and enable people to share content, opinions, experiences, insights, and media themselves” (p. 1). Recently, social media played a signiﬁcant role in how organizations communicated crises situations to audiences as well as how stakeholders were informed about a crisis (Prentice & Huffman, 2008 ). For instance, Twitter and Flickr were used during the 2008 Mumbai terrorist attacks (Beaumont, 2008 ), Facebook and Twitter were employed by the Centers for Disease Control and Prevention (CDC) during the outbreak of the H1N1 pandemic (Reynolds, 2010 ), the 2010 Haitian earthquake (Muralidharan, Rasmussen, Patterson, & Shin, 2011 ), and the 2007 California Wildﬁres (Sutton, Palen, & Shklovski, 2008 ). It appears that in the midst as M.W. DiStaso et al. / Public Relations Review 41 (2015) 222–231 225 well as post-emergency situations, social media are becoming indispensable communication platforms (Scherp et al., 2009 ), thus urging organizations to establish a robust online presence. In a study about the 2007 pet food recall crisis, Stephens and Malone (2009) found that when stakeholders are not properly updated about a crisis, they tend to resort to sources other than those provided by the organization in crisis. Despite the advantages SNS entail for organizations buffeted in a crisis, only 28 (5.6%) of the total 500 Fortune companies who had a Facebook account used it to communicate with stakeholders during a crisis (Ki & Nekmat, 2014 ). 2.6. Advantages of using SNSs during crises Although social media can rapidly transmit dubious and untrue information that can hurt an organization’s image, they also allow for the monitoring of the online ecosystem and the fast correction of rumors before they turn into a fact, averting that way a crisis from escalating (Crush, 2006; Veil et al., 2011 ). For example, crisis managers can post counter statements or provide links containing the accurate facts (Prentice & Huffman, 2008 ). Researchers have argued that the public distribution of information exempliﬁes an organization’s awareness, control and responsiveness toward the situation (Lovejoy, Waters, & Saxton, 2012; Sweetser & Metzgar, 2007 ). Additionally, social media can eclipse past temporal restraints as organizations do not have to rely on ill-informed journalists or time-bound press conferences (Prentice & Huffman, 2008 ). Instead, organi- zations can assume a conversational human voice by conveying real-time and true information (Sweetser & Metzgar, 2007 ) assuring that their message will reach stakeholders (Prentice & Huffman, 2008 ). 2.7. Disadvantages of SNS during crises The lack of, or, inefﬁcient use of social media can worsen a crisis and inﬂict lasting damages that can endanger the ﬁnancial survival of an organization. According to Coombs (2007) , failing to tackle a crisis situation online can generate suspicion among stakeholders. In addition, it can make them resort to other communication sources, therefore, multiplying the chances of receiving false information. For example, it was found that during the 2007 California wildﬁres some people believed that news media and ofﬁcials were not distributing enough information so they began transmitting updates via social media based on-the-ground information they were collecting themselves (Sutton et al., 2008 ). In the era of social media, stakeholder discontent can go viral instantly and consequently an organization’s crisis response strategies can inﬂuence its reputation, credibility, and trust. As Benoit (1997) stated in his classic study on image restoration, “The key question is not if the act was in fact offensive, but whether the act is believed by the relevant audience” (p. 178). 2.8. Crisis response messages Following the outbreak of a crisis, it is necessary for organizations to convey messages to stakeholders. Audiences are keen to assigning responsibilities as to the causes of the crisis (Coombs & Holladay, 1996 ). Thus, organizations should craft crisis response strategies to control the reputational damage and diffuse stakeholder negative feelings. The advent of social networking sites, such as Facebook, has provided public relations practitioners with new tools for crisis management.

However, the mere adoption and use of social media might not yield desired outcomes if employed improperly. Ki and Nekmat (2014) found that 61% of the Fortune 500 companies which used Facebook for crisis management failed to convey appropriate situation responses.

Apology, sympathy and information are some of the crisis response strategies researchers have studied, yet, disagreement exists pertinent to their effectiveness (Coombs & Holladay, 2008; Schultz et al., 2011 ). Apology occurs when an organiza- tion acknowledges, accepts responsibility and asks for forgiveness for the crisis (Benoit & Drew, 1997 ), and promises to avoid repeating the same wrongful act (Kellerman, 2006 ). Scholars have demonstrated that apology is more effective than the response strategy of denial (Kim, Avery, & Lariscy, 2009 ) and better protects an organization’s reputation when held responsible (Benoit, 1997 ). Timely posting of an apologetic statement on Facebook helped the camera manufacturer Nikon to diffuse stakeholders’ brewing frustration about a previous post by the company (Bernstein & Bernstein, 2011 ). Also, apology was found to be the most used crisis response strategy Fortune 500 companies applied on Facebook to communicate with publics (Ki & Nekmat, 2014 ). Nevertheless, organizations are generally reluctant to offer apologetic statements since they can be used against them in courts (Cohen, 2002; Coombs, 2007 ). It is for this reason the response of sympathy is also used by organizations as it is economical and focuses on the victim’s needs. According to Coombs and Holladay (2008) , sympathy can be viewed as the organization’s attentiveness for crisis-affected stakeholders. Using a student population and an oil indus- try crisis, they compared apology to other accommodative response strategies, such as sympathy and compensation, in an effort to evaluate its overall effectiveness in crisis communication. The ﬁndings indicated, however, that all three response strategies scored the same on post-crisis reputation evaluations, anger and negative word-of-mouth intentions. In a study about the image restoration strategies Texaco employed amidst the company’s 1996 racism allegations, it was found that an organization that accepts responsibility for a wrongdoing or shows sympathy for the victims is evaluated more favorably by the public (Coombs & Schmidt, 2000 ).

Crises generate ambiguity and uncertainty, so it is important to transmit information to stakeholders (Mitroff, 2004 ).

The response strategy of information occurs when crisis managers only report what happened. Stephens and Malone (2009) underlined that when stakeholders are unsatisﬁed with the amount of information they receive they will look for alternative 226 M.W. DiStaso et al. / Public Relations Review 41 (2015) 222–231 sources other than the one’s provided by the affected organization. In a study of social media employment in crisis com- munication, Schultz et al. (2011) found that information produced more mitigated crisis reactions than the responses of sympathy or apology. Conversely, in an ofﬂine experiment that compared various response strategies, Coombs and Holladay (2008) found that information resulted in lower post-crisis reputation than those elicited by sympathy and apology.

Although past scholarship has studied apology, sympathy and information, few studies move beyond a student population or case study of a speciﬁc crisis. Also lacking is an examination of Facebook as a communication springboard for imparting crisis response messages in the health sector, and notably, in a hospital context. The purpose of this paper is to address these gaps in the literature by recommending optimal crisis management strategies and the impact they have on an organization’s image and stakeholder behavioral intentions. The following research questions were explored:

• RQ1: How do the crisis responses of apology, sympathy and information disseminated over Facebook inﬂuence the reputation of a hospital in crisis?

• RQ2: How do the crisis responses of apology, sympathy and information disseminated over Facebook inﬂuence perceptions of trust of a hospital in crisis?

• RQ3: How do the crisis responses of apology, sympathy and information disseminated over Facebook inﬂuence perceptions of message credibility for a hospital in crisis?

• RQ4: How do the crisis responses of apology, sympathy and information disseminated over Facebook inﬂuence potential behavioral intentions of a hospital in crisis?

• RQ5: How does the use of Facebook inﬂuence perceptions of reputation, trust and message credibility of communication over Facebook for a hospital in crisis? 3. Method The purpose of this study was to compare the crisis response strategies of apology, sympathy and information in a social media environment with the aim to identify what message elicits higher levels of trust, credibility, reputation, and behavioral intentions. 3.1. Participants This study was conducted through an online survey with 517 adult Internet user respondents who were randomly recruited by SurveyMonkey from their more than 30 million users. SurveyMonkey members complete surveys on a volunteer basis. Once users indicate an interest in taking surveys, they can take up to one survey each week. For each survey completed, respondents are rewarded with charitable donations and sweepstake entries. SurveyMonkey regularly runs benchmarking surveys to ensure that their members are representative of the US population. The questionnaire was distributed in May 2014. 3.2. Design Given the importance of trust, credibility and reputation in healthcare, this study aimed to identify crisis response strate- gies for hospitals. A ﬁctitious hospital was used to control for potential biased responses based on personal past experiences.

Survey instructions explained that the described scenario was hypothetical.

Each participant was randomly exposed to one condition (either apology, sympathy or information). A manipulation check was used to ensure that the conditions accurately reﬂected the appropriate conditions. The apology read as: “We accept responsibility for the incident that occurred this week resulting in nine deaths. We hope those who were affected can forgive us.” The sympathy text was “We are deeply saddened by the incident that occurred this week resulting in nine deaths. Our thoughts and prayers go out to those affected.” The information text was “On April 7, 4 patients, a nurse and 2 doctors died from a highly contagious virus. The hospital is investigating the cause of the outbreak.” Each text was displayed in a mock-Facebook post. The post appeared in the survey as it would on an actual Facebook page with a blue banner containing the Facebook logo, an H logo to denote the ﬁctitious hospital, a time stamp for “yesterday,” and a bottom banner with the words “like,” “Comment,” and “Share.” 3.3. Measures Along with the three manipulation check questions, the respondents were asked 22 questions. Particularly, three ques- tions were used to measure trust based on the Hon and Grunig (1999) 5-point Likert-type trust scale with the anchors of strongly disagree and strongly agree. Three questions measured credibility based on Johnson and Kaye’s (2004) scale also using the same 5-point Likert-type scale. Reputation was measured using Ponzi, Fombrun, and Gardberg’s (2011) condensed four item 5-point Likert-type scale (2011). Behavioral intentions were assessed with six 5-point Likert-type questions that inquired about the actions respondents were prone to take after reading a Facebook post: (1) “like” the post, (2) share the post, (3) comment on the post, (4) talk about the post ofﬂine, (5) seek more information about the post, and (6) go to M.W. DiStaso et al. / Public Relations Review 41 (2015) 222–231 227 the hospital in the future. One question measured respondent frequency of Facebook use and ﬁve demographic questions addressed the respondent’s age, gender, household income, education, and census region location. 3.4. Respondents The 517 survey respondents were similar to the US population; 54% of survey respondents were female (n = 268) and 46% were male (n = 231). Respondent ages were fairly equally distributed with 21% 18–29 (n = 107), 25% 30–44 (n = 126), 27% 45–60 (n = 134), and 27% over 60 (n = 132). The household income was distributed as 13% of respondents made between zero and $24,999 (n = 51), 20% made between $25,000 and $49,999 (n = 79), 37% made between $50,000 and $99,999 (n = 148), 19% made between $100,000 and $149,999 (n = 75), and 12% made over $150,000 (n = 47). Most of the respondents were educated with 1% having less than a high school degree (n = 6), 6% having a high school degree only (n = 30), 32% having “some college” or an associate degree (n = 157), 30% having a bachelor degree (n = 148), and 31% having a graduate degree (n = 151). A total of 80% of respondents indicated that they use Facebook (n = 408), and 51% indicated that they use Facebook at least once a day (n = 254). 4. Results This study sought to compare the crisis response strategies of apology, sympathy and information to identify their impact on trust, credibility, reputation and behavioral intentions for a hospital enmeshed in a crisis situation. 4.1. Reliabilities The reliability coefﬁcients (Cronbach’s alpha) were 0.84 for the trust scale, 0.88 for the credibility scale, and 0.96 for the reputation scale. All represented acceptable reliability scores, so the items were condensed into individual variables. 4.2. Manipulation checks This study involved a manipulation of three crisis response strategies: apology, sympathy, and information. Respondents were asked to indicate their level of agreement to the Facebook post containing either the information, sympathy, or the apology condition. A series of one-way ANOVAs were run to check the efﬁcacy of the response manipulations. The apology condition had the highest mean (M = 4.19) for hospital statement apologizing for the crisis (F(2, 111) = 90.09, p ≤ 0.001).

The sympathy condition had the highest mean (M = 4.35) for the statement that contained the sympathetic response to the hospital crisis (F(2, 111) = 101.19, p ≤ 0.001). The information condition had the highest mean (M = 3.24) for the statement that contained a more informational post about the hospital crisis (F(2, 111) = 90.09, p ≤ 0.001). Therefore, the manipulation was successful. 4.3. Research questions 4.3.1. Reputation The ﬁrst research question explored reputation evaluations of the crisis response strategies–apology, sympathy and information–used by a hospital on its ﬁctitious Facebook page. There was a signiﬁcant effect for Facebook crisis response posts on reputation (F(2, 509) = 7.04, p ≤ 0.001). However, post hoc analysis using Tukey revealed that the sympathy condition was the only cause of the difference. The sympathy condition (M = 1.84, SD = 0.89) resulted in a lower post-crisis reputation than the information condition (M = 2.17, SD = 0.94) and the apology condition (M = 2.16, SD = 0.96).

4.3.2. Trust The second research question sought to identify evaluations of trust in a hospital amidst a crisis situation and contingent on the three Facebook crisis response strategies of apology, sympathy, and information. There was a signiﬁcant effect for crisis response Facebook posts on trust (F(2, 514) = 4.82, p < 0.01). However, post hoc analysis using Tukey revealed that the cause of the difference was the sympathy condition only. The sympathy condition (M = 2.28, SD = 0.85) produced a lower post-crisis trust evaluations than the information condition (M = 2.50, SD = 0.92) and the apology condition (M = 2.57, SD = 0.97).

4.3.3. Credibility The third research question investigated respondents’ credibility evaluations of a hospital in crisis based on the response strategies of apology, sympathy, and information employed over a Facebook page. There was a signiﬁcant effect for Facebook crisis response on message credibility (F(2, 514) = 3.38, p < 0.05). A post hoc analysis using Tukey revealed that the cause of the detected difference only occurred between the information and the sympathy conditions. The information condition (M = 2.41, SD = 0.94) resulted in a higher perception of message credibility than the sympathy condition (M = 2.17, SD = 0.90), but neither were signiﬁcantly different from the apology condition (M = 2.22, SD = 0.91). 228 M.W. DiStaso et al. / Public Relations Review 41 (2015) 222–231 Table 1 Crisis response behavioral intentions. Information Sympathy Apology Like the postM = 1.75 M = 1.76 M = 1.94 SD = 0.88 SD = 0.94 SD = 1.07 Share the post *** M = 2.44 M = 1.92 M = 2.26 SD = 1.32 SD = 1.06 SD = 1.23 Comment on the post ** M = 2.34M = 2.72M = 2.37 SD = 1.25 SD = 1.26 SD = 1.24 Talk about ofﬂine * M = 3.26 M = 3.58 M = 3.26 SD = 1.36 SD = 1.22 SD = 1.18 Seek more information ** M = 4.11 M = 3.81 M = 3.79 SD = 0.99 SD = 1.00 SD = 1.10 Go to the hospital in the future ** M = 2.28 M = 1.91 M = 2.22 SD = 1.00 SD = 0.98 SD = 1.05 *p ≤ 0.05. **p ≤ 0.01. ***p ≤ 0.001. 4.3.4. Behavioral intentions The fourth research question examined the behavioral intentions of participants after viewing an apology, sympathy or an information crisis response message on Facebook. A series of one-way ANOVAs found a signiﬁcant effect for behavioral intentions and the Facebook crisis response strategies (see Table 1). There was also a signiﬁcant effect for the intention to share the post on Facebook (F(2, 506) = 7.82, p < 0.001). Speciﬁcally, respondents were more likely to share the information response post than the sympathy post. In addition, respondents were more likely to comment on the sympathy response condition than the information or the apology conditions (F(2, 506) = 4.91, p < 0.01). Similarly, respondents were more likely to talk about the sympathy response posts ofﬂine than the information response or the apology response (F(2, 506) = 3.58, p < 0.05). Respondents who received the sympathy response condition were also less likely to visit the hospital in the future than those who received the information or apology response conditions (F(2, 506) = 6.32, p < 0.01). Yet, respondents who received the information condition were more likely to seek additional information than those who received the sympathy response or apology response (F(2, 506) = 5.22, p < 0.01). There was not a signiﬁcant relationship between the crisis responses conditions and liking the Facebook posts; they were all fairly equally low.

4.3.5. Facebook use The ﬁfth research question inspected the inﬂuence of Facebook use on perceptions of reputation, trust or message cred- ibility after participants viewed the three conditions. Facebook use was only found to signiﬁcantly inﬂuence perceptions of message credibility (F(2, 507) = 4.62, p < 0.05). Respondents who use Facebook indicated higher perceptions of message credibility (M = 2.31, SD = 0.93, n = 408) than those who do not use Facebook (M = 2.10, SD = 0.86, n = 101). The frequency of Facebook use was not signiﬁcant. 5. Discussion This study examined stakeholder reactions after receiving crisis response messages of apology, sympathy, and information in a Facebook post for a hospital in crisis. The results indicated that the strategy of sympathy resulted in lower post-crisis reputation evaluations than the conditions of information and apology. This is in contrast to Coombs and Holladay (2008) who found information was responsible for lower post-crisis reputation when compared to the conditions of sympathy, apology, and compensation. A possible explanation is that our experiment was conducted using a mock Facebook post, and thus crisis response messages might had triggered different cognitive and affective evaluations when employed in the context of social media. Another possible explanation is that their study with college students may not have been representative of an adult population as was used in our study.

The ﬁndings also contradict Dean (2004) who argued that organizations that express concern in their responses are perceived more favorably than those whose responses lack sympathy and fairness after conducting a study with a student population. Given that social media favor shorter messages (Schultz et al., 2011; Sweetser & Metzgar, 2007 ), the brevity of the message stimuli (only 140 characters) might account for this difference. In sum, since crisis response strategies can reduce the reputational damage by allaying negative emotions produced by stakeholders making attributions (Coombs & Holladay, 1996 ), the results of our study suggest that the sympathy condition should be avoided by crisis managers.

With regard to organizational trust, the response strategy of sympathy scored lower than the conditions of information and apology. This also contradicts past research that found no signiﬁcant difference between the various response strategies employed, and notably among apology and regret on respondents’ trust evaluations of an organization (Verhoeven, Van Hoof, Ter Keurs, & Van Vuuren, 2012 ). Our study also examined a ﬁctitious crisis situation that resulted in deaths in a hospital M.W. DiStaso et al. / Public Relations Review 41 (2015) 222–231 229 setting; however, respondents in the Verhoeven et al. (2012) experiment watched a video clip of the media coverage of the unfolding crisis instead of reading a Facebook screenshot. It can be argued that the medium used to disseminate crisis messages might have affected how people evaluated organizational trust. This may also be seen, in a study that examined a mix of different online communication channels (Twitter, blogs online newspaper), various crisis response strategies (apology, sympathy, and information), and behavioral intentions, where Schultz et al. (2011) found that the medium was more important than the message. Nevertheless, public relations professionals and organizations in the health sector should pay considerable attention since a decline in trust levels is often linked to a decline in conﬁdence, benevolence, reliability, competence, honesty and openness (Tschannen-Moran & Hoy, 2000 ). Consequently, deteriorating trust levels can increase for an organization the costs of business operations (Limerick & Cunnington, 1993 ) since it tends to persist over time ( Tschannen-Moran & Hoy, 2000 ).

Data from our study indicated that the information strategy resulted in higher evaluations of message credibility than the strategy of sympathy; nevertheless, neither of them was signiﬁcantly different from the apology condition. Other studies also showed that the process of stealing thunder, that is, if an organization quickly self-discloses negative information about itself results in overall enhanced credibility and message persuasiveness (Arpan & Roskos-Ewoldsen, 2005; Williams, Bourgeois, & Croyle, 1993 ). With the introduction of social media, organizations in crisis can rapidly convey information to stakeholders and assume a proactive approach that will allow them to frame the message as well as the crisis (Arpan & Roskos-Ewoldsen, 2005; Williams & Treadaway, 1992 ). The literature showed that adopting a proactive approach during a crisis situation by communicating a robust and informative instant response – such as in the case of Johnson & Johnson’s handling of the second Tylenol tampering crisis (Benson, 1988 ) as opposed to the reactive stance in the Exxon Valdez oil tanker grounding ( Williams & Treadaway, 1992 ), can win public conﬁdence and mitigate negative reactions and publicity.

This study also extends past scholarship on impression formation that advocates that sources who share harmful infor- mation about themselves early in their interaction with others make them more appealing (Archer & Burleson, 1980; Jones & Gordon, 1972 ). A proactive approach can in general improve the organization’s credibility and yield long-term market- ing beneﬁts, as information stemming from credible organizations can positively inﬂuence the attitudes and behaviors of stakeholders pertinent to the issue of interest (Belch & Belch, 2003 ).

This study sheds further light on the behavioral intentions the crisis strategies of apology, sympathy, and information elicit. Particularly, the results revealed that it is more likely for stakeholders who received an information message to share it and inquire for additional information than those who received the sympathy response. These ﬁndings are consistent with Mitroff (2004) who underlined the need for information during uncertain crisis events, as well as Stephens and Malone (2009) , who found that approximately 50% of the time during a crisis stakeholders either sought additional information or imparted information to other individuals. The results also partly reﬂect those of Schultz et al. (2011) who demonstrated that social media users (Twitter) were more likely to share the apology and the information message than the sympathy response.

The ﬁndings also indicated that people are keen in commenting on the sympathy response than on the strategies of apology and information. Similarly, individuals who received the sympathy condition were more willing to discuss the received message than those who viewed the information or the apology response. These ﬁndings should be interpreted with caution as commenting can be used by stakeholders to voice their discontent. Past studies have shown that the Internet facilitates the creation and dissemination of negative word-of-mouth (Schlosser, 2005 ), which subsequently affects future purchase intentions (Coombs & Holladay, 2007 ). The results are also consistent with the ﬁndings by Schultz et al. (2011) where the sympathy condition generated higher secondary crisis reactions. This logic appears to hold true since the data indicated that respondents who viewed the sympathy message are less likely to visit the hospital in the future.

Finally, it was found that the frequency of Facebook use signiﬁcantly inﬂuenced only stakeholders’ perceptions of message credibility. This is not surprising given the profusion of information Facebook users encounter around-the-clock. These ﬁndings might be explained in relation to the organization’s authoritative status and the message’s quality. Research on persuasion showed that the characteristics of a message source can capture the attention of low involvement individuals ( DeBono & Harnish, 1988 ). This, along with the conversational human voice of social media which can provide timely information in a crisis situation (Kelleher, 2009; Sweetser & Metzgar, 2007 ), might account for the enhanced stakeholder perceptions of message credibility. 5.1. Future research directions and limitations In conclusion, this is the ﬁrst study to our knowledge that experimentally studied the role of one of the most dominant social networks, Facebook, in evaluating stakeholder perceptions and behavioral intentions during a crisis situation in a health setting. Taken together, the results suggested that the sympathy condition produced lower post-crisis reputation, trust evaluations and higher secondary crisis reactions (negative word-of-mouth). The ﬁndings have practical implications for public relations practitioners and organizations in the health sector seeking appropriate social media crisis responses.

Given the lurking fear of lawsuits apology messages can bring, along with the negative repercussions entailed in a sympa- thy message, it is recommended that practitioners and organizations alike should refrain from embracing and uploading sympathetic messages on their organization’s Facebook page. Another strength of the study is that the results have external validity because respondents were randomly selected Internet users (not college students as was the population of many past crisis studies) who are also potential stakeholders in a similar crisis at a hospital scenario. 230 M.W. DiStaso et al. / Public Relations Review 41 (2015) 222–231 Nevertheless, further research is warranted to juxtapose various crisis response strategies in the context of social media.

Future studies can beneﬁt by comparing crisis response messages between different types of communication channels (e.g.

YouTube videos, print press releases, online press conferences); a new line of research that can make valuable contributions to the crisis literature. Future research may wish to also examine equivalent ﬁctitious versus real crisis situations by juxtaposing the employed social media and response strategies.

The study has several limitations that need to be addressed. Since this crisis was ﬁctitious, respondents were not familiar with the hospital, thus their judgments might not truly represent their responses in a real scenario. Personal involvement and interaction as well as an organization’s reputation and credibility can affect stakeholders’ evaluation of negative information by forming counterarguments and discarding it altogether. For example, it is possible for stakeholders in small towns with only one hospital present to develop interpersonal relationships with the stuff, something that can subsequently inﬂuence their evaluation of the hospital’s efﬁciency in crisis management. Another limitation is that the present study focused on only three crisis response strategies. Future studies should attempt to broaden the spectrum of the crisis response conditions and compare them in the social media ecosystem. Moreover, the results should be viewed with caution since they might be only applicable in a health-sector crisis. A cross-sector meta-analysis might be useful to accentuate if and what differences apply among different response strategies and mediums.

In summary, this study is a signiﬁcant step toward developing an understanding of how to effectively handle communi- cation through social media for a health-sector crisis.

Acknowledgement This study was supported by funds from the Arthur W. Page Center at Pennsylvania State University.

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