MANAGEMENT OF INTERNAL AND EXTERNAL COMMUNICATION IN PRIVATE HOSPITALS IN SPAIN DURING THE COVID-19 CRISIS
Abstract
This paper analyses the communication strategies that private hospital institutions in Spain have employed during the COVID-19 crisis, as well as the tools they have applied to reach their internal and external audiences. Through a questionnaire composed of 52 questions, data has been collected from 13 of the best hospitals according to the Merco 2020 ranking. The results show that the composition of the Communication departments is varied and that they belong to different areas within the institutions. The tools commonly used in both internal and external communication have been expanded to deal with the pandemic and new content has been created, adapted to different audiences, with the aim of remaining a reliable source of information about the disease and retaining the trust of both employees and patients. The conclusions indicate that the health crisis has transformed the work routines of the internal and external communication departments and that it has helped them to become more agile, immediate and reactive. The strategic management of crisis communication has been fundamental in the private hospital environment to successfully confront the pandemic and will be fundamental in the future to address the challenges brought about by the New Normality.
Gestión de la comunicación interna y externa en instituciones hospitalarias privadas en España durante la crisis del COVID-19
Resumen
Este trabajo analiza las estrategias comunicativas que han empleado las instituciones hospitalarias privadas en España durante la crisis del COVID-19, así como las herramientas que han aplicado para alcanzar a sus públicos internos y externos. Mediante un cuestionario compuesto por 52 preguntas se han recabado datos de 13 de los mejores hospitales según el ranking Merco 2020. Los resultados muestran que la composición de los departamentos de Comunicación es variada y que pertenecen a distintas áreas dentro de las instituciones. Las herramientas empleadas habitualmente tanto en comunicación interna como externa se han visto ampliadas para hacer frente a la pandemia y se han creado nuevos contenidos adaptados a los diferentes públicos con el objetivo de mantenerse como fuente fiable de información sobre la enfermedad y retener la confianza tanto de empleados como de pacientes. Las conclusiones indican que la crisis sanitaria ha transformado las rutinas de trabajo de los departamentos de comunicación interna y externa y que les ha servido para ganar agilidad, inmediatez y capacidad de reacción. La gestión estratégica de la comunicación de crisis ha sido fundamental en el ámbito hospitalario privado para afrontar con éxito la pandemia y lo será en el futuro para abordar los retos que traiga consigo la Nueva Normalidad.
Keywords
communication, crisis, public relations, health, COVID-19, hospitals.
INTRODUCTION
The COVID-19 pandemic has been a global crisis with a high impact not only on the economy but also on health systems in all countries (Andrikopoulos & Johnson, 2020) and "has led to dramatic changes in the clinical care environment" (Shalowitz, Lefkowits, Landrum, Von Gruenigen & Spillman, 2020 p.1). This has forced health care systems to readjust their strategies and resources, and to adapt hospital areas to the new situation (Santillan-Doherty, 2020), with measures such as the great expansion of telemedicine (Voulgaris, Ferini-Strambi, & Steiropoulos, 2020). The unprecedented situation has forced health professionals to work and communicate in a context of great uncertainty (Carico, Sheppard, & Thomas, 2020).
For Mira (2020), the Public Health System must plan the post-crisis scenario to achieve an orderly return to normality, which implies paying attention, among other issues, to measures to identify organizational changes, as well as recognizing and compensating the collective effort of health personnel, key to dealing with the situation and who have suffered great physical and emotional damage. This strategic planning aimed at overcoming the effects of the pandemic in the public sector is also needed in private hospital institutions. Mental health care and the development of communication skills have emerged as necessary actions for healthcare professionals, who are continuously dealing with new situations in the current context (Grover et al., 2020). Healthcare organizations focus on decentralized and participative leadership to "ensure optimal communication within the healthcare organization and consolidate the motivation, training and awareness of professionals regarding their role, objectives and functions" (Danet, Garcia, & March, 2016, p.92).
Thus, it is essential to maintain excellence in clinical care and in communication and documentation processes, as is normally the case in health emergency departments, in order to reduce both the possibility of malpractice and other risks (Maniya & Mcgreevy, 2020). An appropriate communication strategy allows managing a health crisis without generating social alarm, as happened in the case of Crimean-Congo haemorrhagic fever in Spain in 2016 (Mestre & Bote, 2018).
Communication during the COVID-19 crisis
Outbreaks of emerging infectious diseases have increased dramatically in recent years - such as SARS or H5N1 influenza - and have highlighted the relevance of maintaining effective communications for their management (Sa, Mounier-Jack, & Coker, 2009). For the World Health Organization (WHO) "communication expertise has become as essential to outbreak control as epidemiological training and laboratory analysis" (World Health Organization, 2005, p.1). Two concepts are relevant in this regard: risk communication and risk management.
Risk communication refers to the process by which information regarding outbreaks is identified and shared for the purpose of raising awareness of the threat among key stakeholders. Key stakeholders in public health threats include WHO, national governments and the public. Risk management, on the other hand, refers to the management processes associated with outbreak response, for which communication is crucial at every stage (De Sa, Mounier-Jack & Coker, 2009, p.643).
Crisis communication is a specific area of study that focuses on a "strategic and image problem involving a crisis in an organization" (Micaletto, 2018) and occurs in situations of high health risk with the goal of enabling the population to cope with negative feelings and overcome perceived dangers (March, 2011). Poor management can lead to very negative consequences, as happened in the Ebola crisis in Spain (Micaletto and Gallardo, 2015). In fact, communication management during the Ebola crisis in Spain has been the focus of several studies such as that of González Pacanowski, Medina Aguerrebere and Iglesias García (2017), which proposes a model to optimize the emergency communication process based on aspects such as: developing a communication plan for serious infectious diseases; having channels, training plans and specific arguments for internal audiences as well as authorized spokespersons; generating informative and educational content for general audiences; using mobile channels and content; and having a contagion information protocol.
According to Castillo (2010, p. 205) crises have their own characteristics, but they have a series of unifying elements: the image and reputation of the organization, as well as its internal audiences, are affected; they attract media attention and the interest of the public authorities; they entail a good image of the victims; and they generate feelings of surprise and urgency. There are guidelines for managing communication in these cases, such as taking the initiative (Almada, 2009), communicating with credibility and confidence, assuming responsibilities (Barquero and Barquero, 2005), unifying interventions in the figure of a spokesperson, avoiding lies, silence (Luecke, 2005; Xifra, 2009) and improvisation (Rodríguez, Marauri, Armentia and Marín, 2020).
The unprecedented COVI D-19 crisis has had consequences among many other aspects in the communicative field, as there is a lot of rapidly evolving information. Even the WHO has used the term Infodemic ( ; Alfonso and Fernandez, 2020) (Allahverdipour, 2020) to refer to a context in which there has been widespread dissemination of false information and in which fear and insecurity have played a major role. "To the complex health, economic and social situation have been added challenges arising from the management of information about the disease, which has increased exponentially, and which can be addressed by providing objective and well-founded information" (Aleixandre-Benavent, Castelló-Cogollos, & Valderrama-Zurián, 2020). Fake news circulating on social networks (Pérez-Dasilva, Meso-Ayerdi, & Mendiguren-Galdospín, 2020) and hoaxes (Salaverría et al., 2020) increase the need for reliable sources of information.
In crisis situations, audiences actively seek information through different channels depending on their needs: if they seek to obtain privileged information they turn to social media, but if their needs are educational they turn to traditional media (Lu & Jin, 2020). The goal of health communication is to change attitudes and behaviors to improve the quality of life and public health, for which it can use informative or entertainment-education based messages (Igartúa, 2011), i.e. employing rational or emotional appeals, since "risk perception to a large extent is a feeling" (Stajnolovic, 2015, p. 106).
In the case of the coronavirus, the public has increased its information consumption and the frequency with which it is informed and maintains a critical position towards the content of the media, influenced by the editorial line and with an unnecessary sensationalist and alarmist treatment (Masip et al., 2020). Digital media have been the most used medium to publish about COVID and have been very relevant to meet the information needs of the population (Lázaro-Rodríguez & Herrera-Viedma, 2020). According to Igartua, Ortega-Mohedano and Arcila-Calderón (2020, p.9) "the consumption of specialized health information on the Internet, official websites and through health personnel improves the perceived knowledge about coronavirus".
Communication during a crisis in the hospital setting
In crisis contexts "the need to be present at all times is a non-negotiable imperative" (Losada, 2018, p.23). This is the reason why health institutions must have a crisis plan that serves as a guide for corporate behavior, as well as maintain stable relations with the media and a continuous presence in social networks, in order to minimize the impact of these situations and facilitate actions and communications aimed at controlling them (Calvo-Calvo, 2016).
Communication in hospital institutions must consider both the internal and external spheres in order to comprehensively manage all the needs of the organization and reach the target audiences: "At the institutional level, care centers and public and private hospitals need to communicate with their potential and/or effective customers, in addition to their internal audiences" (Sánchez, 2011, p.11). It is important to involve professionals in the organization's communication and to apply analog and digital tools in a complementary way (Cabero, Terceño, & Vallés, 2018; Costa-Sánchez & López-García, 2020).
Thus, having a strong communication system that facilitates knowledge sharing helps to prevent and buffer the effects of new public health incidents, as the health workers involved use their experience and informal, mainly local, networks, thus building on relationships of trust and credibility that help them to make decisions and communicate during periods of crisis (Sanford, Schwartz, & Khan, 2020).
Communication constitutes "the cornerstone for the phenomena of change necessary for knowledge management and innovation in the hospital organization to occur, obtaining better results in productivity and satisfaction of external and internal clients" (Prieto and Olmo, 2010, p.6). In addition to the constant presence in the media, the use of social communication channels and the fact of including all stakeholders in communications are measures that help to ensure adequate and effective risk communication, especially important during the management of pandemics such as the coronavirus, due to its high rate of infection and morbidity and the lack of specific treatments (Abrams & Greenhawt, 2020).
Tools such as videoconferencing platforms and telephone message groups have been used during the COVID-19 period to maintain communication, healthcare community cohesion and continuing education (Edwards et al., 2020). Regarding the use of social media by hospital facilities in a crisis context, quick responses elicit greater trust in the institution (Huanga & Distaso, 2020). The permanent updating of digital media becomes necessary to maintain control of the situation (Martin, 2013, p.46) as well as the expression of sympathy towards publics and the display of organizational learning, which generate positive feelings in users towards entities during crises (Zhao, Zhan, & Ma, 2020). Thus, social networks enable proactive crisis communication that enhances proximity with publics, although in many organizations this channel is not fully incorporated into crisis management (Calleja-Reina, Paniagua, & Victoria, 2018).
In recent years, the development of Internal Communication (IC) has been boosted in healthcare institutions (Costa, 2011), since "internal audiences (employees) should become one of the main audiences for healthcare organizations" (Bustamante, 2012, p.88). For Medina (2012), CI in the hospital setting has a strategic nature by allowing global goals to be achieved, as it affects patient satisfaction and, therefore, the image and reputation of the entity, which justifies the creation of a CI department within the organization. "Communication in healthcare centers is essential for coexistence and efficient work, taking into account the diversity of professional profiles and the multiple lines of command and multiple goals that coexist depending on the professional groups" (Sánchez, 2011, p.11). To achieve its objectives, the IC involves all employees and uses various communication strategies and media, such as corporate magazines or intranet (Medina, 2012). The creation of new content becomes essential to maintain the attention of the public, as has been done by public health in Mexico and Spain in the face of the COVID-19 health crisis (Estrella, 2020).
However, in the case of the current crisis, it is not only the communication management carried out by each individual institution that is key, but continuous inter-institutional cooperation and communication is essential to respond effectively to a pandemic, as this makes it possible to apply proactive strategies instead of reactive ones (Kortepeter, Kwon, Christopher, Hewlett, & Cieslak, 2017). This is why in health crises "administrations must always act under the criterion of alerting the population of the risks to which it may be exposed, but, at the same time, trying to avoid unnecessary alarms" (Rodríguez, 2011, p.42).
In recent decades, public bodies and private companies have been interested in communicating science and carrying out informative work as part of their public relations policy and corporate social responsibility (García-Hernández, Martínez-Rodrigo, & Mas, 2016). This positioning acquires even more consistency during the COVID-19 crisis, as the hospital centres raise their communication as a manoeuvre to manage the situation and, at the same time, as part of their public relations strategy. For Xifra (2020, p. 6) in the context of the current pandemic, "the management of internal communication also becomes a matter of corporate social responsibility" and will be key to safeguarding the safety and well-being of the workforce. Therefore, communication during a crisis determines the relationship with both internal and external audiences in order to build trust and credibility and contribute to the resolution of the problematic situation (Acevedo, 2020).
OBJECTIVES
The objective of this research focuses on analyzing the way in which private sector hospital institutions have dealt with the COVID-19 crisis in the communicative aspect. In order to achieve this purpose, other secondary objectives have been set out, such as the following:
• To study the composition of the communication departments in these organizations.
• Determine which IC and CE tools are commonly used by these institutions and which tools have been most prominent during the pandemic.
• To describe the communication strategies used during this period by the hospital institutions analysed, both towards their internal publics and towards society and external publics.
METHODOLOGY
This research is framed within the studies on communication and health and, more specifically, in the line on strategic communication in periods of health crisis. Specifically, it focuses on the way in which hospitals in the Spanish private sector have managed communication, both internally and externally, during the crisis caused by COVID-19.
We opted for a mixed methodological design (Teddlie & Abbas, 2010) in order to obtain a more complete view of the phenomenon (Hernández, Fernández, & Baptista, 2010). The sample is made up of 13 Spanish hospital institutions belonging to the ranking of private hospitals of the Merco Health Reputation Monitor 2020 (Monitor Empresarial de Reputación Corporativa). The data provided by Merco are a reference in the sector and are commonly used for scientific research ( ; Gost, 2015) (Costa-Sánchez, Túñez-López, & Videla-Rodríguez, 2016; Mira, Lorenzo, Navarro, Guilabert, & Pérez-Jover, 2015).
The tool used to obtain the information was a questionnaire (Wimmer & Dominick, 1996) with 52 questions formulated in a concise and clear manner in order to avoid errors of interpretation. The questionnaire is constructed by means of closed questions and open questions, which provide a qualitative value to the research, and evaluations through the Likert scale. The questions are divided into three blocks: the first contains aspects on the organization and socio-demographic profile of the person in charge of Communication (gender, studies, field of specialization, remuneration...); the second addresses questions on IC in the hospital institution in the scenario prior to COVID-19 and during the pandemic (internal communication specialists, instruments and strategies used, crisis communication plan, tools applied during the crisis...); and the third focuses on the internal communication specialists, instruments and strategies used, crisis communication plan, tools applied during the crisis....); and the third focuses on EC management in the organization before and during the pandemic (position in the organizational chart, composition of the work team, strategies and actions employed, external crisis plan, tools used during the pandemic...).
After creating the template using Google Forms, the questionnaire was sent to the corporate e-mail addresses of the different hospitals, which had been previously contacted. They were also offered the possibility of responding in a text file to solve security problems arising from access to external links from their organizations.
The communications management of the HLA Group hospitals refused the possibility of participating in the research, so the Hospital Universitario HLA Moncloa, the Clínica Vistahermosa Grupo HLA, the Hospital HLA El Ángel and the Hospital HLA Jerez Puerta del Sur were ruled out.
RESULTS
The size of the workforces of the centres comprising the sample is mostly large, since 69.2% have more than one thousand employees, although medium-sized and small institutions are also present, since 15.4% have between 251 and 500 workers and 15.4% have less than 50 employees. With regard to the annual volume of patients attended to, all of them exceed 20,000 people.
The budget allocated to communication is variable (graph 1) but usually exceeds 100,000 euros. The departments or teams that manage communication are made up of an average of 4 people and most of them are men (72.4%). They usually have a master's or postgraduate degree (66.7%) or a bachelor's degree (30.3%), while the doctorate level is hardly present (3%). The specialty of their studies is in most cases Communication, although Marketing-Commercial Communication appears and to a lesser extent Economics-MBA-Organizational Management.
Source: Prepared by the authors.
Regarding the figure of the Dircom, in all cases the position is occupied by men, although the age varies, as 46.2% are between 46 and 55 years old; 30.8% between 30 and 45 and 23.1% between 56 and 65 years old. The position held by the Communication Director in the organisation is linked to different areas: Corporate Communication (38.5%), Communication Management (30.8%) and Corporate Affairs (30.8%).
As for the training of Dircoms, the main speciality of their studies is Communication (92.3%), followed by Marketing and Commercial Communication (38.5%) and a not very significant presence of Journalism (7.7%); the majority (69.2%) have a master's or postgraduate degree, 23.1% have a degree or bachelor's degree and only 7.7% have a doctorate. The gross annual salary they receive ranges from 70,001 to 100,000 euros (38.5%) and from 20,000 to 40,000 euros (15.4%), although the majority (46.2%) receive remuneration in the range between 60,000 and 70,000 euros per year.
The activities associated with the position are very varied (Figure 2) and include strategic communication and coordination, media relations and events. Crisis communication plays an important role, although internal communication does not.
Source: Prepared by the authors.
The management of IC in the organization depends on different areas such as Human Resources Management (46.2%), Corporate Affairs Executive Director (30.8%) or General Management (15.4%). It is important to note that in only 7.7% of the organisations analysed does CI report to the Communications Department. The average number of professionals dedicated to this area is 2, although in more than half of the centres there is only one person in charge of managing CI.
The planning of CI in the institutions analyzed is very polarized between those that have a previously designed plan to which they incorporate actions when they deem it necessary (53.8%) and those that base their CI on specific and sporadic actions (46.2%). To develop these strategies, they use a wide variety of tools (graph 3). They combine traditional tools -such as events, suggestion boxes, training or welcome manuals- with digital and audiovisual instruments -newsletters, intranet, blogs, videoconferences, digital magazines, videos, their own applications or virtual reality- and in some cases with informal face-to-face communication with employees. No organization uses physical internal magazines, podcasts, internal social networks, instant messaging or bulletin boards in its strategy.
Source: Prepared by the authors.
Most of the centres (76.9%) develop campaigns to promote the well-being of their staff in aspects such as employee participation, active listening, integration of diversity, promotion of equality/support for female talent, care for physical and mental health, emotional retribution and social benefits, grants and financial aid, the possibility of teleworking, conciliation and rationalisation of timetables, promotion of sports practice, reduction of stress and development of innovative spaces that promote communication and the feeling of belonging.
Strategic issues for the future development of IC include: strengthening links with the brand to boost confidence in the organization (76.9%); training, internal training and talent retention (76.9%); and creating and managing new channels and internal content (53.8%). All the participants consider IC to be a key element in the organization, as one of them said: "Internal communication is just as strategic as external communication. Without proper management of the internal public, you can break the coherence between what you are and what you say you are".
The tools used to measure results in CI are mainly four: meetings with employees (92.3%), internal satisfaction and work climate surveys (76.9%), external communication audits (30.8%) and monitoring of the different channels used (30.8%).
The IC has been totally disrupted by the COVID-19 crisis, a statement that all respondents agree on, but it has been a challenge from which they have learned valuable lessons. Some of their comments in this regard are:
• "It has tested us in the worst-case scenario we've ever known. Having a specific continuity plan for this scenario has helped us to have a starting point, but that plan has evolved and grown during the pandemic to adjust channels and messages."
• "Precisely, it has strengthened internal communication and the attachment and attachment of staff to the company".
• "It has taught us to bring out the best in each of our employees and to generate synergies between the different departments.
Although the majority of the centres (77%) had an internal crisis plan, only 30.8% of them contemplated a situation as extreme as the current pandemic.
All agree that the management of the IC during the COVID-19 crisis has been totally different from that of previous crises. The main differentiating aspects were the intensity, immediacy, permanence over time, the need for diverse and constant responses, the degree of uncertainty and the different profile of the activity. One of the participants explains it as follows:
All our doctors, nurses, technicians, assistants, receptionists, security staff, cleaners, etc., were still living through the pandemic (and the associated uncertainties) when they returned home. Our obligation was also to accompany and help them and their families in this area, to be able to better understand and manage the situation (young children, elderly people in their care, their own emotional stress...).
All of the hospitals have adopted new measures in the area of IC (graph 4), among which internal training, an increase in protective equipment, active listening to staff proposals and psychological support for employees stand out.
During the crisis, all the organisations created specific CI materials adapted to each stakeholder (table 1) and the tools most used were videoconferencing (84.6%), email (61.5%), instant messaging - specifically the WhatsApp service - (53.8%), the intranet and telephone (46.2%), internal applications and streaming channels (30.8%) and internal social networks (7.7%).
|
Material |
Usage rate |
|
Physical and virtual signage |
93,2% |
|
Messages from Management |
93,2% |
|
Notes and circulars |
76,9% |
|
Infographics |
69,2% |
|
Newsletter and emailing |
69,2% |
|
Training videos |
69,2% |
|
Informative videos |
69,2% |
|
Motivational videos |
46,9% |
|
Information brochures |
38,5% |
Source: Prepared by the authors.
Another critical element in the management of the IC during the crisis has been the role of managers and team leaders, who have participated very actively in all cases, have been involved in the coordination of tasks and have taken part in the proposed initiatives. In this way, coherence was maintained between what the entity manifests and what they transmit to their teams. Local leadership has been a success factor in the management of IC during the crisis, as they consider it to be a critical issue for the organisational culture in which the whole company must be involved.
100% of the participants agree that the crisis has changed the way IC is managed in hospital institutions and that it will continue to do so in the future. It has influenced the relationship and link between the organization and its employees and contributed to the IC teams gaining immediacy, agility and effectiveness and being aware of the importance of all communication mechanisms working properly. In addition, it has brought them closer to all management areas, highlighting the need to make the work of the organisation's members more permeable.
As for External Communication (EC), it reports to Corporate Communication (38.5%), Corporate Affairs (30.8%), General Management (23.1%) and Communication Management (7.7%). The average number of members of the departments is 4.5 (46.5% of the organisations have 4 people dedicated to this area). In all cases, the EC is managed by means of a previously designed and organised plan, although in 92.3% of them, actions can be incorporated if deemed necessary. Among the tools they use the most (graph 5), the relationship with the media, the corporate website and the use of social networks stand out. The measurement of results does not occur in 7.7% of the cases, although it is usual for the rest of the entities to use various methods such as impact in the media and social networks, response to external events, measurement of kpi specified in the annual plan (penetration of the message in key audiences, reflection in reputation rankings, own measurement of reputation...), etc.
The trends in the area of EC identified by those surveyed are: strengthening the conversation to establish more lasting relationships of trust, satisfaction and closeness through friendlier and less aggressive communication; disseminating an activity based on humanisation; strengthening the participation of users to find out their opinions and make the hospital's services better known, promoting its values; and in the use of digital platforms and online solutions aimed at increasing the brand's presence.
.Source: Prepared by the authors.
With regard to the COVID-19 crisis, 69.2% of the organisations did not have a crisis plan that contemplated a scenario of the current magnitude. The Sanitas centres had already incorporated an annex on pandemics into the 2020 Communication Plan in view of the previous alerts issued by the WHO. As in the case of the IC, the pandemic has affected the EC since, according to one participant, "it has put us to the test in the most hostile and uncertain scenario we have ever experienced". In fact, all the respondents pointed out that the EC's management of this crisis was completely different from any other and described it as "unique" due to its scale and its specific characteristics: immediacy, uncertainty and misinformation.
Therefore, it has forced the teams to gain agility and anticipate users' questions in order to provide quick and effective responses, and through this, in most cases, it has strengthened the position of the organization externally. During the crisis, there has been the particular situation of having to send any required information more regularly and urgently to Public Health. According to one of the participants, "it has required rapid learning and, at the same time, a very constant response, adapted to each new development offered by the pandemic". This has meant that in most cases the messages have been adapted to the different external audiences of the organizations, transmitting the activity of the centers and the current situation of the crisis.
The EC tools most used by the hospitals in this crisis (graph 6) have been the social networks, followed by telephone attention to the patient, personal attention and media appearances. However, in 15.4% of the cases the centres opted for silence: "It was not appropriate to give an opinion or appear in the media. It was necessary to channel communication in Public Health".
Source: Prepared by the authors.
77% of the organizations have created specific CE materials focused on the COVID-19 crisis (table 2) such as physical and virtual posters, newsletters and emailing, informative videos or messages from the Management.
|
Material |
Usage rate |
|
Physical and virtual signage |
84,6% |
|
Messages from Management |
76,9% |
|
Newsletter and emailing |
76,9% |
|
Informative videos |
76,9% |
|
Infographics |
69,2% |
|
Motivational videos |
53,8% |
|
Information brochures |
38,5% |
Source: Prepared by the authors.
The feedback obtained from stakeholders has been positive in all cases. These results have been obtained by the centres through the use of their own measurement tools and in some cases they have had the support of external reputation monitors. Also "it has been well valued to be available to the Ministry and / or Ministry of Health to accommodate patients Covid and other surgeries referred by public hospitals".
As for the effects that this crisis will have on the management of EC in the hospital environment, 90% of the responses indicate that it will generate changes due to the great impact that the pandemic has had on organizations. Anticipation and proximity in communications will be encouraged and the use of simpler narratives that are closer to the interests of the public will be promoted in order to get them to participate in the conversation.
DISCUSSION
The COVID-19 crisis has forced health systems to adapt in order to cope with an unprecedented situation, as several studies have already documented ( ; Santillán-Doherty, 2020) (Andrikopoulos & Johnson, 2020; Shalowitz, Lefkowits, Landrum, Gruenigen, & Spillman, 2020). Communication has become a key factor in managing health crises (Mestre & Bote, 2018; ; WHO, 2005) (Sa et al., 2009) and in the current pandemic, in which there have been a large number of hoaxes and fake news (Pérez-Dasilva et al., 2020; Salaverría et al., 2020), reliable sources of information have become more necessary than ever, asAleixandre-Benavent et al. (2020) point out. One of these sources of information has been private hospital institutions, which have tried at all times to adapt their IC and EC (Sánchez, 2011) to the new and changing reality, in a period of high uncertainty and great misinformation, the results obtained coinciding with other research ( ; Alfonso and Fernández, 2020) (Allahverdipour, 2020; Carico et al., 2020).
In a context in which the impact of the messages had the capacity to affect not only the brand, but the health network as a whole and society in general, private hospitals have worked from their crisis plans to apply all kinds of analog and digital communication tools (Medina, 2012; ) (Cabero et al., 2018; Costa-Sánchez & López-García, 2020) and create specific content with which to inform and attract audiences (Estrella, 2020). Organisations have developed both internally and externally different tactics and implemented new tools that would allow them to face the health crisis while maintaining the trust of their audiences. Some of those that have been applied and that coincide with previous research (Abrams & Greenhawt, 2020; Edwards et al., 2020; Huanga & Distaso, 2020; Martín, 2013) are videoconferencing, instant messaging, social networks or media appearances.
CONCLUSIONS
This study has achieved its objectives by determining the use made of EC and CI by Spanish private hospitals during the recent health crisis, being able to verify the use of different tools and the strategies they have applied to their different audiences. However, despite the fact that the entities studied had crisis plans, in most cases these did not contemplate a scenario as extreme as the current one, and not all the centres had planned internal communication actions. During the pandemic, the work routines of the communication departments have been modified, and valuable lessons have been learned from this crisis, such as greater agility, immediacy, responsiveness, cohesion among the members of the organization and involvement of team leaders. In addition, tools that in normal circumstances would not be the most commonly used, given the exceptional nature of the situation, have been strengthened. Internally, and although the centres already had employee care programmes in place, measures have been increased to protect the health of the workforce and enhance safety and a sense of belonging.
On the other hand, there is little uniformity in the situation in the organisational chart in the EC departments and especially in the CI departments, which do not usually report to the Communication Department, so that despite its strategic nature, the Communication area does not seem to have sufficient autonomy.
In the hospital environment, communication has been fundamental in dealing with the COVID-19 crisis and plays a critical role in facing the next phases of the pandemic and the period of New Normality, which will bring with it challenges hitherto unknown and which open up new research topics in the area of health communication and crisis communication.