The Institutional Black Box of Friction Between Digital Agility Demands and Clinical Bureaucracy in Hospital Social Media Management.

BACKGROUND: In the contemporary healthcare landscape, hospitals face a paradox between the need for digitally agile, emotionally engaging communication and the rigid, risk-averse nature of clinical bureaucracy. While social media enables narrative-based engagement, its implementation in hospitals remains constrained. This study aims to examine how institutional dynamics shape the implementation of narrative content and to explain the gap between audience engagement and observable electronic word-of-mouth (e-WOM). METHODS: This study employs a qualitative approach using Directed Qualitative Content Analysis (DQCA). Data were collected through in-depth stimulated recall interviews with hospital audiences and internal management, and analyzed using ATLAS.ti to identify thematic patterns related to institutional constraints, content implementation, and audience responses. FINDINGS: The findings reveal two key mechanisms. First, narrative content is constrained by institutional logics and bureaucratic processes, particularly approval bottlenecks, resulting in delayed, modified, or diluted implementation. Second, although narrative content generates high affective audience engagement, this does not consistently translate into public e-WOM. This engagement-behavior gap is explained by the role of dark social, where content is shared through private channels due to privacy concerns, social norms, and perceived risks. CONCLUSIONS: This study contributes by proposing a conceptual framework of institutional friction and introducing a practical Quality Control (QC) checklist to support the implementation of narrative content in hospital settings. The findings highlight the need to align communication strategies with institutional realities while recognizing that conventional metrics may underestimate the true impact of digital engagement due to the prevalence of dark social.