Social media practices on Twitter: maximising the ...

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Social media practices on Twitter: maximising the impact of cardiac associations Robyn Gallagher, Professor of Nursing, Sydney Nursing School, Charles Perkins Centre; Trifon Psaroulis, Registered Nurse, Sydney Nursing School, Charles Perkins Centre; Caleb Ferguson, Chancellors Postdoctoral Fellow, University of Technology Sydney; all based in Sydney, Australia; Lis Neubeck, Professor, School of Health and Social Care, Edinburgh Napier University, Edinburgh; Patrick Gallagher, Research Assistant, Sydney Nursing School, Charles Perkins Centre University of Sydney, Australia. Email: [email protected]

© 2016 MA Healthcare Ltd

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ocial media is used by cardiac professional associations to engage with and inform members, as well as the general public, of new information. A common platform for this activity is Twitter—a messaging service through which users send short messages (‘Tweets’) of no more than 140 characters to deliver information to ‘followers’. Twitter combines features of blogging (a small, focused audience for direct and tailored communication in the form of followers) with features of social networking (hashtags and mentions) to distribute their message across a breadth of interested people. Many health professionals use Twitter because it is a flexible tool, suitable for many diverse purposes, which can include delivery of health services, health promotion and education, and collecting epidemiological data (Donelle and Booth, 2012; Grajales et al, 2014; Ferguson et al, 2014; Jaarsma, 2014; Smith and Lambert, 2014). A successful example of a Twitter group for nurses is WeNurses (Twitter handle: @WeNurses), which engages in regular conversations and communications with nurses around the world. Cardiac professional associations, such as the British Association for Nursing in Cardiovascular Care (@bancccouncil), have also identified the potential of Twitter to raise awareness, and increasingly use this method to communicate key messages to their followers (Redfern et al, 2013). In contrast to individuals, the Twitter practices of professional bodies must align with the mission of the organisation so that they are appropriately represented (Steyn, 2003; Gombeski et al, 2007; Wiggill, 2011). Tweets by cardiac professional associations ultimately aim to fulfil the association’s mission. Professional associations depend upon development of lasting and mutual relationships with stakeholders, which can be promoted by communication (Knox and Gruar, 2007; Wiggill, 2011), with the intent of strengthening and building trust and transparency (Mainardes et al, 2011). Messages used can be differentiated into strategic (selling ideas) and tactical (selling products and services) communications (Mainardes et al, 2011). Such communications are therefore planned, systematic efforts to aid in fulfilling the

British Journal of Cardiac Nursing

October 2016 Vol 11 No 10

Abstract

Twitter is a social media platform often used by cardiac professional associations to engage and inform their members and the public. However, the effectiveness of the strategy is seldom assessed or published. Aim: This study evaluates the Twitter activities of nine cardiac professional associations. Each organisation’s purpose and stakeholders were described individually and classified. Extracted Tweets (n=3920) were content-analysed and metrics were determined. Results: There was alignment between the associations’ mission statements and their Twitter activities. However, most Tweets were one-directional, disseminating research-based evidence/professional education materials and communicating association events and activities, as well as using hashtags to enable searching. Conclusion: Social media communication by cardiac professional associations through Tweets is an important activity; however, at present, the use of dialogue and conversations are not fully realised and could be used more strategically. Key words w Social media w Twitter w Cardiac professionals w Professional associations Submitted for peer review: 17 May 2016. Accepted for publication: 22 June 2016. Conflict of interest: None.

stated objectives of the organisation (Thomas and Stephens, 2015). Ultimately, organisations need to regularly evaluate their Twitter practice to determine the effectiveness of their policy and guide future endeavours. There is little evidence that this occurs in cardiac professional associations and particularly in published form.

Study aim

The objective of this study is to investigate the patterns of social media activities of key cardiac professional associations, as well as the relationship to the association’s goals, and the impact of these activities.

Methods

Study design and eligibility criteria

The current study used a mixed-methods design, incorporating quantitative descriptive methods for overall Tweet 481 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 138.025.078.025 on October 8, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.

Technology Table 1. Cardiac professional association characteristics Twitter handle

Purpose

Stakeholders Members

Secondary

American Association @AAHFN of Heart Failure Nurses

To lead heart failure nurses

Heart failure nurses

Tertiary health-care sector

American College of Cardiology

To improve cardiovascular health education, research, quality care and health policy

Cardiologists

Health-care workers, tertiary health-care sector, regulatory & government bodies, researchers, health consumers

Australasian @ACNC1 Cardiovascular Nursing, College

To lead cardiovascular nurses

Cardiovascular nurses

Tertiary health-care sector

Australian Cardiovascular Health and Rehabilitation Association

@ACRA_ACRA

To support and advocate for health professionals; to promote evidencebased practice in cardiovascular care

Cardiovascular health professionals

Tertiary health-care sector, regulatory & government bodies, health consumers

Preventive Cardiovascular Nurses Association,

@HeartNurses

To provide advocacy and education (profession and community); to promote evidence-based practice



Cardiac Society of Australia and New Zealand

@thecsanz

To facilitate professional development, improve medical practice, enhance quality of care

Cardiologists, cardiac health professionals


@CSANZCNC Cardiac Society of Australia and New Zealand Cardiovascular Nurses Council

To facilitate professional development, improve medical practice, enhance quality of care



American Heart Association

@AHAScience

To fight heart disease and stroke


Health-care workers, regulatory & government bodies, general public, health consumers

European Society of Cardiology

@escardio

To reduce cardiovascular disease burden in Europe



World Heart Federation

@worldheartfed To fight heart disease and stroke

Affiliated associations, councils, societies


@ACCinTouch

activity and influence, and qualitative methods for the Tweet content. Data were collected from cardiac professional association webpages and associated Tweet content/ attachments. Cardiac professional associations were selected across a range of diverse cardiac professional associations, as well as geographical regions (e.g. Europe versus Britain), professions (e.g. nurses, doctors, allied health), and public and membership-based organisations. Furthermore, the associations had to have an active Twitter handle (username/active Twitter account), a Twitter timeline of >1000 Tweets, >100 followers and Tweets that were in English. The resulting sample included nine cardiac professional associations as listed in Table 1: ww American Heart Association (AHA) ww American Association of Heart Failure Nurses (AAHFN) ww American College of Cardiology (ACC) 482

ww European Society of Cardiology (ESC) ww World Heart Federation (WHF) ww Cardiac Society of Australia and New Zealand (CSANZ) ww Cardiovascular Nursing Council of CSANZ (CSANZCVNC) ww Australian Cardiovascular Nursing College (ACNC) ww Australian Cardiovascular Health and Rehabilitation Association (ACRA). Ethics approval was not required as all the data collected were publically available on the web.

Data collection

Data were collected from the association websites, and included mission statements, stakeholders and Tweets. The organisational purpose, scope of mission activities, and mission statement stakeholders were recorded. Tweets


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Organisation

Technology ©Stephen Lillie

(n=3636) were extracted retrospectively from the Twitter timelines, with a minimum of 100 from each organisation on 19 July 2015. Thus, 100 Tweets may represent an association’s activity for 24 hours or for 1 year according to the Tweet rate.

Data analysis

Each organisation’s purpose and stakeholders were described individually and classified into whether the scope of the mission was broad or narrow (Mainardes et al, 2011). Extracted Tweets were thematically analysed in four steps using the National Centre for Social Research framework (Smith and Firth, 2011). The first step involved extracting 20 of the most recent consecutive Tweets for each organisation, and two of the researchers (lead and second author) independently classified the content into broad themes. In the next step, the two researchers reached consensus on six broad themes of Tweet content and inclusion criteria relevant to each theme. Through an iterative and exhaustive process between the two researchers, the entire Tweet sample was classified into six themes (by the second author). Upon completion, another researcher (third author) independently reviewed random Tweets for the coding for theme fidelity. Tweet characteristics and themes were described using frequencies/ percentages, with quotes used to illustrate the theme. Tweet attachments were noted and described using frequencies/percentages. Twitter influence was determined using two publically available social media analytic platforms: KredTM (www. kred.com) and PeerIndexTM (https://www.brandwatch. com/peerindex-and-brandwatch/). The basic metric feature of each platform was used to calculate an overall influence score generated by each organisation’s Twitter handle. Each platform defines influence by the attributes it measures, then applies this to algorithms to determine the scores.

Results

The cardiac professional associations, along with their purpose and stakeholders, are described in Table 1. The majority (70%) have a narrowly defined mission to provide leadership within cardiac health professions, or areas of the profession’s interest, and their specific membership (primary stakeholders). The focus was on cardiovascular education, research, health policy and advocacy. In contrast, associations with broad mission statements incorporated aspirations to fight heart disease or reduce its burden. Secondary stakeholders were generic health professionals, the tertiary health-care sector, regulatory and government bodies, and health-care consumers.


Twitter content

Six Twitter content categories were identified from the 3620 Tweet sample (Table 2) on the basis of the intention of the message and the anticipated audience: ww Research-based evidence/professional education (31%) ww Social communication (28%) ww Public health/advocacy (13%)



Cardiac professional associations use social media to disemminate information but could engage members more effectively through two-way dialogue ww Professional opinion/case studies (12%) ww Marketing/promotion (11%) ww General news/events (5%).

1. Research-based evidence/ professional education

This category included Tweets intended to promote evidence-based knowledge to a professional audience; primarily association members and like-minded individuals and organisations. The content included recently-published journal articles, or professional guidelines and reports, for example: Heart Failure Patients Wind Up in ER Too Often: Study http://t.usnews.com/Z2vr9q via @usnews Readmission Solutions? http://bit.ly/1lyjlF4 ACCF/AHA 2013 Guidelines for Managing Heart Failure http://bit.ly/1f590Nj #readmissions #heartfailure 483 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 138.025.078.025 on October 8, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.

Technology Table 2. Tweet content categories, stakeholder, message type and attachments (n=3620) Category

Anticipated audience

Message intention

Attachment type %

Hyperlink

Data file

Photo

YouTube

Research-evidence/ professional education

Members

Strategic

31

97

20

3

1

Social communication

Members

Strategic

28

35

18

12

2

Public health/advocacy

Members & secondary stakeholders

Strategic

13

60

8

32

7

Professional opinion/ case studies

Members

Strategic

12

28

2

6

4

Marketing/promotion

Members

Tactical

11

82

2

6

4

General news/events

Members & secondary

None

5

82

16

12

2

stakeholders

2. Social communication

Tweets in this category aim to foster, maintain and build the relationship between the organisation and its members, and mainly occured during events with social elements such as Christmas parties, awards nights, conferences or symposiums. The Tweets often included statements of gratitude and appreciation; notices and calls; organisational news and updates; and event highlights and occurrences, for example: @AHAMeetings Scientific Session in #Chicago starts today. See you there! #AHA14 #CVD #health @thecsanz thank you to Lynne and team for #fabulous #work we really appreciate your support #csanz2013

The simplicity of the messages suggests that the target audience is general health consumers, with an aim to reinforce knowledge and public opinion. This content is strategic communication and associations varied markedly in the use of this type of content. For instance, less than 10% of the Twitter content examined in the current study is in this class; the exception to this is @worldheartfed, whose content in this class is at 66%.

4. Professional opinion/case studies

These Tweets contained primarily advice, opinions and personal experiences of experts; such as interviews, recommendations, personal stories and conversations, for example: Inspirations From an Extraordinary Life: Joseph K. Perloff, MD, FACC http://ht.ly/FKaSb DASH diet should be recommended for people with hypertension. Prof Houston Miller @HeartNurses #WCC2014

The purpose of these Tweets is to strengthen the sense of community, by keeping members informed of the current affairs of the organisation and engendering a sense of inclusivity and connectivity. Individual members rarely Tweet this way and there are no replies evident. This means organisations are engaging in monologues and broadcasting information publically, in a one-to-many form of engagement personalised to its online community members. The message is strategic, to promote active engagement and cultivation of the organisation’s image and brand.

Such Tweets communicate information of a less-technical nature, avoiding research journals and technical terminology, and thereby ensuring more accessibility to a wider audience. However, the professional topics suggest that the target audience is still the members, and appear to reinforce the message of evidence-based practice by presenting it in another format.

3. Public health/advocacy

5. Marketing/promotion

This category contains Tweets disseminating general heart-health-related information or advocacy for causes/ campaigns; emphasising the importance of heart health: Let’s all sign up to recognize #CHD Awareness week @ACCinTouch @childrenshealth http://wh.gov/ig8ao 484

how many #vegetables do I need—answer is 5 serves/day to prevent #earlydeath http://1.usa.gov/ VpepYh

Tweets within this category are for the marketing/promotion of products and services, for example: Hey Nurses, our 20th Annual Symposium in Atlanta will feature new sessions on behavior & lifestyle change, nutrition and obesity! #PCNA14


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These strategic messages aim to promote uptake of evidence-based practice within the profession. The proportion of this category varied between organisations, with a larger proportion from @AHAScience (62%), @ ACNC1 (60%) and @ACCinTouch (54%).

Technology Check out our newest On-Demand CE course: Patient Advocacy in Post-Hospitalization Care of ACS. Register here: http://ow.ly/Bl8nP These Tweets are commercial. They foster business for the organisation, primarily for members who consume these services for professional development, and aim to fulfil commercial objectives. These represent a minority of Twitter activity in the current study.

6. General news/events

This smallest category contains general interest and news items and the content originates outside the organisation, for example: Mobile apps now account for over 50% of the time Americans spend consuming digital media. http:// on.wsj.com/1scavwk Volcano erupts in Papua New Guinea http://on.wsj. com/1lkambE These Tweets are non-strategic and may have been intended to break up the relatively monotonous nature of routine posts with general interest items.

Inclusions, microblogging and information dissemination

There was a high use of attachments; 75% of Tweets contained at least one attachment and 16% contained multiple. Four key attachment types were found (Table 2): hyperlinks (65%), data files (14%), photos (12%) and Youtube links (2%). Hyperlinks are most popular, linking followers to related websites, oftentimes to extend content beyond the 140-character limit and most evident in the research-based evidence/professional education category where 97% of Tweets have attachments linking to source articles. These Tweets act like headlines, inviting readers to explore further. Not all organisations extensively use attachments. The ESC posts attachments to only 17% of its Tweets compared with the other cardiac professional associations, where more than 70% of Tweets have attachments.


Social networking behaviour

Twitter facilitates social networking through hashtags (#) and mentions (@). In cardiac professional associations, there is a preference for hashtagging—occurring in 70% of Tweets versus mentions in 16% of Tweets. Moreover, 25% of Tweets contain multiple hashtags, a means by which organisations attempt to spread their ‘voice’ or message to wider audiences as they ‘join the conversation’. Mentions are mainly restricted to category-1 Tweets (85%), with only 3% of Tweets containing multiple mentions. This preference for hashtags indicates that cardiac professional associations more readily engage in one-to-many conversations as opposed to one-to-one conversations that are derived through mentions. It also indicates the preference for one-way information projection over dialogue.



Table 3. Twitter handle influence scores Twitter Handle

Followers Retweets

Kred

Peer Index

Score

Score

(0–1000)

(0–100)

@AHAScience

31 100

1137

750

60

@escardio

24 500

1100

798

60

@ACCinTouch

20 900

1382

784

61

@worldheartfed

6002

2677

784

57

@AAHFN

1206

130

600

35

@HeartNurses

1181

2694

629

33

@thecsanz

719

775

629

37

@ACRA_ACRA

324

11 833

627

27

@CSANZCNC

226

966

634

26

@ACNC1

192

5972

557

28

Social media influence

Social media metric scores strongly correlated with the number of followers (Table 3). The same top four Twitter handles of @escardio, @ACCinTouch, @worldheartfed and @AHAScience occur in both metric systems. The two handles with substantially more ‘retweets’ (where a user reposts someone else’s existing Tweet) came from a relatively small number of Tweets; with @ACRA_ACRA having one Tweet being retweeted 9466 times and @ACNC1 having 5 Tweets being retweeted 3793 times. This relatively low retweeting activity illustrates the effect of their Twitter content specificity, which is primarily targeted towards their members.

Discussion

Cardiac professional associations align Twitter activity with their mission, either for members or for a more public audience. The majority of social media activity is onedirectional, disseminating research-based evidence/professional education materials, and communicating association events and activities or using hashtags to enable searching. The impact of strategic social media communication is not fully realised, particularly the use of conversations. There is a preoccupation with one-way distribution of information at the expense of dialogue and therefore the potential to engage. Our findings are consistent with other studies investigating Twitter activity of cardiac professional associations (Redfern et al, 2013) and non-profit organisations in general (Lovejoy and Saxton et al, 2012; Lovejoy et al, 2012). The overwhelming majority of content delivered by cardiac professional associations is devoted to education through evidence-based research for the profession, or generic statements of facts for the layperson. This encourages using attachments and hyperlinks to extend the quantity and quality of information disseminated beyond the 140-character limitation. One finding of this study is that most cardiovascular associations operate in a one-to-many communication 485 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 138.025.078.025 on October 8, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.

Technology

w Social media, particularly Twitter, is being increasingly used by cardiac professional associations to communicate w There have been few published studies that determine and compare the Twitter profiles of cardiac professional associations w Cardiac professional associations are Tweeting messages that are consistent with their mission using a focused (membership) and/or broad (general public) strategy w The overwhelming majority of Tweets from cardiac professional associations are unidirectional, information-giving w There is a lack of use of conversational strategies in cardiac professional Tweets, reflecting either poor understanding or unwillingness to engage in this effective method

mode, rather than interacting with individual members. It could be argued that this is a function of the utility of Twitter rather than a misunderstanding of the scope of Twitter to engage members. However, there are professional groups on Twitter which do successfully engage many people in regular Tweet Chats, such as @WeNurses. Robust evaluation of how this is successfully achieved would help inform future communication strategies. What is currently entirely unknown is what population of people observe Tweet Chats, such as this in the capacity of ‘lurker’, where they are passive rather than active participants, and the relative value in passive or more active engagement. The social networking aspect of Twitter is only active in the minority of organisations. Hashtags outnumber mentions, and mentions occur more often in social communications. This is predictable, as hashtags are authordriven and precede social interest, and mentions are audience-driven and follow from social interest. Thus, when mentions are used to engage, it is through public messaging towards individuals aiming to express sentiments witnessed by their online community. This may well act as a type of online social glue to strengthen the relations between cardiac professional associations and their online community. An important finding is that popular social media metrics provide limited insights for cardiac professional associations to differentiate their activities, as similarities in mission scope produce similar communication strategies. While popular social media metrics produce influence scores that correlate to follower numbers and high volumes of activity, including retweets, this limits the possibility of benchmarking between organisations on the basis of influence scores alone. Strategies are needed that increase the popularity of Tweets (Liu et al, 2012; Bian et al, 2014). A very popular or controversial Tweet (for example, a Tweet about the activities of a famous person) might reach more people, but mass communication for the sake of increasing metric scores may result in alienating some stakeholders including members. 486

Conclusion

Cardiac professional associations use Twitter strategically to communicate to key stakeholders and manage relationships with members and interest groups. Most Twitter activity provides education-related material to professionals and health consumers, and this is primarily through microblogging in the form of one-way communication. The social aspect of Twitter is less used, and appears primarily in the form of hashtags. The only place where mentions predominate is in the social communication category, in order to engage with members to strengthen relations and bonds. Promotion of conversation through Twitter may enable more strategic communication. Finally, regular evaluation of strategic communication outcomes should be undertaken by cardiac professional associations to ensure alignment with their mission statement. BJCN Acknowledgements: We would like to thank Sydney Nursing School of the University of Sydney for the summer scholarship for second author, Trifon Psaroulis.

References

Bian J, Yang Y, Chua TS (2014) Predicting trending messages and diffusion participants in microblogging network. Proceedings of the 37th International ACM SIGIR Conference on Research & Development in Information Retrieval, Gold Coast: 537–46 Chretien KC, Azar J, Kind T (2011) Physicians on Twitter. JAMA


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Key Points

As the social media landscape continues to evolve and change, the way cardiac professional associations use Twitter to service stakeholders must also change. For instance, a recent study has shown high Twitter uptake rates and usage by physicians, with a majority of their Tweets constituting medical issues (Chretien et al, 2011). Moreover, another study found physicians self-appraising social media highly; as it helps them deliver quality care effectively (McGowan et al, 2012). Astute organisations that know their members will be able to accommodate this growing need. However, this is influenced by the resources an association has. For some large, well-resourced associations, Tweeting is carried out by staff, whereas for many smaller volunteer-based associations, these duties must fit in with the volunteers’ workload. Twitter policies and practices would benefit from considering what approaches to engagement may be most effective, particularly for cardiac nurses, while aligning with their aims and mission statement. Regular stakeholder analyses should be conducted to identify the most receptive stakeholder groups and the type of needs that the medium can address best. The social networking aspect of Twitter should be used strategically to strengthen relations and to build trust between the organisation and the targeted stakeholder group. For example, if the purpose of the Tweet is to disseminate professional information, e.g. publication of a relevant paper, measuring the uptake of that activity as a result of that Tweet, such as the number of people in the organisation who access the link to the paper via Twitter, would help demonstrate that the relationship and activity were congruent with the purpose.

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