Purpose This study applies the Affect Theory of Social Exchange (ATSE) to examine how symbolic service recovery strategies, specifically apologies and gratitude expressions, influence patient empathy, forgiveness, and trust. It addresses the challenge of rebuilding trust following healthcare service failures through emotionally grounded mechanisms. Design/methodology/approach Five experimental studies (N = 1,221) were conducted to assess patients' emotional responses and behavioral intentions across varying levels of error severity, attribution, and history, as well as patient trait empathy. Findings Gratitude expressions elicited stronger patient empathy than apologies in isolated, low-severity errors, particularly among individuals with high trait empathy. In contrast, apologies were more effective in high-severity, system-attributed failures, where explicit acknowledgment of responsibility was expected. Practical implications The findings provide evidence-based guidance for tailoring recovery communications to the severity, attribution, and recurrence of errors, as well as to patients' empathy levels. Implementing these strategies can help healthcare organizations strengthen patient trust and promote more empathetic, relationship-centred care. Originality/value This research extends ATSE to healthcare service recovery by demonstrating how affective mechanisms drive trust restoration. It positions gratitude as an effective yet underused recovery strategy, offering theoretical clarity and practical relevance in contexts where providers may be constrained in offering apologies due to legal or reputational concerns.
Xu et al. (2026) studied this question.