Don't be a nocebo! Why healthcare organizations should value patients' expectations

Healthcare organizations face numerous challenges, including staff recruitment, cost control, and quality improvement. Increasingly, managing patient expectations is recognized as a crucial aspect of operational success. Patient expectations are multidimensional, encompassing probability, value, and anticipated treatment benefits. These expectations are not static; they evolve based on patient experiences, information received, and observations of others' experiences within the healthcare system. This complexity necessitates a broader organizational approach to managing patient expectations, primarily to avoid negative nocebo effects. Nocebo effects, in this context, are negative consequences arising from unmet or neglected patient expectations at any level of the healthcare organization. These effects can impact patients (e.g., symptom exacerbation, treatment non-adherence), the organization (e.g., negative referrals, staff burnout), and overall patient care outcomes. This paper focuses on how organizational policies, practices, and processes can inadvertently contribute to nocebo effects due to a failure to effectively manage and meet patient expectations, expanding the usual focus from clinician-patient interactions to the entire healthcare organization.

The paper draws on existing research on nocebo effects and expectations in laboratory and clinical settings. It acknowledges extensive research into nocebo effects and expectations in controlled settings, but emphasizes the need to consider the broader context of the healthcare organization in understanding and managing these effects. The authors cite various studies concerning person-centered care, patient experience measurement, the role of front-line staff, and the impact of organizational culture on patient care. They also reference existing literature on the challenges of implementing person-focused care models and the potential conflicts between clinician and managerial perspectives on patient expectations. The review highlights the lack of research focusing specifically on how organizational factors, beyond individual clinician behavior, contribute to nocebo effects.

This is an opinion paper, not an empirical study. The methodology relies on a qualitative analysis of real-world experiences within healthcare organizations. The authors present three scenarios illustrating how different aspects of the organization can generate nocebo effects. These scenarios are based on the authors' combined professional experience and observation of healthcare practices, processes, and policies. The paper uses these scenarios to illustrate the different perspectives of clinicians and managers on patient expectations, the impact of front-line staff interactions, and the conflict between organizational rhetoric (e.g., commitment to person-centered care) and operational realities (e.g., time constraints). The authors provide examples from the UK National Health Service (NHS) to support their arguments, highlighting the potential for a perfect storm of nocebo effects when multiple organizational factors interact negatively. This paper is primarily a conceptual analysis, drawing on real-world examples rather than quantitative data or statistical analysis.

The paper identifies three key scenarios contributing to nocebo effects within healthcare organizations: 1. **Disconnect between stated values and operational realities:** Organizations often communicate values such as person-centered care but fail to operationalize these values due to competing priorities (e.g., efficiency metrics), creating a gap between what is promised and what is delivered. This disconnect can manifest in reduced appointment times, increased clinician workloads, and unmet patient expectations for individualized care. 2. **Conflicting perspectives on patient expectations:** Clinicians focus on individual patient needs and clinical outcomes, while managers often emphasize aggregate patient experience measures (e.g., satisfaction scores). This difference in perspective can create tension and misaligned priorities, particularly when satisfaction scores don't align with clinical outcomes. Prioritizing operational efficiency over clinical effectiveness can lead to unmet patient expectations regarding quality of care and treatment effectiveness. 3. **Inadequate training and role clarity for front-line staff:** Front-desk staff are frequently the first point of contact for patients. Inadequate training can result in ineffective communication, inappropriate triage decisions, and negative patient interactions, creating nocebo effects. Unqualified triage decisions, for example, can directly affect patient care and clinical outcomes. The paper uses the example of the UK NHS's First Contact Physiotherapy initiative to illustrate how pressure to reduce wait times can lead to shorter appointment durations, potentially causing patient dissatisfaction and perpetuating nocebo effects through multiple interacting organizational factors.

The paper's findings highlight the importance of moving beyond a narrow focus on clinician-patient interactions in understanding and managing nocebo effects. The authors argue that healthcare organizations must adopt a holistic perspective, considering how all aspects of the organization contribute to patient experience. The three scenarios illustrate the interconnected nature of organizational factors in shaping patient expectations and outcomes. The suggested strategies—patient engagement, aligning performance metrics, comprehensive staff training, and role clarification for front-line staff—emphasize the need for organizational-level changes to mitigate nocebo effects. The discussion emphasizes the need for a systems-level approach to improve patient care and reduce the incidence of nocebo effects, improving both patient and staff well-being. The example of the UK NHS underscores the potential for widespread negative consequences when multiple organizational factors contribute to unmet patient expectations.

This opinion paper advocates for a more comprehensive understanding of nocebo effects within healthcare organizations. By acknowledging the various ways in which organizational factors can contribute to negative patient experiences, healthcare systems can proactively implement strategies to mitigate these effects. This includes fostering patient engagement, aligning organizational objectives with patient values, enhancing staff training, and clarifying roles to ensure that all team members contribute to positive patient experiences. Future research should focus on developing and evaluating interventions that address organizational-level factors contributing to nocebo effects. The authors' work serves as a call to action for healthcare organizations to proactively address patient expectations and create a positive care environment.

As an opinion paper, this work does not present original empirical data. The analysis is based on the authors' observations and experiences, which might limit the generalizability of the findings. The scenarios presented are illustrative examples, and the specific factors contributing to nocebo effects may vary across different healthcare organizations and contexts. Future research should focus on quantitative studies exploring the prevalence and impact of these organizational factors on patient outcomes and the effectiveness of interventions to mitigate nocebo effects.