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

Healthcare organizations face persistent operational challenges and have increasingly turned attention to managing patients’ expectations. Expectations are multidimensional (e.g., probability expectations, value expectations, treatment/care expectations) and are shaped by information, personal and observed experiences. When patient expectations are overlooked or unmet, organizational-level nocebo effects can arise, producing negative consequences for patients (worsened symptoms, poorer clinical course) and the organization (dissatisfaction, reduced adherence, negative word-of-mouth, drop-outs, staff frustration and turnover). The authors argue that consideration of expectations must extend beyond the clinician–patient dyad to the entire healthcare organization. The paper’s objectives are to: (1) describe potential scenarios of organizational nocebo effects stemming from how expectations are handled across policies, practices, and processes; and (2) suggest implications for managing these effects.

The paper notes that nocebo effects and expectations have been extensively studied in laboratory and clinical settings, but less so at the organizational level. Prior research highlights the role of expectations in shaping outcomes and the presence of nocebo effects across health outcomes, while also emphasizing person-focused care. The authors identify a gap in considering how organizational structures, priorities, and roles (leaders, managers, clinicians, front-desk staff) collectively influence expectations and may generate nocebo effects when misaligned.

This is an opinion paper that synthesizes the authors’ real-world experiences with organizational practices, processes, and policies. It presents three illustrative scenarios demonstrating how organizational actions and misalignments can create nocebo effects when patient expectations are neglected. A contemporary example from the UK NHS First Contact Physiotherapy model is used to illustrate a potential ‘perfect storm’ of organizational nocebo effects. The paper also summarizes practical implications (Table 1) as considerations for organizations rather than prescriptive, context-invariant solutions. No empirical data collection or formal analytic methods were employed.

• Three organizational scenarios likely to generate nocebo effects when patient expectations are not addressed:
  1. A disconnect between what an organization claims (mission/values such as person-focused care) and what it operationalizes (e.g., shorter visits, higher caseloads, efficiency-driven metrics), leading to unmet expectations of care.
  2. Tension between managerial and clinical perspectives on expectations and their measurement (aggregate satisfaction versus individual clinical outcomes), risking misaligned decisions and diminished emphasis on clinical quality.
  3. Front-desk staff roles and training gaps that can produce negative patient experiences (e.g., task-centered interactions, unqualified triage, mismanaged priorities) and consequent nocebo effects.
• A ‘perfect storm’ example from the UK NHS First Contact Physiotherapy model: pressure to reduce wait times and appointment durations may leave clinicians unable to practice person-focused care; patients feel unheard or redirected to perceived less-qualified providers; front-desk staff face patient frustration—all breaching expectations and amplifying nocebo effects.
• Practical implications to mitigate organizational nocebo effects include: meaningful patient engagement in governance; recruiting clinicians into management roles; organization-wide training in a person-focused approach and communication; aligning outcome measures with patient values; conflict management training; and ensuring front-desk staff operate within appropriate scope with adequate training.

Addressing patient expectations at the organizational level can mitigate nocebo effects by aligning what is promised with what is delivered, harmonizing managerial and clinical perspectives, and supporting front-desk staff as critical first contact points. Integrating patient expectations into governance, metrics, and resource allocation reinforces person-focused care across the patient journey. Clear communication, shared understanding of goals, and training can reduce the disconnects that fuel organizational nocebo effects. The NHS First Contact Physiotherapy example illustrates how pressures for efficiency without alignment to patient expectations can cascade into dissatisfaction, poorer perceived quality, and staff demoralization. By re-centering expectations, organizations can improve patient experiences and outcomes while supporting staff and operational performance.

Providing care within a positive organizational context that consistently values and manages patient expectations is essential to avoid organizational nocebo effects. The paper calls for expanding focus beyond the clinician–patient interaction to organizational policies, processes, and roles. Raising awareness of organizational triggers of nocebo effects and embedding patient expectations into decision-making, metrics, training, and communication can transform care delivery. Educational initiatives on placebo/nocebo for healthcare providers are aligned with this priority. Future efforts should further develop and evaluate organization-level strategies to integrate patient expectations and measure their impact on outcomes and satisfaction.

As an opinion paper, there is no empirical methodology or data analysis. The scenarios and implications are based on the authors’ experiences and literature, which may limit generalizability. The authors explicitly note they cannot offer specific, context-invariant solutions because organizational contexts vary. No quantitative evaluation of recommended strategies is provided.