The "Are You OK?" Paradox: A Scoping Review of Nocebo and Negative Suggestion in Healthcare Communication

Background: Nocebo effects are described as adverse symptoms arising from negative expectations rather than direct physiological harm, and are increasingly recognised across healthcare. While traditionally examined within pharmacological trials, emerging literature suggests that nocebo effects are shaped by broader interactional, situational, and communicative processes. In dentistry and paediatric care, where behaviour support and reassurance are central to practice, these mechanisms remain under-synthesised. Objectives: This scoping review aimed to map how nocebo effects are conceptualised across healthcare literature, with particular attention to the role of communication, reassurance, and behaviour support, and to explore how these mechanisms are discussed in paediatric, procedural, and dental contexts. Methods: An interpretive scoping review was conducted in line with JBI guidance and PRISMA-ScR reporting standards. Multidisciplinary literature spanning experimental, clinical, ethical, and applied domains was systematically identified and charted. Studies were grouped using a conceptual framework encompassing expectancy, learning, communication-mediated, ethical, and contextual mechanisms, allowing overlap between categories. Results: A large and heterogeneous body of literature was identified, with most studies conceptualising nocebo effects through overlapping mechanisms rather than discrete pathways. Expectancy and learning processes formed a foundational substrate across contexts, while communication, including framing, tone, reassurance, and checking-in, emerged as an active mechanism shaping symptom perception and vigilance. Ethical discussions highlighted tensions between transparency and potential harm, particularly in consent and risk communication. Paediatric and procedural settings, including dental sedation, were comparatively underrepresented despite features likely to amplify nocebo effects, such as reduced agency and heightened attentional focus. Conclusions: Nocebo effects are best understood as interactional phenomena that emerge within everyday clinical encounters. This review highlights the need to critically examine behaviour support practices, including reassurance, that are typically assumed to be benign. Greater conceptual clarity and reflexivity in communication may support future research and training aimed at minimising unintended distress within dental and paediatric care. These findings suggest that routine communication practices, including reassurance and expectation-setting, should be understood as active components of care that can influence patient experience, rather than as neutral or purely supportive interactions.