Navigating emotional demands: a qualitative study of emotion regulation among physiotherapists managing private practice clinics

Introduction

This study explores how physiotherapists managing private practice clinics use emotion regulation to navigate emotional demands in patient care, collegial interactions, and broader management responsibilities. Physiotherapists are expected to play an increasingly central role in future healthcare systems, driven by rising global rehabilitation needs linked to a growing aging population with functional decline, complex multimorbidity and the lasting impacts of the post-pandemic context (McCarthy et al., 2023; Wong et al., 2024). Understanding how these professionals manage emotional demands becomes particularly important.

Health care professions are increasingly recognized as emotionally demanding, with significant consequences for professionals' mental well-being (Delgado et al., 2017; Broetje et al., 2020; Fernandez-Basanta et al., 2023). Research shows that the ability to wisely regulate emotions is central to maintaining both professional functioning and mental well-being to ensure empathetic and safe patient care, ethical decision-making and constructive teamwork (Saccaro et al., 2024; Sattar et al., 2024). Ineffective emotion regulation, on the other hand, has been associated with emotional exhaustion, reduced quality of care, and increased turnover intention among health professionals (Garcia et al., 2019; Zhang et al., 2020; Krebs et al., 2025).

Research among physicians and nurses shows that clinicians draw on multiple emotion regulation strategies, including reappraisal, suppression, surface acting and deep acting to manage emotionally charged encounters. Whereas, reappraisal and deep acting are generally associated with more adaptive psychological outcomes, suppression and surface acting are consistently linked to emotional strain and burnout (Edward et al., 2017; Jackson-Koku and Grime, 2019; Feng et al., 2024).

In the field of physiotherapy, emotional demands arise both in direct patient interactions and in professional collaboration (Preece, 2020; Burri et al., 2022; Venturini et al., 2024). Accordingly, (Venturini et al. 2024) found in a systematic review that approximately 27% of physiotherapists globally experience emotional exhaustion. These findings indicate that physiotherapists, like other health professionals, face substantial emotional demands in their clinical work.

To understand how such emotional demands are regulated in clinical practice, two complementary theoretical frameworks are applied: Gross's process model of emotion regulation and Hochschild's theory of emotional labor (see Supplementary files Figure 1). Gross's process model of emotion regulation focuses on intrapersonal strategies, such as reappraisal and suppression (Gross, 1998, 2015). In this study, we use the term reappraisal as a shorthand for cognitive reappraisal, one of several antecedent-focused emotion regulation strategies in Gross's (2015) process model. Reappraisal involves altering one's interpretation of a situation to influence the resulting emotional response positively (Gross, 2015; Naragon-Gainey et al., 2017; Wang et al., 2025). For example, rather than focusing solely on the negative aspects of a conflict, physiotherapists might view it as an opportunity for learning, thereby altering its emotional impact (Peña-Sarrionandia et al., 2015; Troy et al., 2018; Torrence and Connelly, 2019). This strategy has been consistently linked to enhanced mental well-being (Liddell and Williams, 2019; Haver et al., 2023; Wang et al., 2023).

In contrast, suppression involves concealing genuine emotions and emotional expressions, a strategy that has often been associated with reduced mental well-being (Chervonsky and Hunt, 2017; Cameron and Overall, 2018; Grandey and Sayre, 2019). For example, rather than expressing anger in a workplace conflict, physiotherapists may present a facade of calm control while suppressing the underlying emotions, gradually depleting energy resources over time (Naragon-Gainey et al., 2017; Haver et al., 2023). Hochschild's (1983) sociological theory of emotional labor, highlights how professionals manage emotional expressions in social interactions through surface acting and deep acting. Surface acting occurs when individuals adjust their outward expressions to conform to professional norms, without altering their internal emotional state (Gabriel et al., 2020; Feng et al., 2024; Melloy et al., 2026). A typical example is when a physiotherapist must inform a frustrated patient that there is a long waiting list before treatment. The physiotherapist delivers this message calmly and professionally, despite feeling moral distress about not being able to offer timely care. When there is a discrepancy between expressed and felt emotions, the resulting dissonance may increase stress and undermine mental well-being (Grandey and Sayre, 2019; Gabriel et al., 2023; Humphrey, 2023). Deep acting on the other hand entails actively modifying one's internal emotional state to align with professional expectations (Fernandez-Basanta et al., 2023; Gabriel et al., 2023; Wang et al., 2025). Through deep acting, physiotherapists may attempt to genuinely regulate positive emotions internally and express support, thereby enhancing patient motivation. Deep acting has been linked to greater authenticity in emotional expression, which in turn is positively associated with mental well-being (Humphrey, 2023; Melloy et al., 2026). Taken together, these frameworks capture both the internal regulation of emotions and the outward management of emotional displays, each central to professional practice.

In this study, conceptualization of mental well-being aligns with the World Health Organization‘s definition, which emphasizes “mental health as a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn and work well, and contribute to their community” (World Health Organization, 2025).

Despite the growing body of research on emotion regulation in health care settings, no previous studies have explored how physiotherapists working in private practice clinics experience and regulate emotional demands within this organizational context. This gap underscores the relevance and timeliness of the present study. Understanding how physiotherapists regulate emotions in this context is important not only for their own mental well-being, but also for the quality of patient care they provide.

Against this background, the study seeks to address two research questions:

• How do physiotherapists managing private practice clinics use emotion regulation?
• What is the significance of their use of emotion regulation for their mental well-being?

Methods

Design and setting

This study employed a qualitative, exploratory research design, using a reflexive thematic analysis process to enable an in-depth exploration of subjective experiences and meaning-making processes (Braun and Clarke, 2006) anchored in an interpretivist paradigm. A semi-structured interview guide was used to collect the data, grounded in the research literature on emotion regulation and its relationship to mental well-being. This approach allowed for a flexible and open-ended exploration of participants' reflections, facilitating rich descriptions of their experiences without being constrained by predefined theoretical assumptions or hypothesis (Polit, 2020). The interview guide was originally developed and used in previous research (Haver et al., 2014) and was subsequently adapted to the physiotherapy context to ensure its relevance for physiotherapists with municipality agreements managing private clinics in Norway. The interview guide was refined prior to data collection, by two physiotherapists managing private clinics who did not participate in the study. No revisions were deemed necessary.

Physiotherapists managing private practice clinics in Norway operate within a distinct organizational structure characterized by high autonomy and limited formal managerial hierarchy. They are self-employed and work in flat organizational settings where administrative and managerial responsibilities- such as budgeting, it-systems, patient administration, and ensuring quality assurance- are frequently rotated among colleagues. This dual role as both clinician and manager requires continuous balancing between patient care and operational management tasks. Unlike in municipal or hospital services, private clinics typically lack formal managerial support systems, making adaptive, self-directed, and context-sensitive forms of leadership particularly important in everyday practice.

Participants and recruitment

A criterion-based, purposive sampling strategy was employed to recruit participants who could provide rich and relevant insights into the study phenomenon (Malterud, 2021). Eligible participants were self-employed physiotherapists with municipal agreements who co-owned and managed private physiotherapy clinics for at least 3 years. Physiotherapists without municipal agreements, or those employed in hospitals or municipal healthcare services, were excluded. Efforts were made to ensure variation in clinical expertise, acknowledging that emotional demands and emotion regulation strategies may differ across areas of practice.

The final sample included 14 physiotherapists (five men and nine women) from seven municipalities, reflecting the gender distribution within the profession. Nine participants specialized in general physiotherapy, two in manual therapy, one in psychomotor physiotherapy, one in oncological physiotherapy, and one in pediatric physiotherapy. The participants were between 45 and 61 years of age, with an average work experience of 27 years (see Table 1). The interview data provided substantial informational power, offering rich and nuanced accounts of participants' experiences (Malterud, 2021; Thagaard, 2021).

Table 1. Participant characteristics.

F, female; M, male. Postgraduate qualification refers to a master's degree, PhD, or specialist qualification.

The recruitment process involved reviewing municipal websites to obtain email addresses of physiotherapists who hold agreements with the municipality. In addition, a publicly available Norwegian database providing information about registered companies was used to verify their roles within their respective businesses, identifying individuals who served as managing directors, board chairs, and co-owners of physiotherapy clinics. Some participants were contacted through professional physiotherapy networks. After identifying the participants, each candidate was contacted individually by the first author via a secure institutional email system with an invitation to participate in the study. The email included an information sheet and an informed consent form outlining the study's purpose, procedures, anonymization protocols, confidentiality measures, and contact details for any queries.

Ethical considerations

The research was reported to the Norwegian Agency for Shared Services in Education and Research (Sikt), which oversees data protection and ethical approvals in Norwegian higher education and research institutions. The approval from Sikt was assigned the reference number; 452396 and was received prior to the commencement of data collection. According to national regulations, approval from the Regional Committees for Medical and Health Research Ethics was not necessary. Participation was based on voluntary, written, informed consent. This allowed participants to make an informed decision about their involvement with the right to withdraw their consent at any time. Participants who agreed to participate were asked to sign the consent form and return it.

Data collection

Individual semi-structured interviews were conducted by the first author (VWA) after receiving the consent forms. Appointments for the interviews were scheduled between August and October 2024. To maintain confidentiality, VWA conducted the interviews alone in a private and soundproof location. Likewise, participants ensured they were in a private setting where they felt comfortable during the interviews. This ensured optimal conditions for a reflective dialogue. Each interview began with an introduction to the study's purpose and an explanation that the recording device was in use. The flow of the interviews varied depending on the participants' narratives ensuring that essential themes relevant to the research questions were thoroughly explored- while avoiding rigid standardization of the interview process (Malterud, 2021; Thagaard, 2021). This opened for spontaneous reflections as well. The duration of the interviews lasted at an average of 55 min.

The interviews were conducted via Teams or telephone and were simultaneously recorded using the “Nettskjema” Dictaphone App (version 5.0.8), provided by the University of Oslo, Norway. The recordings were encrypted within the mobile app and then transferred to “Nettskjema's” secure, web-based storage platform, where they were automatically transcribed using Artificial Intelligence. The transcriptions were subsequently transferred to the local University‘s secure OneDrive platform, protected by two-factor authentication. Once thoroughly revised and verified by the first author (VWA), the transcripts were uploaded to NVivo 15 for a reflexive thematic analysis. Participants corrections were deemed unnecessary.

Data analysis

The interviews were transcribed verbatim. The inductive analysis strategy was based on Braun and Clarke's (2006) reflexive thematic analysis following six phases (Braun and Clarke, 2022). (1), Becoming familiar with the data (2), generating initial codes (3), searching for themes (4), reviewing themes (5), defining and naming themes, and (6) producing the report.

The first author (VWA), first read through the transcribed interviews multiple times while recording reflective notes to gain an overall understanding of the data. Second, the first author (VWA) generated initial codes using the NVivo 15 software tool. Third, the first and second authors (VWA, AH) subsequently sorted the coded data into potential recurring themes covering physiotherapists emotion regulation and significance for mental well-being. Fourth and fifth, all authors (VWA, AH, KA) discussed, reviewed, modified, and made refinements to the five main themes. Sixth, the report was compiled by the first author who has a clinical background as a physiotherapist, is a female manager of a private clinic, and did this study as part of her master thesis. The report was approved by the second (AH) and third (KA) author who holds PhD backgrounds in emotion regulation, emotional intelligence and mental well-being.

Researcher reflexivity

The first author's position as a physiotherapist with 26 years of clinical experience informed both access to the field and familiarity with participants' professional language and practices. This insider perspective may have facilitated rapport during interviews and supported a context-sensitive understanding of participants' accounts. This positioning was recognized as shaping the research process. Throughout data collection and analysis, reflexivity was thus actively practiced by critically reflecting on how prior knowledge and professional assumptions could influence data generation, coding, and theme development, including through ongoing discussions with the other authors. These strategies were used to enhance analytical rigor and to mitigate potential bias associated with the first author's insider position.

Findings

The findings show that the participants described a range of emotional aspects associated with private physiotherapy practice. Across interviews, they reported experiences characterized by both positive emotions and work-related pressures, alongside ongoing considerations of empathy, self-protection, emotional openness, and professionalism. Their narratives reflected diverse ways of responding to these demands, encompassing both deliberate and instinctive strategies in patient interactions and workplace relationships. The analysis generated five themes (see Table 2), illustrating patterns of physiotherapists' emotion regulation in managing everyday practice.

Table 2. The five identified themes and categories.

Positive emotions and community dynamics as a catalyst for healthy emotion regulation

This theme highlights how positive emotions were described as part of everyday practice for the participants' emotion regulation. In many situations, they referred to adopting a positive mindset to navigate daily challenges and to foster a supportive environment.

“I believe that the most important thing we have in the field of physiotherapy is to be positive. You need to bring that positive tone with the patient and the situation. We see a lot of sad things. We encounter many unfortunate and challenging destinies...” (P3).

Alongside this, the participants described their profession as meaningful. Many spoke about their profession in terms of helping others and referred to patients' improvement during treatment as a source of positive feelings. Experiences of joy, pride, hope and gratitude were described in relation to these situations. Affirming feedback from patients was also mentioned as something they appreciated.

“It includes everything from difficult conversations about high mortality risk to patients who show significant improvement, the full spectrum of experiences. There is joy even in the challenging aspects of the job...A great deal of happiness and meaningful moments. I find that incredibly rewarding” (P10).

At the organizational level, the clinic culture was described as emphasizing the maintenance of a positive atmosphere. Music and humor during training sessions were mentioned as part of everyday interactions, contributing to easing tension and shaping the overall environment.

“We play music in the exercise room to foster a sense of joy in the patient. If a colleague expresses frustration, I use a bit of irony or humor simply to shift the mood. We cannot spend the entire workday in a tense atmosphere; I find that exhausting. The air needs to be cleared, or the focus needs to shift. After all, I am at work, and my attention must remain on the patient (P4).”

“We are mindful of trying to create a pleasant atmosphere, not just focusing solely on exercises. We have conversations physiotherapists and patients across, to foster a joyful environment and have some fun. There are many moments filled with humor!” (D2).

The participants also described maintaining a positive tone in interaction with colleagues. Meanwhile, they reported limited engagement in each other's patient cases and individual responsibility for their own patients. In daily practice, some said to feel alone in various matters, particularly when handling complex or challenging situations.

“Yes, we do see each other at least once during the day. It is indeed a very independent profession. Consequently, one often finds oneself working alone on various matters (P14).”

At the same time, the participants described a willingness to consult colleagues in situations where professional advice was needed. However, time constraints and work pace were reported as limiting opportunities for such interactions. Long waiting lists and busy schedules with few breaks were described as leaving little time for administrative tasks, with some work being completed in the evenings.

”We're reaching out to each other, knocking on each other's doors. 'Hey, I have a patient with neck pain here... Would you be able to have a look at this patient?' “ (P4).

“I often find myself spending too many evenings writing discharge summaries or completing the day's patient records” (P13).

In addition to these work-related exchanges, everyday social interactions were also described as strengthening the sense of community within the clinic. Lunch breaks were referred to as a space where colleagues met, often involving informal conversations and humor. Some described these situations as occasions where experiences and challenges were shared.

“I arranged for the secretary to prepare two hot lunches each week. This became a unifying activity, as it encouraged people to spend time together. Often, simply chatting about everyday topics, such as weekend activities, fosters a sense of community, rather than just rushing around and becoming frustrated with one another at the clinic” (P3).

Participants also described how professional autonomy and reliance on their own experience shaped how they approached daily challenges, including how they managed emotionally demanding situations. Professional autonomy was reflected in the freedom to make decisions and take responsibility for their work. When navigating management-related challenges in running the clinic, participants described relying on their own experience.

“The significant degree of freedom we have serves as a substantial counterbalance. It is largely up to me. I do not feel trapped in anything, this is something that can be adjusted. I cannot really attribute that to the job itself. Rather, it is the pattern one develops over time” (P12).

Influencing and shaping mindset through reinterpretation and deep emotional adjustment

This theme highlights how the participants described regulating their emotions through reflection and change in perspective, which were described as shaping how they approached demanding situations. Some mentioned taking short breaks or having a cup of coffee to pause and refocus. Several also referred to physical activity, such as brief walks after work, as part of how they dealt with experiences from patient encounters that were experienced as challenging.

“I use my coffee cup as a tool for self-regulation… I sit in my chair, take a moment, and use coffee to calm myself and regulate my emotions” (P8).

“I used to feel very stressed and overwhelmed... What I have changed is allowing myself more time for reflection, creating small pockets of breaks throughout the day. I ensure to arrive at work early to properly prepare for the clinical day” (P5).

In addition to breaks and physical activity, some participants described trying to focus on situations in a different or more positive way. Some referred to this when talking about how they approached patient encounters they experienced as demanding.

“I can quickly shift my perspective to: ‘Who are you? It's exciting to get to know you!' I try to focus not only on helping the patient feel better but also on the sense of being part of something larger, the healthcare system, which plays a crucial role in keeping society functioning” (P12).

Similarly, participants described presenting patients' situations in different ways during consultations. They referred to giving patients feedback and talking with patients to help them gain a broader understanding of their experiences.

“I give them a lot of praise when they manage to do the activity they are supposed to, despite the pain. I try to ignore pain-related behaviour and provide plenty of positive feedback when they do things that are beneficial for them. I also encourage them to notice that they can do more and tolerate more, even if their pain levels remain the same” (P13).

“It's about helping them see more sides of an issue… I provide a lot of support” (P8).

Beyond patient encounters, the participants also described approaching challenges related to clinic management by trying to shift perspective about these situations. In their roles as both physiotherapists and clinic owners, several referred to working with such challenges as part of running the clinic. Some participants mentioned reframing management-related challenges as opportunities to improve the clinic. They also referred to positive emotions when such issues were addressed.

“I believe that the conflict we experienced was ultimately a valuable learning opportunity. Among other things, it highlighted the importance of clear and well-defined contracts and agreements, which we have now successfully established” (P3).

Social awareness and professional ethics as drivers of deep emotional adjustment in patient encounters

This theme highlights how the participants described attending to patients' experiences and perspectives in their practice, often involving professional and ethical considerations in how they responded to patients' emotional needs. They referred to engaging with patients' emotions with both empathy and being present during interactions. Some participants also mentioned experiencing a sense of close connection with patients and described how they responded during situations involving distress, sorrow, or joy.

“As a professional, I strive to maintain a high level of professionalism in all my interactions. This involves meeting people where they are in their current situation. Mostly I work with cancer patients. I often encounter individuals in crisis, but I also meet them in moments of joy and sorrow. There are a wide range of emotions involved” (P1).

At the same time, the participants described adjusting how they expressed their own emotions in interactions with patients. In some situations, they said they concealed or modified their own emotional responses during consultations, depending on how they understood the patient's situation.

“I had an ALS patient… She came in crying and feeling down…I try to suppress my own emotions and instead focus on staying positive. I know what benefits the patient is for me to be positive and strong, rather than overly compassionate, because that doesn't help her. It doesn't provide the patient with anything new. My focus is what will yield the best possible outcome for the patient, rather than what I personally feel” (P3).

In addition, the participants described the need to transition between emotionally contrasting patient encounters as part of everyday practice. Shifting from emotionally demanding situations to new consultations requiring a warm and welcoming approach was experienced as abrupt. These transitions were often described as routine and occurred with limited time for reflection, while also being perceived as potentially taking a greater toll over time than initially acknowledged.

“You may have a tearful patient in front of you, and yet, within moments, you need to step out and greet the next person with a warm and welcoming tone…This transition can feel abrupt…” (P4).

“Of course, you have to switch quickly to remain professional. And I think that, over time, you don't even reflect on it anymore. I do believe it takes a greater toll than we realize” (P11).

Emotional masking: hiding emotions in practice

This theme highlights how the participants described concealing primarily negative emotions during patient interactions while maintaining a professional manner. Some participants said this was part of how they approached clinical assessments and avoided personal emotions influencing their work. At the same time, they described that encounters with patients in difficult life situations could affect them emotionally and lead them to think about these patients' situations beyond working hours.

“When we encounter serious situations with patients... It's also a form of masking, but we must not appear resigned. It is a form of masking to try to behave calmly” (P11).

“It is very difficult to avoid feeling the impact of those shocking stories…And it's in those moments that it's hardest to go home and forget about the job, when you must suppress your emotions” (P4).

The participants also described feeling uncomfortable when informing patients about long waiting times. In situations where patients expressed frustration, some said they took on a more formal or reserved manner during the interaction. They also reported concealing their own emotional responses when patients reacted negatively or expressed expectations that were difficult to meet.

“Some patients may even attempt to dictate their own treatment, which can be quite provocative, right? In these situations, you must suppress your emotions and then express them in a more empathetic and understanding way. The goal is to engage with the patient in a way that allows for user involvement, without compromising your professional convictions” (P14).

In addition, the participants described that patients who did not improve as expected or who had more complex conditions sometimes expressed strong emotional reactions. In these situations, participants reported concealing their own emotional responses. Some also described distancing themselves emotionally from these situations when they felt overwhelmed, while continuing their work in accordance with professional standards.

“There are certain things that cause emotional stress… I notice a sense of heaviness within myself, largely because many patients carry a heavy burden” (P12).

“The turtle in the Bamse universe... His name is Shellman. So, I tend to say that I go into Shellman mode… So, I put on my shell, and then I become professional, but I cannot involve myself as deeply, or as humanly, as I perhaps should. This typically happens when you have been working for a long time, and the vacation is approaching” (P14).

In interactions with colleagues, masking was described as less common. However, concealing emotions were mentioned in situations involving disagreements in clinic management to maintain a positive atmosphere. Some described themselves as conflicts averse, often concerning financial matters. When such issues were not discussed, participants noted that this could be reflected in everyday interactions, for example through reduced eye contact or by not joining colleagues for lunch.

“In my experience as a leader, what I have found most rewarding is creating a positive and energetic work environment. At the same time, I must admit when it comes to addressing conflicts, whether at work or in other areas of life has never come easy” (P7).

”So, we've tried to address it, but there's been a bit of an ostrich mentality... Yes, but that's often the case when there's disagreement about assigned tasks or something related to finances“ (P12).

They described managing emotions outside the clinic when workplace conflicts became more challenging, while concealing their emotions during working hours. At the same time, most reported addressing disagreements related to clinic management directly with colleagues.

“Yes, my wife had to bear the brunt of it when there was that personnel conflict at work. I tended to conceal my feelings while at the clinic. I don't want the entire day to revolve around the conflict, so I carry it home with me and need to let it out in some way. I have often talked it through with her when I get home” (P3).

Authentic emotional expression in the workplace: opportunities for natural emotional displays among colleagues

This theme highlights how the participants described expressing emotions in interaction with colleagues. The participants referred to speaking openly about their emotions and having close and familiar working relationships with colleagues, which were described as fostering a psychologically and socially safe environment. This was particularly mentioned in situations related to patient care, where some described talking openly with colleagues when dealing with challenging encounters.

“We maintain open office spaces with one another, ensuring that if someone is experiencing frustrations, we take the time to engage in conversations… Our relationships are characterized by a strong sense of closeness” (P1).

“I find that many patients share distressing stories and experiences that leave a strong impression. I believe the most important aspect is having the opportunity to talk about these matters with colleagues” (P2).

At the same time, however, a few participants described expressing emotions was less common in interactions with colleagues. In these situations, attempts to share feelings were sometimes met with advice rather than support. Some also reported that not talking about emotional reactions following challenging patient encounters was associated with feeling drained.

”For a long time, I did not ventilate my emotions with anyone. As a result, I nearly reached a breaking point. We encounter so many individuals in life situations that are utterly overwhelming, and an increasing number of patients are mentally ill. When you are highly empathetic yourself, you inevitably absorb some of that burden. I try not to carry thoughts of patients' situations home with me, but it is difficult not to; they remain present in my mind“ (P4).

In addition, time constraints, confidentiality, and responsibility for their own patients were described as influencing what they shared with colleagues. A few participants also reported attending supervision groups outside working hours, where they discussed experiences and challenges related to patient care.

“You hold individual responsibility for the patients assigned to you, and not everything can be shared. This is due to the busy workday, and to confidentiality regulations. There is no formal system for processing such matters; one must create it oneself. Any meetings set up for this purpose inevitably take time away from patient care and have financial implications” (P14).

“I had a patient who was suicidal. It caused me considerable concern, and I found myself worrying about that patient outside of work. Through the supervision group, I was able to process these feelings, which were immensely helpful. It supported me in regulating my emotional responses in relation to the patient” (P8).

Beyond everyday clinical interactions, the participants described that issues related to regulations and financial arrangements from health authorities were infrequent but emotionally salient when they occurred. In such situations, some experienced reduced autonomy and feelings of frustration. During these interactions, participants described concealing their emotional responses and maintaining a formal manner. By contrast, sharing these frustrations openly with colleagues was described as a way of alleviating emotional strain.

“I value my autonomy, while also wanting to be part of the system. When issues related to the municipal agreement arise and the municipal leader has the final say, a negative response feels discouraging and frustrating. I conceal my reaction in those interactions, then quickly share it with a colleague to let it out” (P7).

“It is essentially a feeling of powerlessness of not being able to maintain the level of quality within the clinic that one initially aimed for as it is ultimately health authorities that determines the conditions...“ (P1).

The participants described open emotional expression as part of everyday collegial interaction. This included sharing personal life events, such as becoming grandparents or losing a close family member. These situations were described as part of routine workplace exchanges.

“Space is made for such matters when the timing allows within the clinic… When there is openness among colleagues, there are remarkable opportunities to be genuine in one's emotional expression, whether that involves joy, sorrow, frustration, or whatever emotions may arise” (P5).

Taken together, these themes illustrate the varied ways in which physiotherapists described managing emotional demands in private practice. Emotion regulation appeared as an integral part of everyday clinical work, collegial interactions, and management responsibilities, as reflected in participants' accounts across shifting contexts and patient situations. Overall, it was described as a continuous and multifaceted aspect of practice, shaped by both professional roles and workplace conditions.

Discussion

The findings of this study suggest that physiotherapists managing private clinics experience a high degree of autonomy. They referred to using reappraisal as an emotion regulation strategy when addressing management-related challenges. In patient encounters, reappraisal and deep acting were described as supporting patient motivation and their own mental well-being. In contrast, when patients expressed intense negative emotions, participants reported sometimes relying on suppression while maintaining a professional demeanor. Debriefing with colleagues, experienced as fostering a sense of relatedness, appeared to support physiotherapists in managing the potential strain associated with suppression; however, such opportunities were reported to be limited due to time constraints. Overall, the interplay of autonomy, competence, and relatedness within the workplace was described as shaping how emotion regulation processes unfolded among the physiotherapists.

Positive emotions and relatedness as resources for emotional resilience

A key finding of this study was that the physiotherapists relied on positive emotions and a sense of community when managing the emotional demands of clinical practice. A shared sense of unity within the clinic was described as counterbalancing the potentially isolating aspects of working individually with patients. These findings align with the Self-Determination Theory (Ryan and Deci, 2000), particularly the role of relatedness as a basic psychological need associated with mental well-being (Ryan and Deci, 2017, 2023). Closely tied to this sense of community was the use of positive emotions, including humor, joy, and shared experiences in everyday workplace interactions. The participants described actively contributing to a positive atmosphere, which supported their efforts to manage emotional demands. This is consistent with Fredrickson's broaden-and-build theory (2001), which posits that positive emotions expand individuals' momentary thought–action repertoires and contribute to the development of personal resources relevant for coping in emotionally demanding contexts (Fredrickson, 2001; Fredrickson and Joiner, 2018). Similarly, (Kunst et al. 2023) suggest that positive emotions may be associated with the use of effective emotion regulation strategies, such as reappraisal, in the context of emotional demands.

However, the findings also point to a potential drawback. Among the participants in this study, a strong emphasis on positivity within the clinic environment was described as sometimes limiting opportunities to express negative emotions. While a cohesive professional community was experienced as supporting mental well-being and collaboration, it could also constrain more authentic emotional expressions when positivity functions as a social norm (Diefendorff et al., 2005, 2019). In situations involving interpersonal conflicts, the participants described suppressing negative emotions and express an outwardly positive demeanor, which may be understood as emotional incongruence (Scheibe and Moghimi, 2021; El Khawli et al., 2025). At times, this was accompanied by tendencies toward social withdrawal, which may have implications for the experience of relatedness (Ryan and Deci, 2017). Previous research has linked prolonged suppression and reduced perceived relatedness to emotional strain in emotionally demanding contexts (Grandey and Melloy, 2017; Wang et al., 2023). However, participants reported how interpersonal conflicts, particularly those related to clinic management, were mostly addressed through open and constructive dialogue. Such expressions among colleagues were described as fostering professional relatedness and mental well-being (Grandey and Sayre, 2019; Gabriel et al., 2020).

Building on the role of relatedness, a central theme that emerged was how autonomy shaped physiotherapists' use of emotion regulation (Grandey and Sayre, 2019; Wang et al., 2023). While a strong sense of community was described as an interpersonal resource in the management of emotional demands, the participants also emphasized a sense of personal empowerment associated with having control over their professional environment.

The role of autonomy in shaping emotion regulation in clinic management

In line with the Self-Determination Theory (Ryan and Deci, 2000), the findings suggest that professional autonomy was experienced through self-directed decision-making and relatively limited formal managerial structures. The dual role as self-employed clinicians and clinic co-owners was described as enabling alignment between organizational practices and professional values, reflecting the fulfillment of autonomy needs (Ryan and Deci, 2020, 2023). Previous research has associated such value-congruent practice with enhanced mental well-being (Ryan and Deci, 2017; Latzke et al., 2021). Participants also described that autonomy influenced how managerial challenges were approached, with some accounts suggesting that such challenges could be reinterpreted in constructive ways, supporting clinic development. In this context, autonomy appeared to be associated with the use of emotion regulation strategies such as reappraisal. This is consistent with previous research indicating that experiences of autonomy may be related to the use of reappraisal when encountering challenges (Grandey and Sayre, 2019; Torrence and Connelly, 2019; Haver et al., 2021).

The findings further suggest that regulatory constraints imposed by health authorities were relatively rare; however, when such constraints occurred, they were experienced as restricting professional autonomy. In these situations, participants reported relying on suppression in interaction with external stakeholders, which was associated with experiences of emotional strain (Benita et al., 2020; Patel and Bartholomew, 2021; Ryan and Deci, 2023). However, shared experiences among clinic co-owners were described as a relational resource, enabling more open and authentic emotional expression without the need for deliberate emotion regulation (Diefendorff et al., 2019; Gabriel et al., 2023). Such exchanges were experienced as contributing to a sense of psychological safety within the work environment, supporting mental well-being (Haver et al., 2023). These patterns may be understood as reflecting elements of self-leadership within this context (Stewart et al., 2019; Harari et al., 2021). Given the high degree of autonomy and relatively limited formal managerial structures, participants described relying largely on individually driven strategies to navigate emotional demands. This aligns with research positioning self-leadership as a potentially important resource in decentralized professional contexts, where clinicians regulate both their work processes and emotional responses independently, with limited formal leadership support (Van Dorssen-Boog et al., 2020; Harrison et al., 2025).

Navigating emotional complexity in patients' interactions

The findings revealed that patient encounters involve a complex emotional dynamic. While emotional demands were described as resting on the individual physiotherapist, participants also referred to a strong sense of purpose associated with witnessing patient progress. Such experiences were often linked to positive emotions and as supporting physiotherapists mental well-being (Kammeyer-Mueller et al., 2013; Latzke et al., 2021). Patient progress was also associated with experiences of competence, consistent with the Self-Determination Theory (Ryan and Deci, 2017; Patel and Bartholomew, 2021), and with emotions such as joy, hope, pride, and gratitude. These positive emotional experiences were described as helping physiotherapists maintain emotional balance in encounters involving patients' negative emotions, which resonate with Fredrickson's broaden-and-build theory (Fredrickson, 2001; Fredrickson and Joiner, 2018).

Challenging encounters were described as arising when patient progress stalled or regressed. In such situations, participants emphasized the importance of recognizing, interpreting, and responding to patients' emotional expressions. Their accounts suggest how emotional awareness and the ability to adapt regulatory responses accordingly may play a role in managing demanding clinical interactions (Peña-Sarrionandia et al., 2015; Sánchez-Álvarez et al., 2016). These capacities were informing clinical reasoning and shaping interactional responses marked by empathy, sensitivity, and compassion (Hings et al., 2018; Pades Jiménez et al., 2023; Haver et al., 2025). Through such processes, they described seeking to maintain emotional composure in demanding clinical interactions.

The findings suggest that the physiotherapists in this study draw on a range of emotion regulation strategies when navigating patients' negative emotions. These included attempts to broaden patients' perspectives by emphasizing nuanced indicators of recovery, alongside the use of deep acting and reappraisal to frame clinical situations in more constructive ways. Such strategies were described as supporting patient motivation and physiotherapists mental well-being (Hings et al., 2018; Wang et al., 2023; Yang and Mischkowski, 2024). Previous research further suggests that aligning emotional expressions with more positive states may contribute to a sense of emotional congruence, which has been associated with enhanced mental well-being (Humphrey, 2023; Wang et al., 2025). In addition, flexible emotion regulation, including reappraisal, may develop with age and professional experience (Scheibe et al., 2015; Santos et al., 2021; Hilger et al., 2025). This may help contextualize why the physiotherapists in the present study combined multiple intrapersonal emotion regulation strategies in response to situational demands. For example, situation modification was described as a way of preparing for potentially challenging encounters, while attentional deployment, such as humor, was used to redirect the emotional tone of interactions toward more positive states (Gross, 2015; Grandey and Melloy, 2017; Troy et al., 2017). Taken together, the findings may be interpreted as reflecting a dynamic interplay between the recognition of patients' emotional expressions and the use of emotion regulation strategies, and how these processes are experienced as supporting physiotherapists' mental well-being.

While strategies such as deep acting and reappraisal were described as beneficial, their consistent use was also experienced as emotionally demanding and complex, particularly in contexts characterized by limited resources and high emotional intensity. Previous research similarly suggests that both the effectiveness and the experience of emotion regulation strategies are shaped by contextual conditions and available personal resources (Aldao et al., 2015; Troy et al., 2018; Scheibe and Moghimi, 2021). In line with (El Khawli et al. 2025), the participants described managing experiences of patients' incivility by maintaining a calm professional demeanor while suppressing negative emotions. In such situations, suppression was described as helpful in de-escalating patients' negative emotions (Melloy et al., 2026). Similarly, organizational constraints, such as long waiting lists, were at times managed through surface acting when the physiotherapists experienced moral distress. The use of reappraisal and deep acting was described as particularly challenging in encounters involving patients with complex pain conditions and strong negative emotional expressions. In these situations, physiotherapists sometimes relied more heavily on surface acting and suppression to maintain professional conduct, which was often experienced as emotionally taxing. Existing research has linked such strategies to emotional incongruence and reduced mental well-being (Diefendorff et al., 2019; Humphrey, 2023; Wang et al., 2025). One participant described entering a so-called 'Shellman mode', characterized by emotional detachment that enabled continued functioning without becoming overwhelmed. Previous research suggests that sustained emotional detachment may be associated with longer-term emotional exhaustion (Scheibe and Moghimi, 2021; McGrath et al., 2024), with potential implications for patient care and safety (Garcia et al., 2019; Burri et al., 2022; Sattar et al., 2024).

The findings point to the relevance of emotional processing through collegial debriefing, and reflective practices after emotionally demanding encounters (Arkwright et al., 2018; Burri et al., 2022; Melloy et al., 2026). This is consistent with (Horton et al. 2022), who suggest that physiotherapists use emotional venting and social support to regulate lingering emotions, and that suppression without relational processing may undermine mental well-being. These findings suggest that opportunities for relational support and reflection may form an important part of how physiotherapists navigate emotional demands in their work.

Mindful emotion regulation individually and contextually

Building on these findings, the role of relational and organizational support becomes particularly salient. Previous research suggests that organized peer support and clinical supervision groups provide valuable spaces for reflection, emotional processing, and resilience (Preece, 2020; Hagen et al., 2025). In contrast, the participants described limited opportunities for such supportive interactions within their workplace. This raises questions about how current clinical contexts accommodate emotional demands in everyday practice (Arkwright et al., 2018; Preece, 2020; Patel and Bartholomew, 2021).

In this context, the participants also emphasized the role of emotional self-awareness in navigating emotional demands. Previous research suggests that the ability to notice and mindfully accept internal emotional experiences may support flexible emotion regulation processes (Peña-Sarrionandia et al., 2015; Jackson-Koku and Grime, 2019; Haver et al., 2025). Such emotional self-awareness may create the space needed for strategies such as reappraisal, through which emotionally charged situations are reframed in constructive ways (Troy et al., 2018; McRae and Gross, 2020). However, the participants described organizational conditions, including economic pressures and long waiting lists, often required prioritizing efficiency over opportunities to pause and attend to their own emotional experiences. This may appear paradoxical, given that private practice is often associated with self-directed scheduling, which could, in principle, allow space for restorative breaks (Watson and Minns Lowe, 2024). Within this context, limited opportunities for mindful self-regulation were described as potentially undermining mental well-being (Jackson-Koku and Grime, 2019; Li et al., 2025).

After particularly intense workdays, the participants further described that they often thought about workplace conflicts and challenging patient encounters outside of work hours. In response, some of them engaged in physical activity, such as short walks, as a way of shifting emotional states. This resonates with (Horton et al. 2022), who found that physiotherapists use post-work physical activity to regulate emotions following demanding clinical encounters. Similarly, (Fredrickson and Joiner 2018) describe how positive emotional experiences through physical activity, contribute to upward spirals, supporting effective emotion regulation and mental well-being. When considered together, these accounts suggest that the management of emotional demands is not confined to individual strategies, but unfolds across individual, interpersonal, and organizational contexts. These dimensions may be intertwined in shaping how physiotherapists use emotion regulation to manage emotional demands and to support their mental well-being (Zhang et al., 2020; McGrath et al., 2024; Krebs et al., 2025).

Methodological considerations and limitations

Several limitations of this study must be acknowledged. First, qualitative designs preclude the ability to draw causal inferences. Second, the first author's insider position as a physiotherapist in private practice provided contextual knowledge and facilitated rapport during interviews, supporting the generation of rich accounts. However, in line with Braun and Clarke's reflexive thematic analysis, this positioning also shaped the research process. The construction of themes was informed by the first author's professional perspective, influencing how data were co-produced and how patterns of meaning were interpreted. Although reflexive practices and ongoing discussions within the research team were employed, this perspective may have privileged certain understandings while rendering others less visible.

These methodological and reflexive considerations underscore that the findings are context-bound and should be interpreted accordingly. The aim is not statistical generalization, but to generate meaningful, contextually grounded insights. Based on a small sample of physiotherapists in private practice within a specific national and organizational setting, the findings are best understood as situated interpretations. Their relevance beyond this setting is therefore contingent on contextual similarities, with transferability resting to the extent which readers find resonance with the analysis. Even so, the findings may offer meaningful insights into clinical practice and directions for future research.

Implications and future research

The findings of this study may have implications for clinical practice and organizational development within physiotherapy contexts. They point to the relevance of emotion regulation in everyday clinical work, especially in managing ongoing emotional demands. Approaches such as collegial debriefing may be understood as one way of navigating these demands within routine practice. In addition, emotion regulation may represent a relevant area of attention within physiotherapy education, potentially contributing to preparedness for the emotional aspects of both clinical and managerial roles in private practice. However, further research is needed to corroborate these findings, as the qualitative design of the study limits their generalizability and calls for additional empirical support.

This study opens several pathways for future research. First, comparative studies across different physiotherapy settings (e.g., private and municipal contexts) could investigate how workplace structures influence emotion regulation and the management of emotional demands. Second, mixed-methods research that integrates qualitative insights with quantitative measures of emotion regulation and mental well-being may contribute to a more comprehensive understanding of how individual and contextual factors interact. Third, future research should examine the effectiveness of training in emotion regulation strategies to support physiotherapists' mental well-being.

Conclusion

This study suggests that physiotherapists use emotion regulation in ways that are experienced as both supportive and challenging to their mental well-being. Within private physiotherapy practice, where clinical work, managerial responsibilities, and emotional demands are closely intertwined, flexible emotion regulation was described as an adaptive resource through which physiotherapists navigate everyday practice. The findings also highlight the relevance of professional autonomy as a contextual factor shaping how emotion regulation is enacted in the management of private practice clinics. While external regulations and governance structures are essential for ensuring quality and accountability, participants described such demands, when experienced as overly restrictive, may be associated with reduced professional autonomy and increased emotional strain. Together, the findings contribute to a more nuanced understanding of emotion regulation as a relational and context-dependent process, operating across individual, organizational, and system levels, and as part of how physiotherapists manage the emotional demands of their work.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/forgp.2026.1815272/full#supplementary-material

Supplementary material Supplementary material at the source

Footnotes

Edited by: Mohsen Khosravi, Zahedan University of Medical Sciences, Iran

Reviewed by: Pasquale Scognamiglio, ASL Napoli 3 Sud, Italy

Greta Brizio, Catholic University of the Sacred Heart, Italy