Rumination and Coping as Pathways from Stress to Emotional Exhaustion among Hospital Pharmacists

1  Introduction

Emotional exhaustion, a core component of burnout, is a prevalent issue among healthcare professionals, leading to fatigue, disengagement, and reduced personal achievement [1,2]. It negatively affects individual well-being, patient care, and workplace morale and has been extensively documented across various medical disciplines [3–5]. Public-sector healthcare workers face unique stressors, including limited resources, insufficient managerial support, and rigid organizational structures, which exacerbate emotional exhaustion [6–8]. The consequences include higher absenteeism, increased turnover, and reduced professional efficacy [9,10], highlighting the need to identify and address the underlying causes of emotional exhaustion in the healthcare industry. Perceived stress, defined as an individual’s subjective understanding and reaction to external sources of stress, has been consistently associated with emotional exhaustion [11]. The Transactional Model of Stress and Coping by Lazarus and Folkman [12] provides a framework for understanding this relationship. According to this model, it is not just the stressor itself but an individual’s perception of stress that determines its psychological impact. When stress is persistent, it can evolve into chronic emotional fatigue [13]. Building on this theoretical foundation, we propose the following hypothesis:

Hypothesis I: Perceived stress is positively associated with emotional exhaustion.

1.1 Rumination as a Mediator

Rumination is characterized by the repetitive focus on negative thoughts and emotions, often as an attempt to process stressors or solve problems [14]. While it can sometimes facilitate problem-solving, excessive rumination is associated with anxiety, depression, and post-traumatic stress disorder (PTSD) [15–17]. Research has suggested that individuals who engage in persistent rumination tend to experience heightened emotional distress, as it reinforces negative thought patterns and prolongs stress responses [18,19]. According to the Response Styles Theory (RST), rumination prolongs emotional reactions to stressors, interferes with adaptive coping mechanisms, and ultimately exacerbates psychological distress [20]. Empirical evidence supports this theory, demonstrating that rumination amplifies stress and contributes to emotional fatigue [21]. Understanding its mediating role provides valuable insights into potential cognitive intervention strategies for mitigating stress-induced exhaustion among pharmacists.

Hypothesis II: Rumination mediates the relationship between perceived stress and emotional exhaustion among pharmacists.

1.2 Coping Strategies as Mediators

Coping strategies play a crucial role in determining how individuals manage stress, particularly in relation to burnout and emotional exhaustion [22–24]. These strategies can be broadly categorized into adaptive (active) coping, which involves modifying stressors or cognitive appraisals, and maladaptive (passive) coping, which hinders active problem-solving and contributes to psychological distress [25,26]. Evidence has demonstrated that coping behaviors help explain why individuals exposed to similar stressors may experience varying levels of burnout [27]. Maladaptive strategies such as avoidance, denial, and substance use—have been consistently linked to increased psychological distress and poorer mental health outcomes [28–31]. In contrast, adaptive strategies—such as active coping, planning, and positive reframing—are associated with better stress management and reduced emotional exhaustion [32]. Skinner et al. [33] proposed that coping mechanisms shape the progression from stress to emotional exhaustion, underscoring the need to explore their mediating role in this relationship.

Hypothesis III: Coping styles (maladaptive/adaptive) mediate the relationship between perceived stress and emotional exhaustion.

1.3 Chain Mediation of Rumination and Coping Strategies

The chain mediation concept, beyond traditional mediation, provides a more comprehensive examination of the interrelated pathways linking stress, cognitive processes, and coping behaviors [34,35]. This study explores the impact of initial stress responses, mediated explicitly through rumination, on the selection and efficacy of coping mechanisms, subsequently influencing outcomes such as emotional exhaustion. Hayes [36] advocates for intricate mediation models in psychological research as they afford a more comprehensive comprehension of variables’ sequential and cumulative impacts. This model emphasizes the need for comprehensive interventions targeting cognitive patterns and behavioral responses to stress. Based on this theoretical framework, we have formulated the following hypothesis:

Hypothesis IV: Rumination and coping styles (maladaptive/adaptive) play a chain mediating role between perceived stress and emotional exhaustion.

1.4 The Present Study

The present research aims to contribute to the extant scholarly literature by investigating the intricate dynamics of stress, rumination, and adaptive and maladaptive coping mechanisms and their combined effect on emotional exhaustion within the pharmacist profession (Fig. 1). Prior research has extensively examined the individual impacts of stress and coping strategies in various healthcare environments. However, a dearth of studies has delved explicitly into these dynamics among pharmacists, who exclusively manage high-stress responsibilities while fulfilling crucial public health obligations. Besides, this research enhances existing knowledge by introducing a dual mediation model that explains how rumination and coping strategies (adaptive/maladaptive) mediate the link between stress and emotional exhaustion. Punjab, the most densely populated province of Pakistan, comprising approximately 53% of the nation’s populace [37], offers a substantial and varied representation that reflects a wide range of healthcare practices and challenges pharmacists encounter [38,39]. The healthcare system in Pakistan is marked by limited resources and differing levels of service provision, leading to distinct challenges and pressures for healthcare practitioners, including pharmacists [40]. These prevailing conditions in Punjab present an opportune context for investigating the complex interplay of stress, coping strategies, and emotional fatigue. The results derived from this geographic area have the potential to yield a comprehensive understanding of stress management techniques that are relevant on both a regional and global scale, particularly within analogous healthcare environments in emerging economies.

Figure 1: The hypothesized model

Consequently, the principal aim of the present research was to investigate the interconnections between pharmacists’ stress levels and coping strategies and the resulting emotional exhaustion. Additionally, the study sought to examine the potential mediating effects of rumination, adaptive coping, and maladaptive coping in this association. The study’s objectives seek to address existing gaps in the literature and provide practical and clinical frameworks for guiding interventions to mitigate burnout and promote well-being among pharmacists.

2  Methods

2.1 Sample Selection and Participants

The present survey was conducted among 30 public hospitals in Punjab, Pakistan, between September 2023 and January 2024. This targeted demographic encounters distinct occupational stressors such as significant workloads, detailed medication management duties, and direct interactions with patients. These factors differentiate their experience from that of other healthcare professionals and underscore the significance of examining their stress and coping strategies.

2.2 Sampling Approach

A descriptive cross-sectional survey was carried out utilizing stratified sampling across all the public hospitals in Punjab province, Pakistan, wherein each hospital served as a stratum. The sample was drawn from hospital administration records, which contain the list of pharmacists working in these hospitals. Only pharmacists who were registered with the Pakistan Pharmacy Council were eligible to participate in the study. The stratification was intended to achieve a representative sample from a diverse range of hospitals, including those of varying sizes, capacities, and geographic locations in both urban and rural areas of Punjab.

2.3 Data Source

The data collection process involved using a structured questionnaire with validated scales, which was sent through online channels such as professional email lists and hospital intranet systems, as well as in person. This approach was employed to facilitate broad accessibility for pharmacists with differing access levels to digital resources. Fig. 2 illustrates the study design of the paper.

Figure 2: Study design

2.4 Pilot Testing

The questionnaire underwent a pilot test with 35 individuals to ensure its reliability and validity within the context of Pakistani pharmacists. The pilot test aimed to identify potential issues inherent in the survey design, including question clarity, response options, and overall comprehensibility. Based on the feedback, minor adjustments were made to the survey instrument through collaborative discussions between the research team and professional experts. The results of the pilot test are available in Supplementary File.

2.5 Sample Size Determination

The sample size was determined using Cochrane’s formula to estimate proportions appropriately within a specified margin of error (5%) and confidence interval (95%). The initial sample size was estimated to be 384; however, to adjust for the design effect resulting from stratification, an effect of 1.5 was employed, a standard practice to mitigate the consequent rise in variance (384 ∗ 1.5 = 576). After accounting for design effects, the estimated sample size was 576. A final sample size of 576 was chosen as a balance between feasibility, manageability, and the need for sufficient statistical power to detect significant relationships within the study’s context.

2.6 Eligibility Criteria

Inclusion criteria: Registered hospital pharmacists actively participating within the Punjab province and willing to participate by completing an informed consent form.

Exclusion criteria: Those on extended leave (e.g., maternity, sabbatical) or retired, not currently employed by the hospital, diagnosed with or receiving treatment for psychiatric or psychological disorders, and non-consenting during data collection.

2.7 Research Questionnaire

2.7.1 Demographic Characteristics

Socio-demographic variables, including age, gender, educational level, marital status, number of Children, ethnicity, year of experience, employment status, shift work, and income level, were reported.

2.7.2 Perceived Stress Scale 10 (PSS-10)

Cohen [41] developed the PSS-10 as a self-reported measure designed to assess individuals’ overall perceived stress levels, delineated into two dimensions: perceived helplessness, reflected in negatively phrased items, and perceived self-efficacy, manifested in positively worded items. Participants were asked to indicate the frequency of their emotions for the previous month using a 5-point Likert scale (Never: 0 to Very often: 4). To obtain the overall scores, the scoring of positive statements was inverted such that a rating of 4 denoted ‘never’ and a rating of 0 represented ‘very often.’ The aggregate score of the PSS-10 spans from 0 to 40, with higher scores indicative of a heightened degree of stress. The PSS-10 scale has been validated in the Urdu version by Mushtaq and Ahmed [42], demonstrating a robust internal consistency coefficient of 0.83. The English version of this measure has been previously validated in the Pakistani community, demonstrating acceptable internal consistency across different demographic groups [43–45]. In this study, the PSS-10 showed high reliability, achieving a Cronbach’s alpha of 0.87 (see Table 1).

2.7.3 10-Item Ruminative Response Scale (RRS-10)

The RRS-10 is a short form of the comprehensive Response Styles Questionnaire, originally developed to evaluate cognitive patterns and responses associated with depression [20]. However, research has shown that rumination is a transdiagnostic factor relevant across various populations [46], including non-depressed individuals, where it influences psychological well-being and responses to stress [47,48]. The RRS-10 consists of ten items divided into two subscales: Brooding and Reflection. Participants rated their responses on a 4-point Likert scale ranging from 1 (never) to 4 (always), with higher scores indicating a stronger inclination toward rumination. The scale has demonstrated strong internal consistency and test-retest reliability across multiple studies [49–51]. Additionally, the RRS-10 has been validated within the Pakistani population, confirming an acceptable level of reliability for this context [52]. The internal consistency of the RRS-10 was confirmed in this study, with a Cronbach’s alpha coefficient of 0.88 (see Table 1).

2.7.4 The Brief-COPE

The Brief-COPE (Coping Orientation to Problems Experienced Inventory) questionnaire is a validated tool that assesses effective and poor coping strategies in response to a stressful life event [53]. The study participants were evaluated using this 28-item self-reported questionnaire on a 4-point Likert scale (1: I have not been doing at all—4: I have been doing this a lot). Within the stress-coping concept, specific coping strategies are categorized as either primarily adaptive (active coping, planning, positive reframing, acceptance, humor, religion, using emotional support, and using instrumental support) or maladaptive (self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame) [54,55]. Individuals with higher scores in adaptive coping demonstrate an inclination towards utilizing constructive strategies when confronted with adversities. In comparison, those who achieve higher scores in maladaptive coping exhibit a propensity toward embracing unfavorable techniques. This measure has demonstrated strong validity and reliability among the Pakistani population in English and Urdu [56,57]. In this sample, the adaptive coping subscale showed good internal consistency (α = 0.89), while the maladaptive coping subscale achieved a Cronbach’s α of 0.91 (see Table 1).

2.7.5 The Oldenburg Burnout Inventory

The OLBI (Oldenburg Burnout Inventory) is a 16-item validated construct that assesses burnout and consists of two distinct components: exhaustion (8 items) and disengagement (8 items) with positively and negatively phrased items. However, our study primarily focused on the exhaustion component of burnout, broadly regarded as the primary feature of burnout, especially in demanding healthcare settings such as hospital pharmacies. The study participants were instructed to assess the frequency with which they encounter a particular sensation using a rating scale ranging from 1 (indicating strongly disagree) to 4 (indicating strongly agree). The validity of this scale has been thoroughly established in a range of professional fields, with a particular emphasis on its application in healthcare environments [58–60]. This subscale has consistently demonstrated strong reliability across various studies [61–63], signifying its ability to consistently and accurately measure burnout. The scale demonstrated good internal reliability in the current sample, with a reliability estimate of 0.91 (see Table 1).

2.8 Ethical Consideration

The study participants were informed that the data collected from these constructs would remain confidential and only accessible to the researchers and their team. Informed consent has been taken from all the participants. The study has been authorized by the Ethics Review Committee (ERC) of the Islamia University of Bahawalpur, Lahore, Pakistan (No. DR/2044).

2.9 Analytic Approach

We initially screened the data on the study variables for normality using the Kolmogorov-Smirnov test to confirm their suitability for subsequent parametric analyses. We then performed Harman’s single-factor test to mitigate potential common method bias. The constructs’ reliability was evaluated by Cronbach’s alpha for each construct, ensuring internal consistency. Convergent validity was estimated by analyzing each construct’s average variance extracted (AVE), with values >0.5 considered acceptable. The structural model was evaluated using path analysis via structural equation modeling (SEM), facilitating the estimation of associations between perceived stress, rumination, coping strategies (adaptive and maladaptive), and emotional exhaustion. The model adequacy was assessed using model fit indices: χ2(df) ratio (<3 acceptable), Comparative Fit Index (CFI) (acceptable at <0.95), Tucker-Lewis Index (TLI) (acceptable at <0.95), and the Root Mean Square Error of Approximation (RMSEA) (acceptable at <0.08) and Standardized Root Means Squared Residual (SRMR) (acceptable at <0.06). Pearson bivariate correlation analysis assessed the relationships between the variables in question. The study employed the bootstrapping method with 5000 resamples to examine the mediation effects of rumination and coping mechanisms. Bias-corrected confidence intervals were used to determine the statistical significance of indirect effects within the proposed theoretical framework. SPSS (26.0 v) and AMOS (26.0 v) were used to perform the analysis with a significance level of p < 0.05.

3  Results

3.1 Common Method Bias (CMB)

The method utilized for data collection in the present survey was based on self-reported measures. Therefore, recognizing these methodologies can introduce a CMB, which may impact the study findings. In response to this issue, we employed Harman’s single-factor test method to analyze the potential presence of CMB in the dataset. The Kaiser-Meyer-Olkin (KMO) score, estimated at 0.853 (at p < 0.001), suggests that the data is appropriate for conducting exploratory factor analysis (EFA). The principal component analysis (PCA) performed on the variable measurement items indicated that the initial principal component explained approximately 29.51% of the overall variation, failing to meet the threshold value of 40%. This implies that the deviation of measurement bias did not substantially influence the study outcomes.

A reliability assessment was performed on the hypothesized model, utilizing data obtained by administering questionnaires. The findings revealed that Cronbach’s alpha coefficients of all selected study constructs varied from 0.86 to 0.91, suggesting a satisfactory level of internal consistency. While the construct reliability (CR) values for each construct exceeded 0.7. The AVE values for each construct exceeded the prescribed threshold of 0.5, indicating favorable levels of reliability and validity within the construct (Table 1).

3.2 Model Fit Analysis

The maximum likelihood method was employed to assess the model parameters. The evaluation of the overall adequacy of the model reveals that all of the indices satisfied the required testing standards. Hence, the model exhibited a robust fit, thus yielding satisfactory outcomes (Table 2).

3.3 Socio-Demographic Information

Table 3 exhibits a socio-demographic analysis of 593 hospital pharmacists, indicating a diversified cohort primarily in the mid-career stage, with 66% of individuals falling within the age range of 36 to 45 years with a considerable proportion (66%) of males. There is a diversity in educational levels within the field, with most individuals holding a Doctor of Pharmacy degree (Pharm. D). The attainment of a degree is a significant accomplishment that marks the successful completion of a program of study at an institution of higher education. Most individuals in this demographic are married and have between one and two children, which reflects common family structures within the study population. A significant disparity in income distribution exists, characterized by a pronounced division between individuals in the middle-income bracket and those in the high-income bracket, which may affect economic dynamics. The workforce composition is predominantly Punjabi and Pashtun, with no statistically significant differences evident in these ethnic demographics. The distribution of years of experience indicates a predominantly seasoned workforce, with a considerable proportion possessing more than six years of experience in the field. Diversity in work patterns and employment status exists, giving rise to variations in job security and lifestyle effects. Many individuals are engaged in contractual arrangements or rotational shift schedules. The present demographic overview offers a comprehensive analysis of pharmacists’ professional and personal characteristics, essential for gaining insights into their working conditions and behaviors.

3.4 Bivariate Correlations between Study Constructs

Table 4 illustrates the bivariate correlations among the study variables estimated using Pearson’s correlation coefficient. The findings demonstrated a significant correlation between perceived stress and the utilization of coping strategies (maladaptive: r = 0.323, p < 0.001: adaptive: r = 0.378, p < 0.001), as well as an association with heightened levels of rumination (r = 0.432, p < 0.001) and emotional exhaustion (r = 0.310, p < 0.001). These results suggested that as perceptions of stress increase, so does their tendency to engage in rumination, coping strategy employment, and feelings of burnout. Likewise, there was a significant association between rumination and coping strategies (maladaptive: r = 0.512, p < 0.001: adaptive: r = 0.581, p < 0.001), suggesting that individuals who exhibit higher levels of rumination are more inclined to employ both adaptive and maladaptive coping mechanisms. Additionally, it demonstrates a positive correlation with increased emotional exhaustion (r = 0.459, p < 0.001), thus underscoring its influence on the deterioration of psychological well-being. Simultaneously, the utilization of maladaptive coping strategies is linked to emotional exhaustion (r = 0.452, p < 0.001), indicating that individuals employing these techniques are likely to be experiencing heightened levels of burnout. The observed weak correlation between adaptive coping suggests that individuals have a degree of independence in utilizing these strategies. Although adaptive coping has been shown to have a positive impact, it is also associated with increased emotional exhaustion (r = 0.509, p < 0.001). This suggests that individuals may rely on coping strategies more frequently in situations of high stress or extreme fatigue, even when these strategies are effective.

3.5 Path Analysis Results

Table 5 demonstrates the results of the path analysis by keeping age, gender, and income level as control variables. The findings indicated that perceived stress has a substantial impact, leading to a significant increase in rumination (β = 0.447), as well as maladaptive (β = 0.253) and adaptive coping (β = 0.305) strategies and emotional exhaustion (β = 0.196). This emphasizes the considerable effect of stress in exacerbating adverse psychological consequences. Despite the implementation of various controls, rumination has been found to enhance maladaptive (β = 0.488) and adaptive coping (β = 0.523) strategies substantially and contribute to emotional exhaustion (β = 0.386), thus underscoring its pivotal role in shaping individual responses to stress. The correlation between maladaptive coping and heightened emotional exhaustion (β = 0.327) suggests that ineffective coping strategies may contribute to the worsening of burnout (emotional exhaustion) associated with stress. Notably, the use of adaptive coping strategies, often perceived as advantageous, is linked to elevated levels of emotional exhaustion (β = 0.365), indicating that employing such strategies may predict responses to heightened underlying stress levels. The statistical models exhibited a moderate to significant explanatory power (R2 = 0.20–0.41), confirming the findings’ strength and reliability, highlighting the necessity of implementing focused interventions to alleviate stress and enhance coping mechanisms among hospital pharmacists.

3.6 Sequential Mediation Analysis Results

3.6.1 Rumination and Maladaptive Coping as Mediators

Table 6 demonstrates the results of sequential mediation analysis with rumination and maladaptive coping strategies as mediators. The findings indicated a statistically significant direct impact of perceived stress on emotional exhaustion, yielding a direct effect size of 0.196 and explaining 37.48% of the overall effect. The indirect effect of rumination alone is particularly substantial, with an effect size of 0.173, accounting for 33.07% of the total effect. In addition, maladaptive coping alone yields a more modest yet significant effect size of 0.083, comprising 15.87% of the total effect. The results indicated a compounded effect size of 0.071 (13.58% of the total) observed in the serial mediation process involving rumination and maladaptive coping. The cumulative indirect effects make a noteworthy contribution to the overall impact, with an effect size of 0.327, accounting for 62.52% of the total impact. This implies that stress influences emotional exhaustion through mediation via these pathways. The overall effect of stress on emotional exhaustion, accounting for both direct and indirect pathways, is substantial and statistically significant (effect size = 0.523). The confidence intervals for all the indirect and direct effect paths did not include zero, suggesting that the estimated effects were significant. The results indicated a partial mediation in which stress directly affects emotional exhaustion and influences it through sequential mediators, explicitly emphasizing the importance of rumination and maladaptive coping strategies in this mechanism.

3.6.2 Rumination and Adaptive Coping as Mediators

Table 7 displays the mediation effects of rumination and adaptive coping in the relationship between perceived stress and emotional exhaustion (Fig. 3). The findings revealed a significant direct effect of stress, indicated by an effect size of 0.196 (34.69% of the overall effect). This suggests a state of partial mediation, in which stress directly impacts emotional exhaustion while also exerting indirect effects through sequential mediators. The indirect effect via rumination is statistically significant, with an effect size of 0.173, accounting for 30.62% of the total effect. Additionally, adaptive coping demonstrates a significant mediation effect of 0.111, contributing 19.65% to the total effect.

Figure 3: The path mediation model. (A) Maladaptive coping; (B) Adaptive coping. ***p < 0.001

Moreover, the consecutive progression from rumination to adaptive coping demonstrates an effect size of 0.085, explaining 15.04% of the overall effect. The cumulative indirect effects amount to a substantial value of 0.369, accounting for 65.31% of the overall impact, thereby emphasizing the significant contribution of mediated mechanisms. The study findings indicated the direct, substantial impact of stress and emotional exhaustion, with an effect size of 0.565. Furthermore, the confidence intervals consistently exclude zero, providing strong support for the significance of the mediation model.

4  Discussion

The present work enhances our comprehension of psychological mechanisms within pharmacy practice by proposing an innovative tripartite mediation model that highlights the functions of stress, rumination, and adaptive and maladaptive coping techniques in developing emotional exhaustion. The results indicated that elevated stress levels were significantly associated with rumination and the adoption of ineffective coping mechanisms, leading to a notable intensification of emotional exhaustion among pharmacists. These findings underscore the negative pattern in which stress not only relates to mental well-being directly but also indirectly aggravates it through maladaptive coping strategies. Contrary to prior research that frequently examined these components separately, our integrated methodology offers a more thorough comprehension of these aspects’ interconnections and mutual influence within the demanding pharmacy practice environment.

The findings of our study supported Hypothesis I by demonstrating a significant positive correlation between perceived stress and emotional exhaustion. The finding was aligned with a substantial body of research that suggested that stress plays a crucial role in the development of burnout, especially in emotional exhaustion among healthcare professionals [64–66]. A cross-sectional study conducted by Durham et al. [65] found that stress, especially in high-pressure settings such as pharmacies, plays a significant role in the depletion of emotional resources, which is consistent with recent research in a similar setting [67]. Furthermore, research conducted in hospital settings, such as the studies conducted by Higuchi et al. [66], Haase [68], and Jones et al. [69], have demonstrated similar patterns, whereby the compounding effects of stress not only hinder day-to-day functioning but also increase the likelihood of experiencing prolonged psychological distress. Furthermore, mounting evidence suggests that sustained high-stress levels can predict the progression of emotional exhaustion over time [64,70,71]. These findings underscore the urgent need for targeted stress management interventions in pharmacy settings, highlighting that reducing workplace stress could significantly alleviate emotional exhaustion among pharmacists.

In addition, our study provided empirical support for Hypothesis II by showing that rumination was a significant mediator in the relationship between perceived stress and emotional exhaustion among study participants. The mediation proposed was aligned with cognitive theories of stress [72], positing that an individual’s cognitive processing of stressors significantly influences their emotional responses. Likewise, researchers have demonstrated that rumination serves to protract the duration of an individual’s emotional stress response while also contributing to the exacerbation of stress-related disorders [73]. In alignment with our findings, Donahue et al. provide additional support that individuals who frequently engaged in ruminative thoughts exhibited elevated levels of emotional exhaustion [74]. This highlighted the maladaptive nature of rumination as a coping mechanism, indicating its propensity to reinforce perceptions of stress. Rumination has been proven to mediate the relationship between work-related stress and burnout over an extended timeframe [75,76], implying that interventions targeting the reduction of rumination may prove effective in alleviating emotional exhaustion. These studies collectively demonstrate the negative association of rumination with mental health and confirm the significance of addressing cognitive processes in stress management programs targeted toward healthcare professionals.

Furthermore, our study’s findings support Hypothesis III, demonstrating that maladaptive and adaptive coping strategies mediate the relationship between perceived stress and emotional exhaustion. The present mediation is aligned with Lazarus and Folkman’s stress and coping theory [12], which emphasizes that the effectiveness of coping mechanisms significantly influences emotional outcomes. Skinner et al. [33] found that maladaptive coping mechanisms, including denial and substance use, intensify stress reactions, resulting in elevated levels of emotional exhaustion. On the other hand, it has been demonstrated that adaptive coping mechanisms, such as problem-solving and positive reframing, can mitigate the effects, as mentioned earlier. However, contextual factors and individual resilience traits may influence their effectiveness [77,78]. Moreover, Folkman and Moskowitz [79] indicated that although adaptive coping strategies may alleviate some immediate stress, they may not consistently diminish long-term emotional fatigue, particularly in ongoing stressors. Our findings suggest that a multifaceted approach is necessary to effectively manage pharmacists’ high-stress levels, as adaptive coping alone may be insufficient. This underscores the importance of comprehensive stress management programs that integrate both proactive and reactive coping strategies to support long-term well-being.

Moreover, our study provided empirical support for Hypothesis IV, demonstrating that rumination and coping styles (both maladaptive and adaptive) function as chain mediators in the relationship between perceived stress and emotional exhaustion among pharmacists. This sequential mediation model extends beyond conventional single-pathway models by illustrating how stress sequentially triggers rumination, which then influences coping behaviors, ultimately leading to emotional exhaustion. This finding aligns with Beck’s cognitive-behavioral stress model [80], which suggests that negative cognitive patterns contribute to maladaptive coping strategies and adverse emotional outcomes. Empirical studies have reinforced this model, showing that rumination increases the use of maladaptive coping mechanisms, particularly avoidance, which, in turn, heightens emotional distress [81,82]. A growing body of research suggests that reducing rumination in healthcare settings can significantly decrease maladaptive coping behaviors and mitigate burnout symptoms [83,84]. These findings highlight the potential effectiveness of cognitive-behavioral interventions in managing these challenges within the healthcare sector. The complex interaction between cognitive processes and coping strategies underscores the need for comprehensive stress management programs to alleviate emotional exhaustion associated with stress effectively.

While adaptive coping strategies are generally associated with psychological resilience and well-being, our findings indicated a significant association between adaptive coping and emotional exhaustion. One possible explanation could be that pharmacists, in an effort to maintain their performance and manage stress, may excessively rely on adaptive coping strategies, leading to cognitive and emotional fatigue. This aligns with research suggesting that even constructive coping mechanisms, when overused, may contribute to burnout and exhaustion in high-demand work environments [85]. Another plausible explanation is that the effectiveness of adaptive coping strategies may depend on contextual factors, such as workload intensity, organizational support, and the availability of recovery time. Prior research has shown mixed findings regarding adaptive coping in stressful professions, with some studies reporting protective effects while others highlight its limitations in highly pressured settings [86]. Future studies should explore the threshold at which adaptive coping becomes counterproductive and how workplace interventions can optimize coping strategies without increasing fatigue.

4.1 Practical Implications

The results of this study hold significant implications for the design and implementation of specific interventions intended to diminish stress and foster the adoption of more adaptive coping strategies within the pharmacy profession. We propose that training programs for stress management and advancing adaptive coping strategies may yield advantageous outcomes. Furthermore, implementing policy modifications targeting the causes of workplace stress may decrease the utilization of maladaptive coping strategies.

4.2 Clinical Implications

The research emphasizes significant clinical implications for managing stress in pharmacists, underscoring the necessity for personalized stress management interventions, workshops focusing on adaptive coping strategies, and policy modifications to mitigate workplace stressors. Enhancing professional support networks and conducting regular mental health screenings can provide pharmacists additional support in effectively managing stress, ultimately reducing emotional exhaustion. Moreover, it is proposed that public health campaigns can be employed to increase awareness regarding the significance of mental health within the pharmacy profession, fostering an environment that promotes open dialogue and the active pursuit of support, ultimately leading to improvements in the personal well-being of pharmacy professionals and the quality of care provided to patients.

4.3 Limitations

While this study provides valuable insights, several limitations must be considered when interpreting the findings. First, the cross-sectional design restricts the ability to establish causal relationships between the studied variables. Future longitudinal research is recommended to understand the directionality of these associations better. Second, the reliance on self-reported measures introduces the possibility of CMB, as participants’ responses may be influenced by social desirability or recall inaccuracies. While self-reporting is a common practice in psychological research, future studies could enhance data reliability by incorporating objective stress indicators (e.g., cortisol levels, absenteeism rates, or supervisor assessments of emotional exhaustion). Third, the study population was geographically limited to pharmacists working in public hospitals in Punjab, Pakistan, which may limit the generalizability of the findings to pharmacists in private healthcare settings, community pharmacies, or other regions. Different healthcare systems may present unique stressors and coping mechanisms, necessitating further research across diverse settings. Additionally, although stratified sampling ensured representation across various categories of public hospitals, it may not fully capture the heterogeneity of individual pharmacist experiences. Fourth, this study applied the RRS-10, which was originally developed for populations with depression. Its use in a non-depressed sample may affect the applicability of findings. Future studies should validate the scale’s relevance across broader populations. Finally, while the study contributes to understanding the relationship between stress, coping strategies, and emotional exhaustion, limiting the sample to hospital pharmacists may narrow its applicability to the broader pharmacist workforce, including those in clinical laboratories, academia, or retail pharmacy settings. Future research should explore these relationships in diverse professional environments to provide a more comprehensive understanding.

5  Conclusions

In conclusion, this study highlighted the significant associations between stress, coping mechanisms, and the mental well-being of pharmacists. Our findings provided empirical evidence on the mechanisms through which stress contributes to emotional exhaustion, particularly emphasizing the amplifying role of maladaptive coping strategies such as rumination. These insights underscore the urgent need for targeted interventions aimed at mitigating these effects. Addressing these factors can significantly improve pharmacists’ well-being, ultimately enhancing the quality of care they provide to patients.

Acknowledgement: We would like to express our sincere gratitude to the reviewers and editorial team for their valuable comments and suggestions, which greatly improved the quality of this article. We are also deeply grateful to all the anonymous participants who took part in this research. Their contributions have been invaluable to the successful completion of this study.

Funding Statement: This research was supported by Social Policy Grant through Nazarbayev University, Kazakhstan.

Author Contributions: The authors confirm their contribution to the paper as follows: study conception and design: Shazia Rehman, Erum Rehman, Mehmood Ahmad; data collection: Mehmood Ahmad; analysis and interpretation of results: Shazia Rehman, Erum Rehman, Mehmood Ahmad; draft manuscript preparation: Shazia Rehman, Erum Rehman, Mehmood Ahmad. All authors reviewed the results and approved the final version of the manuscript.

Availability of Data and Materials: The raw data that support the findings of this study are available upon reasonable request from the authors.

Ethics Approval: The study participants were informed that the data collected from these constructs would remain confidential and only accessible to the researchers and their team.

Informed Consent: Informed consent has been taken from all the participants. The study has been authorized by the Ethics Review Committee (ERC) of the Islamia University of Bahawalpur, Lahore, Pakistan (No. DR/2044).

Conflicts of Interest: The authors declare no conflicts of interest to report regarding the present study.

Supplementary Materials: The supplementary material is available online at https://www.techscience.com/doi/10.32604/ijmhp.2025.063582/s1.

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