Effects of Perceived Stress on Occupational Burnout Among Chinese Nurses：A Moderated Chain Mediation Model Via Insomnia and Psychological Distress

Effects of Perceived Stress on Occupational Burnout Among Chinese Nurses：A Moderated Chain Mediation Model Via Insomnia and Psychological Distress | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Perceived Stress on Occupational Burnout Among Chinese Nurses：A Moderated Chain Mediation Model Via Insomnia and Psychological Distress Dan Wang, Yuanyuan La, Mengzhen Zhao, Qianyun He, Guichun Du, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7890431/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Occupational stress is a confirmed precursor to nurse burnout, yet the underlying mechanisms—the "black box" of how stress translates into burnout—require elucidation. The potential protective role of psychological resilience in this process, particularly through a pathway involving sleep and emotional disturbances, lacks robust empirical evidence. This study aimed to test the chain-mediating effect of insomnia and psychological distress linking occupational stress to burnout and examine whether psychological resilience moderates this entire pathway. Methods A cross-sectional survey of 1133 registered nurses from China was conducted. Participants completed validated scales: the Perceived Stress Scale (PSS-10), Insomnia Severity Index (ISI), Generalized Anxiety Disorder (GAD-2), Patient Health Questionnaire (PHQ-2), Connor-Davidson Resilience Scale (CD-RISC-10), and Maslach Burnout Inventory (MBI). The data were analyzed via correlation analyses and moderated mediation analysis with the PROCESS macro of IBM ®SPSS. Ethical approval was obtained from the Medical Science Research Ethics Committee of the First Affiliated Hospital of China Medical University (Approval No. 2025–595), and all participants provided informed consent. Results The nurses’ average MBI score was 57.27 ± 19.47, and their PSS score was 17.37 ± 5.89. Correlation analyses revealed that stress was positively associated with insomnia (r = 0.28, P < 0.01), psychological distress (r = 0.28, P < 0.01), and job burnout (r = 0.28, P < 0.01). The mediation analysis indicated that stress influenced job burnout through four significant pathways: 1) a direct effect (β = 0.49, P < 0.001); 2) through the mediator of psychological distress; 3) through the mediator of insomnia; and 4) through the chain-mediating path of insomnia → psychological distress. Specifically, resilience buffers the effects of stress on both insomnia and negative emotion, with relationships being stronger for individuals with low resilience than for those with high resilience. Bootstrap analyses confirmed the significance of this moderated mediation model. Conclusions The findings illuminate a key mechanism—the insomnia-distress pathway—through which occupational stress leads to burnout while highlighting psychological resilience as a critical buffer. Interventions aimed at promoting resilience and addressing sleep and mental health issues could be effective strategies for mitigating burnout in the nursing workforce. Burnout Perceived stress Insomnia Psychological distress Resilience Path analysis Occupational health Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviews received at journal 29 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 04 Dec, 2025 Reviewers invited by journal 14 Nov, 2025 Editor invited by journal 27 Oct, 2025 Editor assigned by journal 27 Oct, 2025 Submission checks completed at journal 25 Oct, 2025 First submitted to journal 25 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7890431","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":549744953,"identity":"79479e8e-c119-4154-8104-61518f4a337d","order_by":0,"name":"Dan Wang","email":"","orcid":"","institution":"Beijing Normal University","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Wang","suffix":""},{"id":549744954,"identity":"f3c93ca5-56ef-4c9b-8963-3fd0bc44fc75","order_by":1,"name":"Yuanyuan La","email":"","orcid":"","institution":"Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuanyuan","middleName":"","lastName":"La","suffix":""},{"id":549744955,"identity":"cf346fd6-abc8-4fdd-9bce-430dafbe7fab","order_by":2,"name":"Mengzhen Zhao","email":"","orcid":"","institution":"Beijing Normal University","correspondingAuthor":false,"prefix":"","firstName":"Mengzhen","middleName":"","lastName":"Zhao","suffix":""},{"id":549744956,"identity":"c873f120-4ab1-41bd-a307-2f97f2786155","order_by":3,"name":"Qianyun He","email":"","orcid":"","institution":"Beijing Normal University","correspondingAuthor":false,"prefix":"","firstName":"Qianyun","middleName":"","lastName":"He","suffix":""},{"id":549744957,"identity":"c29d6905-af75-4d8c-9c80-5a5e8d767a56","order_by":4,"name":"Guichun Du","email":"","orcid":"","institution":"The Tenth People's Hospital of Shenyang","correspondingAuthor":false,"prefix":"","firstName":"Guichun","middleName":"","lastName":"Du","suffix":""},{"id":549744958,"identity":"c283387c-d751-455f-8866-77d3a8d54eb2","order_by":5,"name":"Kui Fang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYBAC9gYGBsYGBgke+/bmAwc+VBChhecARIuMAc+xxIMzzhCvhcHGQCLH+DBvCzFa2M8efjmzzYLHnOfMhwO8DQzy/GIHCGjhyUuz3NgmwWPZ3rvhgOQOBsOZsxPwa7FnyDEzfAjUwnDm7IYDhmcYEgxuE9DCw/8GquVGzoMDiW3EaAH6+iHIYQY3chgOHCROyxszxhnnJHgke44ZHGw4I0HYLzz8OcYfe8rq7PnZmx9//lNhI88vTUALELBJIHEkcCpDBswfiFI2CkbBKBgFIxcAAMC/STC0CE66AAAAAElFTkSuQmCC","orcid":"","institution":"The First Affiliated Hospital of China Medical University","correspondingAuthor":true,"prefix":"","firstName":"Kui","middleName":"","lastName":"Fang","suffix":""},{"id":549744961,"identity":"497ca14e-8705-45a2-a0a4-531885463d37","order_by":6,"name":"Jiefu Yu","email":"","orcid":"","institution":"The First Affiliated Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiefu","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2025-10-18 02:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7890431/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7890431/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96914769,"identity":"f3c28b36-7898-488b-937f-eed0b11da63a","added_by":"auto","created_at":"2025-11-27 14:06:21","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":191804,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript251025.docx","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/70475165c664c0fab757d4df.docx"},{"id":96762348,"identity":"6296849c-450a-40e9-81c7-9ea6ea44fb60","added_by":"auto","created_at":"2025-11-25 19:42:23","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9824,"visible":true,"origin":"","legend":"","description":"","filename":"98a7c5c2a9574ff59d2822cbd1cd8862.json","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/a272fe56cd845fd2b57ad722.json"},{"id":96762351,"identity":"0f227c67-abdd-4d09-9812-4f454edde00c","added_by":"auto","created_at":"2025-11-25 19:42:23","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":122435,"visible":true,"origin":"","legend":"","description":"","filename":"98a7c5c2a9574ff59d2822cbd1cd88621enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/52af8d823bb3acdbd132429e.xml"},{"id":96762349,"identity":"1db25e7f-a29a-43ed-af9d-ba40ecab02b5","added_by":"auto","created_at":"2025-11-25 19:42:23","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1074,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/1a9574916689d81a647416f2.jpeg"},{"id":96914706,"identity":"c0703388-cf4a-44c1-8bf4-1d9e17af0e91","added_by":"auto","created_at":"2025-11-27 14:06:15","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":39567,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/81d13bc8f627f046d307c73c.png"},{"id":96915803,"identity":"b189e7d2-56f5-43f1-8014-278b0398d82c","added_by":"auto","created_at":"2025-11-27 14:07:39","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":39612,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/83d1fdcd93b88a28972d0204.png"},{"id":96762353,"identity":"80d09fd4-608d-447b-8cf2-0998346e78fe","added_by":"auto","created_at":"2025-11-25 19:42:23","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":26232,"visible":true,"origin":"","legend":"","description":"","filename":"groupimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/09b15ca77a32e6a761c78c5c.jpeg"},{"id":96762357,"identity":"5fb6bbce-3287-4420-afa4-32923f0016a6","added_by":"auto","created_at":"2025-11-25 19:42:23","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":935,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/7c7d08ba536fb7883a1ab3f2.png"},{"id":96915303,"identity":"02643318-818f-4d22-89c9-f606d5cae9a1","added_by":"auto","created_at":"2025-11-27 14:07:05","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":36287,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/866a46e6d6b5a6068e161036.png"},{"id":96762359,"identity":"7ecc1e5e-231a-4ac2-8235-541aae78a71a","added_by":"auto","created_at":"2025-11-25 19:42:23","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":36705,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/116ccbc03a1919f9034231eb.png"},{"id":96762354,"identity":"ebd7d650-7ec0-47b0-8f8d-2a254a287b9b","added_by":"auto","created_at":"2025-11-25 19:42:23","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14580,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinegroupimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/54cb4db1db8aed79089fe147.png"},{"id":96762358,"identity":"36858f74-0cd5-40dd-8e25-d91a93a92587","added_by":"auto","created_at":"2025-11-25 19:42:23","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":119696,"visible":true,"origin":"","legend":"","description":"","filename":"98a7c5c2a9574ff59d2822cbd1cd88621structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/f2eadf43a9e24216bc301507.xml"},{"id":96762360,"identity":"8b09a007-2240-4533-99c9-59edd2a39260","added_by":"auto","created_at":"2025-11-25 19:42:24","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":138882,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1/c63330ed6f668351e576c7e0.html"},{"id":96922243,"identity":"23c87a89-700d-45f3-a9a0-e163a3410cef","added_by":"auto","created_at":"2025-11-27 14:18:53","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":646610,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript251025.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7890431/v1_covered_a682a4b7-c535-4fe2-9b20-a2e80dd55a04.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of Perceived Stress on Occupational Burnout Among Chinese Nurses：A Moderated Chain Mediation Model Via Insomnia and Psychological Distress","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Burnout, Perceived stress, Insomnia, Psychological distress, Resilience, Path analysis, Occupational health","lastPublishedDoi":"10.21203/rs.3.rs-7890431/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7890431/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eOccupational stress is a confirmed precursor to nurse burnout, yet the underlying mechanisms\u0026mdash;the \"black box\" of how stress translates into burnout\u0026mdash;require elucidation. The potential protective role of psychological resilience in this process, particularly through a pathway involving sleep and emotional disturbances, lacks robust empirical evidence. This study aimed to test the chain-mediating effect of insomnia and psychological distress linking occupational stress to burnout and examine whether psychological resilience moderates this entire pathway.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional survey of 1133 registered nurses from China was conducted. Participants completed validated scales: the Perceived Stress Scale (PSS-10), Insomnia Severity Index (ISI), Generalized Anxiety Disorder (GAD-2), Patient Health Questionnaire (PHQ-2), Connor-Davidson Resilience Scale (CD-RISC-10), and Maslach Burnout Inventory (MBI). The data were analyzed via correlation analyses and moderated mediation analysis with the PROCESS macro of IBM \u0026reg;SPSS. Ethical approval was obtained from the Medical Science Research Ethics Committee of the First Affiliated Hospital of China Medical University (Approval No. 2025\u0026ndash;595), and all participants provided informed consent.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe nurses\u0026rsquo; average MBI score was 57.27\u0026thinsp;\u0026plusmn;\u0026thinsp;19.47, and their PSS score was 17.37\u0026thinsp;\u0026plusmn;\u0026thinsp;5.89. Correlation analyses revealed that stress was positively associated with insomnia (r\u0026thinsp;=\u0026thinsp;0.28, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), psychological distress (r\u0026thinsp;=\u0026thinsp;0.28, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and job burnout (r\u0026thinsp;=\u0026thinsp;0.28, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The mediation analysis indicated that stress influenced job burnout through four significant pathways: 1) a direct effect (β\u0026thinsp;=\u0026thinsp;0.49, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001); 2) through the mediator of psychological distress; 3) through the mediator of insomnia; and 4) through the chain-mediating path of insomnia \u0026rarr; psychological distress. Specifically, resilience buffers the effects of stress on both insomnia and negative emotion, with relationships being stronger for individuals with low resilience than for those with high resilience. Bootstrap analyses confirmed the significance of this moderated mediation model.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe findings illuminate a key mechanism\u0026mdash;the insomnia-distress pathway\u0026mdash;through which occupational stress leads to burnout while highlighting psychological resilience as a critical buffer. Interventions aimed at promoting resilience and addressing sleep and mental health issues could be effective strategies for mitigating burnout in the nursing workforce.\u003c/p\u003e","manuscriptTitle":"Effects of Perceived Stress on Occupational Burnout Among Chinese Nurses：A Moderated Chain Mediation Model Via Insomnia and Psychological Distress","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-25 19:42:19","doi":"10.21203/rs.3.rs-7890431/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-11T02:10:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12979031922402625953353876003261183309","date":"2026-02-01T05:28:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-29T07:01:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164497428471981103018701314207161780618","date":"2026-01-23T18:48:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74761124515433810357698460257641205582","date":"2026-01-23T15:09:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274181290234548306326814852517242178872","date":"2026-01-23T12:33:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318922158257439521344017715667757280944","date":"2025-12-04T10:06:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-14T08:18:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-27T06:30:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-27T06:26:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-25T08:42:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-10-25T08:38:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"292d1819-22e1-475f-82d4-2e4954ba0e38","owner":[],"postedDate":"November 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-25T19:42:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-25 19:42:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7890431","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7890431","identity":"rs-7890431","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}