Abstract
Objective
This study examined the relationships among perceived stress, anxiety, unhealthy alcohol use, and insomnia among hospital staff and explored whether resilience moderates these associations.
Methods
We conducted a cross-sectional survey among 508 hospital staff members at a tertiary hospital in Hainan Province, China. Standardized psychometric instruments were employed, including the Perceived Stress Scale (PSS-10), Generalized Anxiety Disorder Scale (GAD-7), Connor–Davidson Resilience Scale (CD-RISC-10), Alcohol Use Disorder Identification Test (AUDIT), and Insomnia Severity Index (ISI). Statistical analyses included descriptive statistics, t-tests/ANOVA, Pearson correlations, and moderation analyses using the PROCESS Macro (Model 1) with bootstrapping (5,000 samples, 95% CI).
Results
Independent samples t-tests and ANOVA revealed that perceived stress, anxiety, resilience, and unhealthy alcohol use differed significantly across occupational, socioeconomic, and personal characteristics. Correlation analysis indicated that perceived stress and anxiety were positively correlated with unhealthy alcohol use and insomnia, while resilience was negatively associated with all adverse outcomes. PROCESS moderation analysis demonstrated that resilience significantly moderated the relationships between perceived stress/anxiety and unhealthy alcohol use; these associations were significant at low and moderate resilience levels but non-significant at high resilience levels. For insomnia, the associations remained significant across all resilience levels but progressively weakened as resilience increased.
Conclusion
Resilience moderates the associations between perceived stress/anxiety and unhealthy alcohol use/insomnia, with higher resilience levels progressively attenuating these associations. These findings highlight the importance of implementing systematic resilience-building interventions to safeguard the mental and behavioral health of healthcare workers.
Keywords: perceived stress, anxiety, unhealthy alcohol use, insomnia, resilience, Chinese hospital staff, moderation
1. Introduction
Healthcare workers experience substantially higher stress levels than individuals employed in other occupations; in particular, they exhibit elevated rates of depression and anxiety compared with those in the general workforce (1, 2). Healthcare workers face exceptionally demanding work environments marked by extended shifts, the management of critically ill patients, and an ongoing emotional burden (3). They frequently encounter workplace hazards, such as burnout, violence, and heavy workloads (4, 5). Recent research indicates that healthcare workers' anxiety and depression symptoms are significantly associated with work stress and may impair their work capacity (6). These mental health conditions will continue to escalate unless a thorough investigation is made of their development and progression among healthcare personnel, and the consequences will extend far beyond individual suffering. Therefore, understanding the healthcare-specific psychological sequelae and their ripple effects is essential for developing targeted interventions that effectively protect healthcare workers from occupational mental health deterioration (7).
Sleep disturbances, particularly insomnia, represent a prominent manifestation of occupational stress among healthcare workers (8, 9). Indeed, the implications of sleep disturbance extend across multiple domains of an individual's health and occupational performance. For example, acute insomnia impairs critical cognitive functions such as reaction time, memory consolidation, and executive decision-making, directly threatening patient safety (10). Similarly, chronic insomnia precipitates severe long-term health consequences, including major depressive disorder, cardiovascular disease, and burnout syndrome (11, 12). Studies have demonstrated that insomnia among healthcare workers reduces clinical performance (13), increases absenteeism, and reduces overall productivity (14). Epidemiological studies have reported that the prevalence of sleep disorders among healthcare professionals ranges from 38.6 to 69.7%, which significantly exceeds the rate of sleep disorders in the general population (15–17). This study examines whether hospital staff members suffering from occupational stress and anxiety have an increased risk of sleep disturbances in healthcare settings.
Hospital staff members who are experiencing occupational stress and anxiety are more likely to regularly drink alcohol or binge drink. Research has demonstrated that medical students with alcohol dependence show significant correlations with depression (18), while elevated levels of perceived stress and anxiety are associated with substantially higher risks of alcohol misuse and alcohol use disorder (19). In a cross-sectional UK study, doctors who coped with stress through substance use had dramatically increased odds of alcohol dependence (OR = 6.165), binge-drinking (OR = 6.355), and frequent alcohol consumption (OR = 18.836) (20). Another study demonstrated that night-shift healthcare workers often resort to alcohol use or sedatives for sleep and stress reduction, but such self-medication endangers the wellbeing of the staff and threatens patient safety (21). Some healthcare workers suffering from high occupational stress may utilize alcohol to cope with this additional trauma and pressure (22). Although alcohol use may provide temporary relief, it fails to reduce stress over time and actually worsens psychological distress, creating a harmful cycle (23). In light of these findings, we hypothesized that the relationship between perceived stress/anxiety and unhealthy alcohol use would be significantly higher among hospital staff in high-stress healthcare settings.
Although perceived stress or anxiety may increase the likelihood of unhealthy alcohol use or insomnia, not all individuals with high levels of perceived stress or anxiety develop these adverse outcomes, which suggest that resilience may play a moderating role. Indeed, the results of a previous study indicate that resilience buffers the negative effect of stress on insomnia, thereby reducing the risk of impaired sleep quality (24). Similarly, research has demonstrated that resilience functions as a protective factor against problematic drinking behaviors, even under stressful conditions (25). One study found that resilience was negatively correlated with stress and anxiety and positively associated with enhanced psychological adjustment (26). Thus, these findings suggest that the strength of the effects of perceived stress and anxiety on unhealthy alcohol use and insomnia depends on an individual's level of resilience. Individuals with higher levels of resilience are more likely to maintain psychological stability, avoid maladaptive coping strategies such as excessive alcohol use, and experience fewer sleep disturbances as a result. Conversely, individuals with low resilience may be more vulnerable to maladaptive responses when faced with occupational stress and anxiety, potentially leading to unhealthy alcohol use and insomnia. Accordingly, we hypothesized that resilience moderates the relationship between perceived stress/anxiety and unhealthy alcohol use/insomnia among hospital staff.
Based on this theoretical framework and prior empirical evidence, this study explores the relationships among perceived stress, anxiety, unhealthy alcohol use, and insomnia in Chinese hospital staff. In addition, it investigates whether resilience moderates the associations between perceived stress/anxiety and unhealthy alcohol use/insomnia. Identifying such protective mechanisms can inform targeted interventions to strengthen resilience and safeguard mental health among hospital staff. The conceptual framework of the present study is illustrated in Figure 1, and the following hypotheses were proposed:
Figure 1.
The proposed conceptual framework for the hypothetical model.
H1: Perceived stress, anxiety, resilience, unhealthy alcohol use, and insomnia differ significantly across demographic characteristics among hospital staff.
H2a: Perceived stress is positively correlated with unhealthy alcohol use among hospital staff.
H2b: Perceived stress is positively correlated with insomnia among hospital staff.
H2c: Anxiety is positively correlated with unhealthy alcohol use among hospital staff.
H2d: Anxiety is positively correlated with insomnia among hospital staff.
H3a: Resilience moderates the association between perceived stress and unhealthy alcohol use among hospital staff.
H3b: Resilience moderates the association between perceived stress and insomnia use among hospital staff.
H3c: Resilience moderates the association between anxiety and unhealthy alcohol use among hospital staff.
H3d: Resilience moderates the association between anxiety and insomnia among hospital staff.
2. Materials and methods
2.1. Study design and participants
A cross-sectional design was adopted to examine the moderating effect of resilience on the relationships among perceived stress, anxiety, unhealthy alcohol use, and insomnia. This approach provides a practical method for capturing the psychological states and behavioral patterns of hospital staff at a defined point in time, and is consistent with the exploratory nature of this investigation. The target population comprised hospital staff, including doctors, nurses, and non-medical personnel, at a tertiary hospital in Hainan Province of China. The data were collected using a standardized paper-based questionnaire administered between March and May 2025. This study was approved by the Institutional Research Ethics Committee of the Affiliated Cancer Hospital of Hainan Medical University.
The inclusion criteria were as follows: (1) current employment at Hainan Cancer Hospital, (2) voluntary participation, and (3) the provision of written informed consent after receiving a complete explanation of the study. All of the participants' responses to the questionnaires were anonymous. Of the 600 individuals who received the survey, 545 (90.83%) returned completed questionnaires. Following data screening, 37 questionnaires containing missing data or logical inconsistencies were excluded, yielding a final sample of 508 valid responses for analysis.
2.2. Measurements tools
2.2.1. Perceived stress scale (PSS-10)
The PSS-10 is a 10-item self-administered psychometric instrument designed to assess an individual's perception of stress (27). Each item is scored on a 5-point Likert scale ranging from 0 (never) to 4 (very often), with a total score ranging from 0 to 40. Specifically, six of the items (labeled 1, 2, 3, 6, 9, and 10) are forward-scored, while four of the items (4, 5, 7, and 8) are reverse-scored, with higher values indicating greater stress. The Chinese version of the PSS-10 has demonstrated good internal consistency (Cronbach's α = 0.86) (28). In the present study, the PSS-10 demonstrated satisfactory internal consistency (Cronbach's α = 0.839).
2.2.2. Generalized anxiety disorder scale (GAD-7)
The GAD-7 is a 7-item self-reported psychometric scale that measures an individual's anxiety level (29). Items are rated on a 4-point Likert scale ranging from 0 to 3, yielding total scores from 0 to 21, with higher scores indicating more severe anxiety. The Chinese version of the GAD-7 has demonstrated acceptable reliability and validity (Cronbach's α = 0.898) (30). In the present study, the GAD-7 demonstrated excellent internal consistency (Cronbach's α = 0.929).
2.2.3. Connor-davidson resilience scale (CD-RISC-10)
The CD-RISC-10 is a 10-item self-administered psychometric scale that assesses an individual's mental resilience (31). The items are rated on a 5-point Likert scale ranging from 0 to 4, producing total scores from 0 to 40, with higher scores reflecting greater resilience. The Chinese version of the CD-RISC-10 has demonstrated good internal consistency (Cronbach's α = 0.91) (32). In this study, internal consistency was excellent (Cronbach's α = 0.957).
2.2.4. Alcohol use disorder identification test (AUDIT)
The AUDIT was designed by the World Health Organization to identify an individual's unhealthy alcohol use (33). This 10-item instrument includes five response options (scored 0 to 4 points) for items 1–8 and three response options (scored 0, 2, or 4 points) for items 9–10. Total scores range from 0 to 40, with higher scores indicating a greater risk for harmful alcohol use and potential alcohol dependence. The Chinese version of the AUDIT has demonstrated adequate validity and reliability (Cronbach's α = 0.714) (34). In the present study, the AUDIT demonstrated good internal consistency (Cronbach's α = 0.855).
2.2.5. Insomnia severity index (ISI)
The ISI is a 7-item self-reported scale that assesses the severity of insomnia symptoms (35). The items are rated on a 5-point Likert scale ranging from 0 to 4, with total scores ranging from 0 to 28; higher scores indicate more severe insomnia. The Chinese version of the ISI has demonstrated adequate psychometric properties (Cronbach's α = 0.83) (36). In the present study, the ISI demonstrated excellent internal consistency (Cronbach's α = 0.913).
2.2.6. Covariates
The following demographic and socioeconomic characteristics were included as covariates in the analyses: sex (male, female), age (< 25, 25–35, 36–45, >45 years), marital status (unmarried, married, divorced/widowed), occupation (doctor, nurse, non-medical staff), educational level (high school, bachelor's degree, master's degree, doctoral degree), years of work experience (< 2, 2–5, 6–10, 11–15, >15), weekly working hours (< 40, 40–48, >48), and monthly income [ < 5,000, 5,000–10,000, 10,000–20,000, >20,000 CNY (Chinese Yuan)].
2.3. Statistical analyses
All of the statistical analyses were performed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including means, standard deviations (SDs), frequencies, and percentages, were calculated to characterize the sample. Independent samples t-tests were used for comparisons between two groups (i.e., gender), while one-way ANOVA tests were used for comparisons among more than two groups. In cases where the ANOVA revealed significant differences, Scheffé's post-hoc test was applied to determine the source of the difference. A Pearson's correlation analysis was used to examine bivariate relationships among the study variables. The moderating effect of resilience on the associations between perceived stress/anxiety and unhealthy alcohol use/insomnia was examined using Model 1 of the PROCESS Macro for SPSS, version 4.3 (37). To further explore the moderation effects, simple slopes analyses were conducted to examine the conditional effects of perceived stress and anxiety on unhealthy alcohol use and insomnia at three levels of resilience: low (1 SD below the mean), mean, and high (1 SD above the mean). Gender, age, marital status, occupation, educational level, years of work experience, weekly working hours, and income were included as covariates in the moderation analyses. The significance of conditional effects was evaluated using bootstrapping with 5,000 resamples and 95% bias-corrected confidence intervals (CIs). A significant effect was indicated when the 95% CI did not contain a value of zero (38). To reduce multicollinearity, all variables were mean-centered before creating interaction terms. Statistical significance was set at p < 0.05.
3. Results
3.1. Descriptive statistics
The sample was predominantly female, with women comprising approximately two-thirds of the participants (68.31%). The majority of participants were aged 25–35 years (67.72%), and over half were married (54.13%). Nurses represented the largest occupational group (44.29%), followed by doctors (32.28%) and non-medical staff (23.43%). Most participants held a bachelor's degree (71.85%), had 2–10 years of work experience (66.93%), worked 40–48 h per week (61.42%), and earned a monthly income of 5,000–10,000 CNY (50.98%). Detailed distributions for all demographic variables are presented in Table 1.
Table 1.
Demographics characteristics and the distribution of perceived stress, anxiety, resilience, unhealthy alcohol use, and insomnia (N = 508).
| Variable | Respondents | Perceived stress | Anxiety | Resilience | Unhealthy alcohol use | Insomnia | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| N (%) | Mean ±SD | P-value | Mean ±SD | P-value | Mean ±SD | P-value | Mean ±SD | P-value | Mean ±SD | P-value | |
| Gender | |||||||||||
| Men | 161 (31.69%) | 18.88 ± 4.613 | 0.352 | 6.98 ± 5.234 | 0.264 | 25.09 ± 7.588 | 0.668 | 7.43 ± 6.264 | < 0.001*** | 8.71 ± 5.817 | 0.620 |
| Women | 347 (68.31%) | 18.46 ± 4.844 | 6.40 ± 5.417 | 24.77 ± 7.966 | 4.22 ± 5.443 | 8.44 ± 5.858 | |||||
| Age (years) | |||||||||||
| < 25 | 57 (11.22%) | 17.67 ± 6.160 | 0.029* | 5.91 ± 5.546 | 0.172 | 25.02 ± 10.054 | 0.014* | 4.93 ± 6.138 | 0.177 | 8.37 ± 6.326 | 0.391 |
| 25 – 35 | 344 (67.72%) | 19.01 ± 4.545 | 6.69 ± 5.440 | 24.49 ± 7.441 | 5.10 ± 5.839 | 8.55 ± 5.882 | |||||
| 36 – 45 | 81 (15.94%) | 18.01 ± 4.143 | 7.17 ± 4.839 | 24.89 ± 7.853 | 6.44 ± 5.939 | 9.07 ± 5.796 | |||||
| > 45 | 26 (5.12%) | 16.96 ± 5.503 | 4.77 ± 5.218 | 29.65 ± 6.151 | 3.96 ± 5.889 | 6.81 ± 4.000 | |||||
| Marital status | |||||||||||
| Unmarried | 193 (37.99%) | 18.86 ± 5.124 | 0.596 | 6.45 ± 5.569 | 0.631 | 24.31 ± 7.891 | 0.126 | 5.13 ± 5.875 | < 0.001*** | 8.95 ± 5.940 | 0.339 |
| Married | 275 (54.13%) | 18.40 ± 4.518 | 6.77 ± 5.282 | 25.49 ± 7.643 | 4.54 ± 5.391 | 8.17 ± 5.834 | |||||
| Divorced or widowed | 40 (7.87%) | 18.60 ± 4.771 | 6.00 ± 4.925 | 23.38 ± 8.714 | 10.55 ± 6.812 | 8.90 ± 5.368 | |||||
| Occupation | |||||||||||
| Doctor | 164 (32.28%) | 18.91 ± 5.117 | 0.030* | 6.59 ± 5.386 | 0.033* | 25.77 ± 7.282 | 0.105 | 4.81 ± 5.767 | 0.197 | 8.57 ± 5.743 | 0.125 |
| Nurse | 225 (44.29%) | 18.90 ± 4.394 | 7.13 ± 5.636 | 24.09 ± 8.404 | 5.12 ± 6.072 | 8.97 ± 6.078 | |||||
| Non-medical staff | 119 (23.43%) | 17.58 ± 4.865 | 5.55 ± 4.634 | 25.11 ± 7.386 | 6.06 ± 5.726 | 7.62 ± 5.449 | |||||
| Educational level | |||||||||||
| High school | 63 (12.40%) | 18.22 ± 4.144 | 0.580 | 6.73 ± 4.962 | 0.974 | 23.19 ± 7.479 | 0.308 | 8.54 ± 6.601 | < 0.001*** | 8.59 ± 5.662 | 0.861 |
| Bachelor's degree | 365 (71.85%) | 18.60 ± 4.828 | 6.52 ± 5.512 | 25.03 ± 8.211 | 4.83 ± 5.695 | 8.63 ± 6.030 | |||||
| Master's degree | 53 (10.43%) | 19.30 ± 4.241 | 6.79 ± 4.725 | 25.32 ± 5.986 | 4.49 ± 5.669 | 8.08 ± 5.064 | |||||
| Doctor's degree | 27 (5.31%) | 18.00 ± 6.251 | 6.78 ± 5.618 | 25.81 ± 6.451 | 4.56 ± 5.161 | 7.89 ± 5.243 | |||||
| Years of work experience | |||||||||||
| < 2 | 46 (9.06%) | 17.89 ± 6.983 | 0.121 | 4.96 ± 5.404 | 0.013* | 25.54 ± 8.823 | 0.001** | 3.78 ± 4.747 | 0.007** | 6.70 ± 5.304 | 0.155 |
| 2 – 5 | 178 (35.04%) | 19.08 ± 4.196 | 7.54 ± 5.358 | 23.53 ± 7.572 | 6.50 ± 6.060 | 9.05 ± 6.059 | |||||
| 6 – 10 | 162 (31.89%) | 18.86 ± 4.724 | 6.57 ± 5.570 | 25.24 ± 7.815 | 4.93 ± 6.300 | 8.74 ± 6.047 | |||||
| 11 – 15 | 75 (14.76%) | 18.01 ± 4.203 | 5.92 ± 4.693 | 24.28 ± 7.601 | 4.47 ± 5.105 | 8.28 ± 5.306 | |||||
| > 15 | 47 (9.25%) | 17.43 ± 5.038 | 5.64 ± 5.084 | 28.98 ± 6.974 | 4.19 ± 5.902 | 8.00 ± 5.389 | |||||
| Weekly working hours | |||||||||||
| < 40 | 64 (12.60%) | 18.63 ± 4.377 | 0.019* | 5.20 ± 5.538 | 0.006** | 25.17 ± 8.671 | 0.767 | 5.05 ± 5.731 | 0.935 | 7.80 ± 5.655 | 0.065 |
| 40 – 48 | 312 (61.42%) | 18.17 ± 4.732 | 6.40 ± 5.224 | 24.67 ± 7.795 | 5.22 ± 5.946 | 8.26 ± 5.890 | |||||
| > 48 | 132 (25.98%) | 19.57 ± 4.937 | 7.70 ± 5.425 | 25.20 ± 7.572 | 5.37 ± 5.922 | 9.52 ± 5.734 | |||||
| Income | |||||||||||
| < 5,000 | 159 (31.30%) | 18.70 ± 4.257 | 0.102 | 6.80 ± 5.333 | 0.323 | 23.78 ± 7.917 | 0.002** | 6.42 ± 6.024 | 0.012* | 8.52 ± 5.723 | 0.613 |
| 5,000 – 10,000 | 259 (50.98%) | 18.71 ± 5.257 | 6.78 ± 5.654 | 24.80 ± 8.096 | 4.49 ± 5.699 | 8.76 ± 6.044 | |||||
| 10,000 – 20,000 | 73 (14.37%) | 18.60 ± 3.589 | 5.53 ± 4.279 | 26.15 ± 6.317 | 5.16 ± 5.482 | 8.04 ± 5.549 | |||||
| > 20,000 | 17 (3.35%) | 15.76 ± 5.495 | 6.18 ± 5.065 | 30.82 ± 6.002 | 6.00 ± 7.929 | 7.18 ± 5.114 | |||||
*p < 0.05, **p < 0.01, ***p < 0.001.
Independent samples t-tests and one-way ANOVA analyses were conducted to examine differences across various demographic variables. Scheffé's post-hoc tests were performed when significant omnibus effects were detected. For perceived stress, participants working more than 48 h per week scored higher than those working 40–48 h (p = 0.019). For anxiety, staff working more than 48 h per week scored higher than those working fewer than 40 hours (p = 0.009), and nurses reported higher anxiety than non-medical staff (p = 0.033). For resilience, participants over 45 years old scored higher than those aged 25–35 (p = 0.014), staff with more than 15 years of experience scored higher than those with 2–5 years (p = 0.001) and 11–15 years (p = 0.031), and those earning more than 20,000 CNY scored higher than those earning less than 5,000 CNY (p = 0.006) and 5,000–10,000 CNY (p = 0.023). For unhealthy alcohol use, men scored higher than women (p < 0.001), and divorced or widowed staff scored higher than both unmarried (p < 0.001) and married participants (p < 0.001). Participants with a high school education also reported higher unhealthy alcohol use than those with a bachelor's (p < 0.001), master's (p = 0.003), or doctoral degree (p = 0.031), and staff earning less than 5,000 CNY scored higher than those earning 5,000–10,000 CNY (p = 0.014). No significant demographic differences were observed in insomnia scores.
3.2. Correlations among study variables
As illustrated in Table 2, perceived stress was positively correlated with anxiety (r = 0.442, p < 0.001), unhealthy alcohol use (r = 0.220, p < 0.001), and insomnia (r = 0.371, p < 0.001). Anxiety was also positively correlated with both unhealthy alcohol use (r = 0.282, p < 0.001) and insomnia (r = 0.382, p < 0.001). In addition, unhealthy alcohol use was positively correlated with insomnia (r = 0.340, p < 0.001). Resilience was negatively correlated with all of the study variables: perceived stress (r = −0.405, p < 0.001), anxiety (r = −0.241, p < 0.001), unhealthy alcohol use (r = −0.431, p < 0.001), and insomnia (r = −0.423, p < 0.001).
Table 2.
The correlations between the main study variables.
| Variable | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
| 1. Perceived stress | 1 | ||||
| 2. Anxiety | 0.442*** | 1 | |||
| 3. Resilience | −0.405*** | −0.241*** | 1 | ||
| 4. Unhealthy alcohol use | 0.220*** | 0.282*** | −0.431*** | 1 | |
| 5. Insomnia | 0.371*** | 0.382*** | −0.423*** | 0.340*** | 1 |
***p < 0.001.
3.3. Moderating analyses
The moderating role of resilience was examined using Model 1 of the PROCESS Macro. As shown in Table 3, perceived stress and anxiety served as the independent variables, resilience as the moderator, and unhealthy alcohol use as the dependent variable. Perceived stress (B = 0.122, p = 0.023), resilience (B = −0.297, p < 0.001), and the perceived stress × resilience interaction (B = −0.019, p < 0.001) were significantly associated with unhealthy alcohol use. Similarly, anxiety (B = 0.203, p < 0.001), resilience (B = −0.279, p < 0.001), and the anxiety × resilience interaction (B = −0.018, p < 0.001) demonstrated significant associations with unhealthy alcohol use, indicating the moderating effects of resilience.
Table 3.
Moderating role of resilience in the association between perceived stress/anxiety and unhealthy alcohol use.
| Predictors | B | SE | t | LLCI | ULCI |
|---|---|---|---|---|---|
| Perceived stress (independent variable) | |||||
| Constant | 9.797 | 1.901 | 5.153*** | 6.062 | 13.533 |
| Perceived stress | 0.122 | 0.053 | 2.277* | 0.017 | 0.227 |
| Resilience | −0.297 | 0.031 | −9.547*** | −0.358 | −0.236 |
| Perceived stress × resilience | −0.019 | 0.005 | −3.694*** | −0.030 | −0.009 |
| R2 | 0.313 | ||||
| ΔR2 | 0.019 | ||||
| F | 13.646*** | ||||
| Anxiety (independent variable) | |||||
| Constant | 9.456 | 1.864 | 5.074*** | 5.794 | 13.118 |
| Anxiety | 0.203 | 0.042 | 4.796*** | 0.120 | 0.285 |
| Resilience | −0.279 | 0.029 | −9.710*** | −0.335 | −0.223 |
| Anxiety × Resilience | −0.018 | 0.005 | −3.890*** | −0.027 | −0.009 |
| R2 | 0.341 | ||||
| ΔR2 | 0.020 | ||||
| F | 15.133*** | ||||
*p < 0.05, ***p < 0.001.
The same analytical approach was applied with using insomnia as the dependent variable. As illustrated in Table 4, perceived stress (B = 0.311, p < 0.001), resilience (B = −0.247, p < 0.001), and the perceived stress × resilience interaction (B = −0.012, p = 0.028) significantly predicted insomnia. Likewise, anxiety (B = 0.324, p < 0.001), resilience (B = −0.259, p < 0.001), and the anxiety × resilience interaction (B = −0.020, p < 0.001) were significant predictors of insomnia. These findings indicate that lower resilience strengthens the association between perceived stress/anxiety and unhealthy alcohol use/insomnia.
Table 4.
Moderating role of resilience in the association between perceived stress/anxiety and insomnia.
| Predictors | B | SE | t | LLCI | ULCI |
|---|---|---|---|---|---|
| Perceived stress (independent variable) | |||||
| Constant | 9.534 | 1.964 | 4.854*** | 5.675 | 13.394 |
| Perceived stress | 0.311 | 0.055 | 5.637*** | 0.203 | 0.420 |
| Resilience | −0.247 | 0.032 | −7.697*** | −0.310 | −0.184 |
| Perceived stress × Resilience | −0.012 | 0.005 | −2.202* | −0.023 | −0.001 |
| R2 | 0.252 | ||||
| ΔR2 | 0.007 | ||||
| F | 4.851* | ||||
| Anxiety (independent variable) | |||||
| Constant | 9.521 | 1.895 | 5.025*** | 5.799 | 13.244 |
| Anxiety | 0.324 | 0.043 | 7.538*** | 0.239 | 0.408 |
| Resilience | −0.259 | 0.029 | −8.855*** | −0.316 | −0.201 |
| Anxiety × Resilience | −0.020 | 0.005 | −4.268*** | −0.029 | −0.011 |
| R2 | 0.304 | ||||
| ΔR2 | 0.026 | ||||
| F | 18.219*** | ||||
*p < 0.05, ***p < 0.001.
The simple slopes analysis (Table 5 and Figure 2) revealed that the association between perceived stress and unhealthy alcohol use was significant at low [B = 0.273, SE = 0.076, 95% CI (0.123, 0.423)] and moderate resilience levels [B = 0.122, SE = 0.053, 95% CI (0.017, 0.227)] but non-significant among individuals with high resilience [B = −0.030, SE = 0.057, 95% CI (−0.142, 0.082)]. A similar pattern emerged for anxiety: Its association with unhealthy alcohol use was significant at low [B = 0.343, SE = 0.057, 95% CI (0.231, 0.454)] and moderate resilience levels [B = 0.203, SE = 0.042, 95% CI (0.120, 0.285)] but non-significant at high resilience level [B = 0.062, SE = 0.054, 95% CI (−0.044, 0.169)].
Table 5.
Conditional effect results.
| Levels of resilience | Unhealthy alcohol use | Insomnia | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Effect | SE | t | LLCI | ULCI | Effect | SE | t | LLCI | ULCI | |
| Perceived stress (Independent variable) | ||||||||||
| Low resilience (M - 1SD) | 0.273 | 0.076 | 3.576*** | 0.123 | 0.423 | 0.405 | 0.079 | 5.126*** | 0.250 | 0.560 |
| Mean resilience (M) | 0.122 | 0.053 | 2.277* | 0.017 | 0.227 | 0.311 | 0.055 | 5.637*** | 0.203 | 0.420 |
| High resilience (M + 1SD) | −0.030 | 0.057 | −0.523 | −0.142 | 0.082 | 0.218 | 0.059 | 3.706*** | 0.102 | 0.334 |
| Anxiety (Independent variable) | ||||||||||
| Low resilience (M - 1SD) | 0.343 | 0.057 | 6.041*** | 0.231 | 0.454 | 0.480 | 0.058 | 8.321*** | 0.367 | 0.593 |
| Mean resilience (M) | 0.203 | 0.042 | 4.796*** | 0.120 | 0.285 | 0.324 | 0.043 | 7.538*** | 0.239 | 0.408 |
| High resilience (M + 1SD) | 0.062 | 0.054 | 1.147 | −0.044 | 0.169 | 0.167 | 0.055 | 3.028** | 0.059 | 0.275 |
*p < 0.05, **p < 0.01, ***p < 0.001.
Figure 2.
The moderating role of resilience in the association between perceived stress/anxiety and unhealthy alcohol use/insomnia.
Regarding insomnia, the associations remained significant across all resilience levels, but they diminished in magnitude as the resilience levels increased. The association between perceived stress and insomnia was significant at low [B = 0.405, SE = 0.079, 95% CI (0.250, 0.560)], moderate [B = 0.311, SE = 0.055, 95% CI (0.203, 0.420)], and high [B = 0.218, SE = 0.059, 95% CI (0.102, 0.334)] resilience levels. Likewise, the association between anxiety and insomnia was significant at low [B = 0.480, SE = 0.058, 95% CI (0.367, 0.593)], moderate [B = 0.324, SE = 0.043, 95% CI (0.239, 0.408)], and high [B = 0.167, SE = 0.055, 95% CI (0.059, 0.275)] resilience levels. Overall, individuals with lower resilience exhibited stronger positive associations between perceived stress/anxiety and unhealthy alcohol use/insomnia.
4. Discussion
4.1. Demographic differences in perceived stress, anxiety, resilience, unhealthy alcohol use, and insomnia among hospital staff (H1)
Several demographic characteristics revealed meaningful differences in perceived stress, anxiety, resilience, and unhealthy alcohol use among hospital staff. Regarding perceived stress and anxiety, staff working more than 48 h per week reported elevated levels of both measures, and nurses exhibited higher anxiety than non-medical staff, corroborating evidence that direct patient-care roles and extended work schedules impose a greater psychological burden (39, 40). For resilience, higher scores were observed among older staff and those with more years of work experience, suggesting that accumulated occupational experience may foster adaptive coping strategies (41, 42). Higher-income employees also demonstrated greater resilience, consistent with previous findings linking income level to resilience among healthcare workers (43). For unhealthy alcohol use, men scored higher than women, reflecting well-documented gender patterns in drinking behavior (44). Divorced or widowed staff reported higher alcohol consumption, possibly reflecting a reliance on alcohol as a coping mechanism in response to marital loss (45). Lower educational attainment was also associated with elevated alcohol use, which has been attributed to reduced health literacy and limited emphasis on healthy lifestyle behaviors (46). Although insomnia scores did not differ significantly across demographic subgroups, a marginal trend was noted for weekly working hours (F = 2.743, p = 0.065), with staff working more than 48 h reporting higher scores. This same subgroup also reported significantly elevated perceived stress and anxiety, suggesting that excessive working hours may constitute a common risk factor for both psychological distress and sleep disturbances among hospital staff (47). Collectively, these findings highlight the need for targeted interventions for high-risk subgroups, particularly staff with extended working hours, frontline clinical personnel, and those facing socioeconomic or personal adversity.
4.2. The correlation among perceived stress, anxiety, resilience, unhealthy alcohol use and insomnia in hospital staff (H2)
Consistent with H2, perceived stress and anxiety were positively associated with unhealthy alcohol use. This finding aligns with relevant evidence indicating that psychological distress frequently precipitates maladaptive coping mechanisms, particularly alcohol consumption, which individuals often rationalize by citing its perceived anxiolytic properties (48, 49). Perceived stress has also been correlated with problematic drinking patterns (50). Among healthcare professionals, alcohol use disorders intertwine with workplace stressors, simultaneously compromising mental health and diminishing occupational performance (51). Therefore, the observed association between perceived stress/anxiety and unhealthy alcohol use constitute a pathway that warrants targeted intervention strategies. However, this relationship appears bidirectional rather than unidirectional. Different drinking patterns correlate with varying severities of anxiety disorders and psychological strain (52), while alcohol misuse itself exacerbates anxiety, stress, and depression, creating a self-perpetuating cycle of psychological distress (53). Indeed, multiple studies have confirmed reciprocal relationships between alcohol consumption and anxiety symptoms (54, 55).
Likewise, our findings regarding stress-induced insomnia align with previous studies indicating that occupational stressors, including excessive workloads, time constraints, and emotionally demanding patient interactions, consistently precipitate sleep disturbances among healthcare professionals (56, 57). Anxiety has emerged as a particularly robust predictor of insomnia severity (58). Recent evidence has revealed that this relationship operates bidirectionally, with reciprocal influences between anxiety and insomnia (59) as well as between stress and sleep quality (60). Furthermore, alcohol use and insomnia have demonstrated important interconnections. Although some individuals adopt drinking as a stress-management strategy, alcohol consumption paradoxically disrupts sleep architecture and continuity, intensifying insomnia severity (61, 62). Overall, these interconnected relationships among perceived stress, anxiety, unhealthy alcohol use, and insomnia create a self-perpetuating cycle that progressively reinforces maladaptive patterns, highlighting the urgent need to have comprehensive intervention strategies that disrupt this detrimental sequence in high-pressure healthcare environments.
4.3. The moderating effect of resilience on the relationship between perceive stress/anxiety and unhealthy alcohol use/insomnia among hospital staff (H3)
Regarding H3, resilience significantly moderated the relationship between perceived stress/anxiety and unhealthy alcohol use. This positive association between perceived stress/anxiety and unhealthy alcohol use was stronger among individuals with lower resilience, suggesting that those with limited psychological resources are more susceptible to engaging in stress-induced drinking behaviors. This finding aligns with previous research demonstrating that resilience moderates the indirect pathway from stress through negative emotions to problematic alcohol consumption (63) and that individuals with limited resilience are particularly vulnerable to stress-related drinking (64). Notably, at high resilience levels, the associations between perceived stress/anxiety and unhealthy alcohol use were non-significant, suggesting that high resilience may substantially weaken the association between psychological distress and drinking behavior. Highly resilient individuals likely possess more adaptive coping strategies—such as cognitive reappraisal, problem-solving, and social support-seeking—that reduce their reliance on alcohol as a maladaptive coping mechanism. This interpretation is consistent with the self-medication hypothesis, which posits that individuals use substances to alleviate negative emotional states; high resilience may provide sufficient psychological resources for people to regulate their emotions without resorting to alcohol. In support of this view, resilience has been widely recognized as a protective factor against hazardous drinking (65), and evidence from the COVID-19 pandemic indicates that higher resilience can minimize stress-induced increases in alcohol consumption (66).
Resilience also moderated the relationship between perceived stress/anxiety and insomnia. As resilience levels decreased, the positive association between perceived stress/anxiety and insomnia became progressively stronger. This pattern highlights the protective role of resilience in mitigating sleep disturbances related to psychological distress. Previous studies among nurses and medical students confirm that resilience attenuates stress-induced negative emotions and sleep disturbances (67, 68). Furthermore, strengthening psychological resilience has been link to a reduction in insomnia buffering occupational stress (69). These results indicate that resilience plays a protective role in reducing both substance-related maladaptive coping and sleep disturbances. This evidence highlights the critical need for systematic resilience-building interventions to safeguard the psychological and behavioral health of healthcare workers.
4.4. Study limitations and practical implications
This study has limitations that warrant consideration. First, the cross-sectional design precludes causal inferences regarding the relationships among perceived stress, anxiety, resilience, unhealthy alcohol use, and insomnia. The temporal sequence among these variables cannot be determined, and bidirectional relationships remain plausible. Longitudinal studies are needed to clarify the temporal dynamics of these associations. Second, the data were collected from hospital staff at a single tertiary hospital in Hainan Province, China, which may limit the generalizability of findings to healthcare workers in other institutional settings or cultural contexts. Future research should incorporate multi-center and cross-cultural samples to enhance external validity. Third, although the current findings highlight the protective role of resilience, intervention-based research is warranted to determine whether resilience-enhancing training programs can effectively reduce unhealthy alcohol use and insomnia among healthcare workers. Fourth, all of the measures were self-reported, which may introduce social desirability and recall biases, particularly when measuring sensitive outcomes such as alcohol use.
Despite these limitations, the present findings carry considerable practical significance for healthcare institutions. The finding that resilience moderates the associations between perceived stress/anxiety and unhealthy alcohol use/insomnia provides an empirical basis for incorporating resilience-building programs into occupational health frameworks. Hospital administrators may consider integrating evidence-based resilience training, such as cognitive-behavioral stress management, mindfulness-based interventions, and structured peer support programs, into routine staff development activities. In addition, the demographic analyses identified distinct risk profiles among specific subgroups, including staff working extended hours, frontline clinical personnel, male employees, divorced or widowed individuals, and those with lower educational attainment, which can guide the allocation of limited mental health resources toward the populations most in need. Furthermore, the results support the implementation of routine psychological screening protocols that evaluate perceived stress, anxiety, and resilience among hospital staff. Such protocols would facilitate the early identification of at-risk individuals before maladaptive coping patterns become firmly established. By addressing both individual-level psychological resources and institutional-level support structures, healthcare organizations can foster a more protective occupational environment that mitigates the detrimental effects of occupational stress on employee well-being and patient care quality.
5. Conclusion
This study examined the relationships among perceived stress, anxiety, unhealthy alcohol use, and insomnia in hospital staff, with particular attention to the moderating role of resilience. The results confirmed that perceived stress and anxiety were positively associated with both unhealthy alcohol use and insomnia, while resilience substantially attenuated these adverse associations. These findings suggest that resilience serves as a critical psychological resource associated with reduced vulnerability to both maladaptive coping behaviors and sleep disturbances among healthcare workers. Despite limitations related to the cross-sectional design and regional sampling, the demographic analyses revealed distinct risk patterns across employee subgroups, highlighting the need for targeted approaches. Future intervention-based studies are warranted to evaluate the effectiveness of resilience-building programs in reducing occupational stress-related health outcomes among healthcare workers.
Acknowledgments
The author thanks the hospital staff who participated in this study.
Funding Statement
The author(s) declared that financial support was received for this work and/or its publication. This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (RS-2023-00245064). Support was also provided by the National Natural Science Foundation of China (82260275), and the Nanhai Xinxing project of Hainan Province (NHXXRCXM202350).
Footnotes
Edited by: Yuecui Kan, Harbin Medical University, China
Reviewed by: Melanie L. Schwandt, National Institutes of Health, United States
Sait Sinan Atilgan, Atatürk University, Türkiye
Swati Jogi, Shoolini University, India
Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.
Ethics statement
The studies involving humans were approved by the Institutional Research Ethics Committee of the Affiliated Cancer Hospital of Hainan Medical University (No. 20230325). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided written informed consent to participate in this study.
Author contributions
SX: Conceptualization, Funding acquisition, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing. GY: Conceptualization, Investigation, Visualization, Writing – original draft. XX: Investigation, Resources, Writing – review & editing. ML: Conceptualization, Investigation, Methodology, Supervision, Validation, Visualization, Writing – review & editing.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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The author(s) declared that generative AI was not used in the creation of this manuscript.
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Data Availability Statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.