The prevalence of burnout syndrome among military personnel seems slightly lower than in society at large (11). Nevertheless, in line with findings from civilian studies (27, 28), certain military specializations show an increased likelihood of burnout syndrome (29), including personnel in operational roles, flight crews, and medical personnel, particularly in intensive care. Already in 2011, Eisenlohr et al. (6) highlighted the significance of burnout syndrome within the general medical care setting of the German Armed Forces, pointing out specific challenges in the military work environment. Differences are also reflected in specialties of military health care workers, with emergency physicians exhibiting higher levels of burnout than orthopedic surgeons (30).

Other studies have emphasized overseas deployment as a specific risk factor regarding burnout symptomatology. For instance, a study of US military personnel reported a positive correlation between the number of completed overseas deployments and an increased risk of burnout syndrome (31). Adler et al. (13) demonstrated a correlation between the perception of occupational stress among military medical personnel deployed overseas and burnout levels.

Overseas deployments put physical and psychological strains on soldiers. Comparing German soldiers with and without deployments abroad in 2012, the 12-month prevalence of PTSD increased from 0.3% to nearly 3%, with an estimated number of unreported cases of about 50% (32). The prevalence of mental disorders among deployed participants in a study of the German Armed Forces was 21.4% (33, 34). Previous studies have shown that the 12-month prevalence of mental disorders in German soldiers without deployment history is comparable to that of the general population (35). Research indicates that it is not the deployment itself, but instead high combat exposure with threats to life and physical integrity that is linked with increased prevalence rates of anxiety disorders and PTSD (35, 36). An international study demonstrated varying prevalence rates depending on the sending country and the deployment region (36). The stressors faced by soldiers during overseas deployments are likely to favor the phenomenon of burnout syndrome. Further insights could be provided by studies examining emotional stress (37) and the development of depressive disorders and anxiety disorders (20, 38) during deployment, as these show similarities with the symptoms of burnout syndrome (39, 40).

In addition, soldiers on deployment may face traumatic experiences that challenge their individualized psychological value systems. These conflicts often arise from the disparity between internalized Western-liberal values and prevailing views in the country of deployment. Litz et al. (41) have introduced the concept of “moral injury” (MI), in which soldiers are morally burdened by experiences during deployment, either by their own offenses (e.g. exercising or witnessing disproportionate violence), or when they themselves do not act or are not allowed to act (“leadership decisions that were life-ending”, “neglect”). Depending on the type (42) of PMIES (stemming from the actions of self and other), Dale et al. (43) showed an increased risk of specific mental illnesses (self MI: more burnout syndromes/depression, other MI: more anxiety).

Other authors define moral injury as betrayal by authority figures in extreme situations (44), actions that contradict one’s own moral convictions (45) or as breaks in the moral self-concept that cause intense emotional reactions such as guilt and shame (46). Such experiences can have a profound impact on psychological well-being and the integrity of moral character (47). Moral character is seen as dynamic and malleable, influenced by personal experiences, cultural norms and social interactions (48). Moral dissonances, which arises when a person performs actions or witnesses’ events that contradict their moral beliefs (47), can undermine confidence in one’s own moral judgment and sow doubt in one’s own moral integrity.

The consequences of MI are negative feelings and cognitive dissonance. If these cannot be reduced, they can lead to secondary mental illnesses, accompanied by feelings of guilt and shame (41, 49). Studies (48, 50–52) show that MI, like the confrontation with adversity and the killing of opponents, increase the frequency of mental illness after deployment. The moral fragmentation that those affected experience when their actions and beliefs do not coincide also leads to an incoherent perception of their own moral principles (48). In addition, MI represents a differentially mediating variable between the stressor “confrontation with hardship, suffering, violence in the population” and the psychological syndromes “PTSD” and “depression” on the one hand and “burnout syndrome” and alcohol abuse on the other (53, 54).

Moral injury and burnout are two different but often co-occurring phenomena that occur in the context of occupational stress (41). Both can have serious psychological and physical consequences for those affected, but their causes, manifestations and effects differ considerably. In the military context, moral injury results from acts of violence or witnessing civilian casualties, leading to moral dilemmas (42, 48) or from situations in which medical personnel have to deal with end-of-life decisions or medical errors (55, 56). Burnout, on the other hand, is caused by chronic professional overload and emotional stress, e.g. intense physical and psychological demands as well as traumatic events lead to burnout (57) or the emotional strain of dealing with seriously ill patients by medical staff (58, 59). So far it is unknown, whether moral injury leads to higher or lower levels of burnout. For the first time, this research paper addresses this question in order to provide some preliminary results on this topic.

In the medical context (medical service), unresolvable feelings of guilt, shame and self-blame (e.g. due to limited medical resources for the further treatment of locals in the war zone), the experience of potentially morally injurious events (PMIE) and resulting conflicts between personal and professional values may increase the risk for mental illness (53, 60). Furthermore, initial research suggests that values may also play an important role in predicting levels of burnout and engagement (61) as well as mental health (62). From a theoretical perspective, values have also been integrated into the areas of worklife model of burnout as one of six key areas in which a person-job imbalance might affect an individual’s level of experienced burnout (7, 61, 63). It therefore seems necessary to examine personal value orientations in relation to mental health and burnout more closely.

Values, as central beliefs that guide behavior and attitudes, have been identified in several studies (50, 64–66) as personality-related influencing factors in the development and progress of mental health (65). Long-term studies and cognitive consistency theories demonstrate the relative stability (Bardi 2003) of values in adulthood. Biological and developmental psychology perspectives (67, 68) complement this view by examining the role of socialization and genetic factors in the formation of values. Schwartz (69, 70). identified ten types of values (see Table 1 ), which represent different motivational goals deriving from overarching universal human needs. An extensive overview of the relationship between value orientations and mental health is given by Heim et al. (71).

Meanwhile the majority of previous research demonstrates the stability of personal value orientations (72–75), more recent research, such as that by Bardi et al. (73), challenges the theory of value stability and shows that specific events such as the COVID-19 pandemic or terroristic attacks can cause temporary changes in values. The studies by Bojanowska et al. (76) and Daniel et al. (77) suggest that exceptional circumstances such as a pandemic can lead to temporary adjustments in values that do not necessarily reflect long-term changes.

The distinction between temporary and stable changes in values requires a differentiated view of time perspectives and contexts. In the context of foreign assignments, stressful experiences can trigger temporary changes in values by stimulating a reflection or reassessment of life goals and convictions (78, 79) or by raising existential questions. In addition, it seems that people under stress can temporarily adapt their values in order to cope better with challenges (80). Nevertheless, studies show that fundamental values remain stable over longer periods of time and can serve as orientation systems and sources of resilience in stressful situations (81, 82).

So far, we only identified one study reporting on personal values and mental health in the military context (83). Here, certain value types have been identified as commonly held by soldiers, such as benevolence and universalism. These seem to support moral professional conduct but also make individuals more susceptible to moral conflicts. Conversely, individuals who are more materially oriented and less compassionate (high hedonism) may be protected from such stressors. Further evidence in this field of research is missing. Hence, in order to address this research gap, we examine personal values in the military context looking more closely at their association with burnout and their stability over time.

To date, studies on the development of burnout syndrome among medical personnel in the German Armed Forces considering personal value orientations and moral injuries in overseas deployments are missing. It seems that value orientations and moral injuries influence the pathogenesis of mental illnesses and are influenced by participation in military deployments (50, 66). Overall, our study underscores the importance of understanding burnout syndrome, particularly in military contexts, and highlights the need to examine how value change and how MI contribute to soldiers’ burnout symptoms after deployment.

This project provides initial results on the relationship between burnout symptoms, value orientations, and moral injury among medical personnel of the German Armed Forces deployed in overseas missions. We hypothesize that 1) there will be an increase in burnout symptomatology after the deployment period, 2) personal values are associated with burnout and remain stable even after a six months period after deployment and 3) a stronger experience of moral injury is associated with significantly higher levels of burnout.

In this quantitative study, 91 medical soldiers were surveyed via structured questionnaires between December 2014 and November 2016. The study population represents the official proportion of female soldiers in the German medical service of 44.6% and was not specifically selected.

Participants were recruited during a routine health examination (BA90/5) preceding their deployment to various missions abroad (e.g., Afghanistan, Mali, Kosovo). Participation in the study was optional, with interested individuals being briefed about the research project during individual consultations with study personnel. Participants were required to have a minimum deployment duration of 30 days and meet the age criteria of 20-60 years. Exclusion and discontinuation criteria included acute mental illness, suicidality, or concurrent participation in another study.

The study was conducted in accordance with the Declaration of Helsinki guidelines. A positive ethics vote from the Humboldt University of Berlin (Charité) was obtained (No. EA1/203/13). All patients gave informed written consent for an examination and voluntarily participated in the study. The study was registered by the Bundeswehr Medical Academy under a special research number 07-K4-S321315. There was no third-party funding.

The participants were examined at two times of measurement. The pretest (t₁) was conducted 2-4 weeks before deployment (Maslach Burnout Inventory + Portrait Value Questionnaire). The posttest (t₂) was conducted up to 6 months after the end of the deployment (Maslach Burnout Inventory + Portrait Value Questionnaire + Moral Injury Event Scale). Immediate post-measurement was omitted due to difficult scheduling of out-of-mission dates, frequent subsequent vacation and rest days, and other personal reasons of the participants.

Data analysis was conducted using IBM Statistics SPSS 25. Initially, a descriptive analysis of the sample was performed based on sociodemographic information and the assessment of burnout symptoms. To examine whether differences occurred over time, a paired sample t-test was used. The requirements for the t-test were met. A test for normal distribution was omitted, as simulation studies show that the t-test is robust to this violation (89). Furthermore, changes in value orientations over time were examined using a t-test for related samples.

Additionally, Pearson correlation analyses were conducted to see if there was a correlation between Moral Injury (SMBE total score, SUB 1, and SUB 2) and Burnout (EE, PA, DP, IV) subscales. The prerequisites for a correlation (interval scaled variables, linearity) were met. Outliers were left in the data set. The sample size was determined using G-Power. Method used: Correlation, Bivariate normal model. In a power analysis conducted based on a conservatively estimated Pearson correlation of r = 0.3 (mean effect), alpha error =.05 and power (1-beta err. prob.) = 0.80 the minimum sample size (total sample size) is N = 67.

In total, 91 medical soldiers, including male (N=48; 52.7%) and female (N=43; 47.3%) soldiers with an average age of 33.55 years (SD = 6.07) took part in this study. Of these, 80.3% reported being in a relationship, while 19.8% reported being single. Overall, 75.8% belonged directly to the Medical Service section of the armed service, while the remaining participants were soldiers from other military services such as the Land Forces (8.8%), the Air Force (4.4%), and the Navy (2.2%). No information regarding the specific area of service was provided by 8.8% of the participants. The various ranks, which reflect the hierarchy within the German Armed Forces, are broken down as follows, from the lowest (enlisted ranks), through the middle (non-commissioned officers) to the highest ranks (officers): 6.6% NATO rank OR-1 to OR-4, 48.4% NATO rank OR-5 to OR-9, 44% NATO rank OF-1 to OF-5 and 1.1% provided no information.

The deployment was the first overseas assignment for 45.1% of the participants. The other participants had previously participated in an average of 4.60 deployments (SD = 12.82; Mode = 1), the average duration was 238.83 days (SD = 204.89). In the current deployment, participants were deployed to various operational areas of the German Armed Forces (45.1% Kosovo; 36.3% Afghanistan; 9.9% Mali; 5.5% other areas; 3.3% no information provided.

The initial mean values of the MBI (see Table 2 ) in our study sample showed deviating values in individual subscales compared to the normative samples, depending on the occupational subgroup. For example, medical personnel show lower levels in EE and DP as well as a higher level in PA than our study sample. In comparison to the subgroup of mental health personnel the reported means of EE, DP and PA are higher. Using the burnout cutoff values the MBI subscales Depersonalization (MBI_DP M _t1 = 6.93) and Personal Accomplishment (MBI_PA M _t1 = 36.76) indicated a moderate level of burnout at t₁. The scales Emotional Exhaustion (MBI_EE M _t1 = 17.0) and Involvement (MBI_INV M _t1 = 3.72) reflected a low level of burnout.

During the study period, a slight deterioration was observed, but paired t-test analysis showed no significant changes over time in the MBI subscales: MBI_EE t (90) = - 0.030, p = .976, d_z = 0; MBI_DP t(90) = - 0.127, p = .899, d_z = 0; MBI_PA t(90) = 1.46, p = .147, d_z = 0.153; MBI_INV t(86) = -1.75, p = .083, d_z = - 0.188.

Furthermore, paired t-tests were conducted to examine whether the values of the PVQ changed from t₁ to t₂ (see Table 3 ). There were no significant changes in the subscales between the two times of measurement.

To check for an association between the PVQ and MBI subscales at t₁ and t₂ Pearson correlations were calculated. Only a few significant correlations were found.

PVQ Self-direction at t₁ correlates negatively with MBI INV (see Table 4 ) at t₂ (PVQ SD r = -.21, p = .043). The higher self-direction at t₁, the lower the involvement in MBI scale at t₂. Furthermore, the subscale PVQ Power at t1 correlates positively with MBI PA at t₂ (PVQ PO r = .28, p = .006). Lower scores in the MBI INV and higher values in the MBI PA can indicate a lower level of burnout. Thus, higher values in the PVQ Self-direction and lower scores in PVQ PA at t₁ can be associated with an increased occurrence of burnout symptoms after deployment at t₂.

PVQ Tradition at t₁ correlates negatively with MBI PA at t₂ (PVQ TR r = -.23, p = .027) The higher tradition at t₁, the lower the MBI PA at t₂. There was a positive correlation found between PVQ Universalism at t₁ and MBI INV (see Table 5 ) at t₁ (PVQ UN r = .25, p = .018). PVQ Hedonism at t₁ correlates negatively with MBI EE at t₁ (PVQ HE r = -.26, p = .012). The higher hedonism at t₁, the lower the emotional exhaustion in MBI at t₁. In addition, PVQ Benevolence at t₁ correlates negatively with MBI DP at t₁ (PVQ BE r = -.25, p = .016), indicating that the higher benevolence at t₁, the lower depersonalization in MBI at t₁. According to Cohen (90, 91), all correlations represent a small effect size. The detailed tabular view can be viewed in the appendix.

Table 6 shows the moral injuries experienced by soldiers after deployment (t₂). Compared to a possible total score of 54 points, the overall mean score of SMBE (SMBE in total) indicates a rather low score (M _t2 = 21.79), suggesting a lower level of distress in general. Examining the individual subscales, it can be highlighted that soldiers experienced lower moral injury from their own actions (SMBE_Sub2 M _t2 = 7.49) compared to the actions of others (SMBE_Sub1 M _t2 = 14.29).

Table 7 demonstrates that moral injuries resulting from the actions of others as well as from one’s own actions positively correlate with the Emotional Exhaustion (EE) scale of the MBI at t₁ (SMBE_Sub1 r = .48, p = .001, SMBE_Sub2 r = .45, p = .001, SMBE_Sub in total r = -.54, p = .001) and t₂ (SMBE_Sub1 r = .46, p = .001, SMBE_Sub2 r = .38, p = .001, SMBE_Sub in total r = .49, = .001). According to Cohen (92), this represents a medium effect size. The higher the experienced number of moral injuries caused by the actions of others or by one’s own actions, the higher the emotional exhaustion. These findings are reflected in conjunction with the Depersonalization (DP) scale. There is also a medium positive correlation with moral injuries caused by others (SMBE_Sub 1 r = .33, p = .001) as well as moral injuries caused by one’s own actions (SMBE_Sub 2 r = .32, p = .002) and total moral injuries (SMBE_Sub in total r = .38, p = .001) at t₁. At t₂, the correlation changes to weakly positive for moral injuries caused by others and by one’s own actions (SMBE_Sub1 r = .26, p = .011, SMBE_Sub2 r = .28, p = .007), while the total score of SMBE_Sub in total continues to show a medium positive correlation (SMBE_Sub in total r = .31, p = .002). Overall, this means that the more moral injuries a soldier experiences, the stronger the experience of depersonalization.

Furthermore, the subscale Involvement (INV) of the MBI at t₁ shows a medium positive correlation with moral injuries caused by one’s own actions as well as with the total score of SMBE (SMBE_Sub 2 r = 0.34, p = .001, SMBE_Sub in total r = .30, p = .004). No significant relationship could be found for moral injuries caused by others and INV. At t₂, both subscales of SMBE show a low positive correlation with INV (SMBE_Sub1 r = .22, p = .034, SMBE_Sub2 r = .26, p = .013). The total score of SMBE shows a medium positive correlation (Sub in total r = .28, p = .008) with INV. Again, it is evident that the higher the experienced moral injuries caused by one’s own actions or by the actions of others, the higher the experience of involvement in the MBI. No significant relationships could be found between moral injuries and the Personal Accomplishment scale of the MBI.