Occupational diseases and accidents in nurses are diseases and accidents that occur due to activities carried out during work and the work environment. Occupational diseases and accidents in nurses in developing countries are caused by exposure to hazards such as biological hazards (bloodborne pathogens, Hepatitis B, and Tuberculosis from patients), psychosocial hazards (workplace violence, fatigue, job dissatisfaction), ergonomic hazards (musculoskeletal complaints), chemical hazards (exposure to drugs, latex materials and anti-neoplastic) ) (Rai et al., 2021). Physical hazards (hearing problems, headaches, accidental falls) and electrical or mechanical hazards (fire, electric shock) (Prajwal et al., 2020).

Occupational diseases and accidents do not only occur in one patient room but in almost all rooms. In the operating room, 84% of nurses are exposed to the hazards of radiation exposure, bloodborne diseases, and nosocomial diseases, significant risks are exposure to anesthetic drugs and gases, latex allergies, and muscle pain due to inappropriate body position (Saleh et al., 2020). The psychiatric ward identified 10 work activities that have hazards such as lighting, disinfectants, contracting HIV/AIDS, Hepatitis A, Hepatitis B, Tuberculosis, wrong body posture, doing repetitive work, being attacked by patients, frequent contact with patients, panic, overwork, physical and sexual verbal violence (Indragiri & Yuttya, 2020)(Yulis et al., 2023) . Other risks experienced by nurses in all rooms are falls, slips, verbal violence from patients and co-workers in nursing staff, Low Back Pain, Hernia Nucleus Pulposus and drug resistance (Yulis, 2020).

Prevent occupational diseases and accidents by preparing regulations for primary prevention, reducing exposure to potential hazards, conducting monitoring and supervision, education and training (Keefe et al., 2020). Reducing exposure to potential hazards in nurses can be done through indepth interviews with nurses who have experienced occupational diseases and accidents. Related to the cause, time of the incident, feelings at that time, actions taken, and the impacts caused. The results of this interview are important for eliminating hazards or planning other appropriate interventions to control health risks.

This study was conducted at a referral hospital located in the coastal and border areas of Malaysia-Sabah. Preliminary study at the research location, in 2021 to 2023 there were 15 nurses who experienced needle stick accidents and 1 nurse who was exposed to patient body fluids in the eyes. Both work accidents have a high risk of becoming a port of entry for disease transmission from patients to nurses. Another problem is the high number of infectious diseases in the area: 760 cases of pulmonary TB, 553 cases of pneumonia, 4 cases of leprosy, 84 cases of measles, 1223 cases of diarrhea, 109 cases of AIDS (cases new), 653 cases of AIDS (cumulative cases), and 459 cases of Sexually Transmitted Infections (STIs) (Statistik, 2024). The high number of infectious diseases in the area is at risk causing disease transmission to nurses who provide direct care to patients in health facilities and . In addition, nurses who care for patients with infectious diseases are vulnerable to experiencing mild stress (85.1%) and moderate stress (14.9%) (Suhaya & Sari, 2019).

The aim of this research is to use various explanations from nurses about their feelings, perceptions, thoughts and experiences when experiencing occupational diseases or accidents when caring for patients. Another objective is to obtain information related to the causes, actions taken during the incident, the impact of illness or work accidents experienced by nurses, and preventive efforts made by nurses and hospitals. The results of this explanation allow nursing managers to take preventive measures and handle illnesses or work accidents experienced by nurses.

This research uses a qualitative research method with a phenomenological design. This method focuses on nurses' perceptions of Occupational Health and Safety and examines more deeply the experiences of nurses who have experienced occupational diseases and accidents. This research was conducted at a hospital in North Kalimantan, Indonesia. The population in this study were all nurses who had experienced occupational diseases or accidents at the research location. The selection of participants used a purposive sampling method with maximum variation sampling type. The researcher together with the key person (head of the hospital's OHS team) determined 10 (ten) potential participants according to the research objectives, room variations and inclusion criteria: 1) Nurses who have experienced occupational diseases or accidents. 2) Willing to become a participant by giving consent through informed consent. Furthermore, for data variation and completeness of information, researchers selected participants from several locations: Patient Room, Perinatology Ward, Intensive Care Unit (ICU), Operating Room (OR), Emergency Unit and Out Patient Dept. This study has reached data saturation or no new information was obtained from the ninth participant, so the interview was stopped at the ninth participant. The participants involved in research is 9 (nine)participants.

This research has obtained ethical approval from the Research Ethics Sub-Committee at the research location in July 2023. The entire research process refers to the principles of research ethics (Polit & Beck, 2017): 1) Beneficence: this research is beneficial to participants, researchers build a relationship of mutual trust with participants, pay attention to participants' emotional responses, and pay attention to interview times. 2) Respect for human dignity: researchers provide an explanation of the objectives, benefits, procedures, risks, guarantees confidentiality of information and should not be pressured during the research. 3) Justice: provide equal treatment to all participants. 4) Anonymity and confidentiality: researchers guarantee the confidentiality of data obtained from participants.

Data collection was carried out from August to September 2023. The data collection method was carried out using in-depth interviews for 50-60 minutes in a room attended only by researchers and participants. The data collection instruments used were the researcher himself, a questionnaire for sample characteristics, an interview guide, a digital audio recorder to record interview results, and field notes to record respondent expressions. Data analysis was carried out using the Colaizzi (1997) method (Polit & Beck, 2017), starting by listening to the results of the interview and then writing it into written text. This text is then read repeatedly while listening to the recording, to determine which statements are considered related to the research. These statements are then collected according to categories, sub-themes, and themes. The validity of the data was determined using four steps. Credibility by validating data on participants. Dependability by asking the second and third authors to audit all research activities. Confirmability by showing all documentation of research results to the second and third authors. Transferability means that researchers make research results complete and clear so that readers can easily understand them (Afiyanti & Rachmawati, 2014).

Various experiences and feelings when experiencing illness or injury due to work accidents make nurses realize that the implementation of Occupational Health and Safety (OHS) is very important in maintaining the safety of themselves, patients, nurses' families and maintaining productivity. Nurses feel the need to maintain personal safety while working because the profession as a nurse is a job that carries a higher risk of experiencing occupational diseases or accidents compared to other health workers. Previous research found that infectious, cerebro-cardiovascular and other diseases are more susceptible to nurses than doctors, dentists or other hospital staff (An et al., 2020). Implementing OHS is also important to prevent disease transmission from nurses to patients and nurses' families. Referring to the case of the spread of SARS CoV 2, it was found that the spread of the disease was not only from patients to health workers but could also be from health workers to patients and the public who interacted directly or indirectly with health workers (Abbas et al., 2021). Therefore, nurses feel it is important to implement OHS.

Hospital OHS Management has been implemented at the research location, but occupational diseases and accidents still occur among nurses. The phenomenon found in this research was that the data reported by nurses was only one occupational accident. Namun however after conducting in-depth interviews the researchers found that participants had experienced occupational diseases or accidents more than once. For example, a participant experienced being splashed with a patient's body fluids, back and hand pain when holding a baby for too long, back pain due to an unergonomic position when bathing the baby, slipping because the floor was slippery after bathing, and experienced verbal and physical violence from other health workers. Other nurses have experienced needle sticks incident and back pain when performing CPR. This figure is quite large if you consider that their work period is still relatively new, namely an average of two to four years.

Occupational diseases or accidents experienced by nurses in coastal and border areas have many similarities with previous research, but there are also several differences for example, feeling sad seeing the patient's condition. Feelings of sadness that arise as a result of overly sympathizing with the patient's condition can be categorized as compassion fatigue. Compassion fatigue, if not treated immediately, can contribute indirectly to increased depression in nurses (Ma et al., 2022). If this depression is not treated, it will affect nurse productivity.

Another example is that working as a nurse can make complaints of previous illnesses worse. As felt by one participant with a history of pain in the tailbone due to falling down the stairs 5 years before working as a nurse. The pain felt during the incident can heal itself after one week. However, one year after working as a nurse, a recurrence occurred and it became worse, especially if they experienced fatigue or after lifting heavy objects (equipment for receiving new born babies). Previous literature states that acute lower back pain usually has a good prognosis, however cases of recurrence are quite common (Hidayati, 2022). This recurrence can be caused by incorrect body posture when doing activities or lifting heavy objects (Soeradji Tirtonegoro Klaten, 2022).

Another example is physical and verbal violence from co-workers, whether from nurses or other health workers, which was reported by participants in the Out Patient Dept and Perinatology Wards. The results of this study are in line with previous research that the units with the highest exposure to violence from co-workers came from the Outpatient/External Consultation Room, Surgery, Mental Health, Maternal and Child Care, Emergency Unit, and Internal Medicine (Alves et al., 2021). The reason for this violence is dissatisfaction with the performance of nurses, such as procedures that are carried out for a long time or are not appropriate, different thoughts which then lead to rude, degrading comments and even physical violence in the form of throwing objects at nurses.

Another phenomenon that researchers found was that the average number of reports received was data on work accidents involving needle stik injury or being splashed with patient body fluids, while data on occupational diseases was rarely reported. This can happen because occupational accidents can be detected when they occur and their causes, whereas occupational diseases cannot be directly ascertained whether the cause originates from the hospital or activities outside the hospital. Apart from that, based on the results of interviews with several participants, it was found that they chose not to report occupational diseases or accidents they experienced to the head of the room, the OHS team or IPC because they considered the injury or illness incident to be less important, having experience that their reports were sometimes not responded to by management and a blaming culture. The culture of blaming workers when work accident occur must be eliminated by managers because it can cause psychological stress and trauma to nurses, decrease nurses' willingness to report errors and increase turnover (Okpala, 2020). If this happens continuously then nurse managers will experience difficulties in creating OHS risk management for nurses.

One of the occupational diseases that is not reported is violence from co-workers, whether from nurses or other health workers. This is due to feelings of reluctance and fear to report colleagues because of their higher position, the nurse leader did not dare to reprimand the reported person, and there is a perception that violence is part of the risks of the job so it does not need to be reported. Previous research similarly suggests that violence between co-workers occurs when organizations allow, ignore, or reward such behaviour and leaders minimize complaints (Alves et al., 2021). This shows that managers have an important role in the occurrence of violence between co-workers and should have the ability to mediate this violence problem.

Occupational diseases and accidents occur due to Unsafe act and conditions. Unsafe act can originate from the nurses themselves or co-workers. For example, a participant does not work according to procedures in the operating room, causing exposure to patient body fluids. Another study (Risanti et al., 2021) found that nurses' compliance with the implementation of the Surgical Safety Checklist in the Central Surgical Installation was influenced by the nurses' motivation, attitude and knowledge. This Surgical Safety Checklist is important to reduce the very high number of occupational accidents in the operating room. Another unsafe act is that a participant works in two different hospitals. This condition must be of concern to managers because working hours that exceed productive working hours can cause nurses to feel tired, lack of concentration and stress which can result in negligence while working (Sofiantika & Susilo, 2020). Another unsafe act is that nurses force themselves to work even though they are sick (presenteeism). Other research related to presenteeism found that nurses often force themselves to come to work even though they are sick or less productive due to workload considerations, the leave system, feelings of guilt, and financial needs (Shan et al., 2021). Feelings of guilt and not wanting to increase the workload on co-eorkerss made one of the participants who were needle stik injury while treating a COVID-19 patient ,choose to wait to take off his hazmat suit and clean the wound until after duty hours. So, unsafe act is sometimes carried out by nurses consciously because of certain conditions.

Unsafe conditions that cause occupational diseases or accidents, such as increased workload due to additional tasks (accreditation committee), poor communication with other health workers, making them susceptible to verbal and physical violence and work duration. The results of this study found that musculoskeletal disorders are usually felt by nurses during night duty, while needle stick injuries usually occur during day duty or at the end of the second night duty. This is because the duration of night duty is longer and heavy nursing activities such as bathing patients and changing bed sheets cause nurses to feel tired and therefore less focused on work. The difference found with previous research (Alfulayw et al., 2021) is that most needle stick injuries usually occur in the morning shift (68%), then the night shift (23.2%) and the afternoon shift (8.8%). This is because there are usually more activities during morning service.

Nurses in this study reported changes that occurred after experiencing occupational diseases and accidents. One of them is psychological discomfort in the form of feelings of trauma due to the verbal or physical violence experienced, feelings of anxiety, fear and shame if a disease is infected or the disease is transmitted to the family. Violence in the workplace must be a concern for nurse managers because violence in the workplace will directly and indirectly affect the performance of health workers. In fact, according to (Alves et al., 2021) experiences of violence can cause stress and have a negative impact on psychological health, causing nurses to consider leaving their jobs and having a negative impact on patient care and attention if they continue to work. This is due to several factors (Rasool et al., 2020). First, harassment reduces the morale of health workers, which consistently reduces performance. Second, mobbing (intimidation) in the workplace reduces productivity, increases levels of stress, anxiety, depression and irritability, decreases work engagement, attendance and destroys work. Third, workplace ostracism reduces motivation among workers and organizations, which reduces work efficiency. Fourth, work stress is considered a stigma among health workers who face stress at work

Aware of the impact and causes of occupational diseases or accidents, both nurses and hospitals try to prevent or minimize potential dangers. The efforts made by participants include physical, mental preparation, knowledge and skills before working. Even when working, they try to work according to procedures and implement safe behavior. However, to cultivate safe behavior at work, support from the hospital is needed in the form of giving rewards and incentives to staff who implement safe behavior at work (Restuputri et al., 2024). Apart from safe behavior, creating a safe work environment is also very important. Creating a safe work environment for nurses requires the support of all parties, starting from patients, patient companions, hospital staff and hospital managers. This is because patients, patient companions or hospital staff are hazard for nurses, while hospitals have a role in providing a safe Occupational Health and Safety Management for nurses. Participants in this study realized that the hospital had made efforts to minimize the potential dangers of risks for nurses, but there were still things that needed to be improved. For example: increasing the number of personnel, providing education regarding PPE, equipment maintenance, providing facilities according to standards, risk management, responding to incoming reports and eliminating blaming culture. Overall, hospitals and nurse managers have made efforts to maintain the safety of nurses, but have not been fully implemented properly.Therefore, in creating a safe work environment, it is very important to build commitment from all hospital residents and also involve nurses in identifying risks of hazard to nurses in the hospital, so that risk management can be implemented properly.

Although this research focuses primarily on nurses who have experienced occupational diseases or accidents in coastal and border areas, the results found in this research are only slightly different from previous research. This research found that nurses who work in hospitals have experienced more than one type of occupational disease or accident during their two to four years of work. However, the problem is that there are still some nurses who do not report the injuries they experience for various reasons. So occupational diseases or accidents are still like an iceberg phenomenon for managers.

The causes of occupational diseases or accidents in nurses are: negligence of the nurses themselves, co-workers, patients and patient companions, excessive workload, inadequate facilities, and an unsafe work environment. There are two types of effects. The positive effect is that nurses are more careful when working, while the negative effect is temporary or long-term physical and psychological discomfort which can affect nurses' work productivity. To prevent similar incidents from occurring, nurses have made several efforts such as being more concerned with personal safety, increasing their personal knowledge and skills, as well as working according to procedures and behaving safely. However, nurses realize that if they want to create a safe work environment, they really need support from all hospital residents and also the hospital. Because hospital management and all hospital residents must be committed to implementing OSH management in the hospital environment. Suggestions for future researchers are to examine the experiences of nurses who have experienced occupational diseases or accidents in primary health facilities in remote areas.

We would like to convey our appreciation to the Faculty of Health Sciences and Universitas Borneo Tarakan for financial support, mentorship, and access to the research location.

Data are available upon request to the authors to support patient privacy.

The ethical statement for this study is No. 145/KEP/VI/2023 from the Universitas Borneo Tarakan Ethical Committee.

Rahma Yulis (RY), Gusni Fitri (GF), Fitriani (F)

Conceptualization (RY, GF, F)

Methodology (RY, GF)

Data curation, Writing- Original draft preparation (RY, F),

Visualization, Reviewing, and Editing (RY, GF, F)

All authors approved the final version of the manuscript.

This study received funding from Universitas Borneo Tarakan

The authors declare no conflict of interest in this study