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Vol. 6, No. 1, 2024, pp. 39-50 ISSN 2656-6052 (online) | 2656-1107 (print) 
      http://journal2.uad.ac.id/index.php/eshr/index                                                   eshr@ikm.uad.ac.id 

 
 

      10.26555/eshr.v6i1.9687  

  
 

  

39 

Research Article 
 
Variables Influencing Nurses' Adherence to Personal 
Protective Equipment (PPE) Utilization at PKU 
Muhammadiyah Hospital Bantul 
 
Atni Setiyo Ningsih,1,2* Dyah Suryani,1 Widodo Hariyono1 
1Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indonesia 
2PKU Muhammadiyah Bantul Hospital, Bantul, Indonesia  
Setiyo Ningsih: Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indonesiah 
* Correspondence: atniningsih@gmail.com. Phone: +6281226323510 
 
Received 27 December 2023; Accepted 07 February 2024; Published 16 February 2024 
Suryani: Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta, HariyantoFaculty 

of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indones 

ABSTRACT 

Background: A hospital is a health service facility that provides outpatient and inpatient 
patient services. Hospitals can also be a source of infection for officers, patients, and other 
visitors. To prevent nosocomial infections in officers, hospitals must protect all health 
workers, for example, by wearing gloves, masks, gowns, face shields, shoes, and aprons. 
Compliance with PPE on health workers is supported by a positive attitude from officers and 
supervision carried out by management. This study aims to determine factors related to 
compliance with use among nurses.  
Method: This was quantitative research using correlation with the cross-sectional approach. 
The population in this study was 130 permanent nurses. The sample was calculated using 
the Slovin formula, resulting in 100 samples. The respondent was selected via proportional 
random sampling among the care units. Chi–Square was used to analyze the data.  
Results: There was a relationship between PPE compliance and age (p=0.005), attitude 
(p=0.000), and supervision (p=0.016). Meanwhile, factors that were not related to PPE 
compliance were gender (p=1.000), education (p=0.054), knowledge (p=0.170), facilities 
(p=0.505), and training (p=0.811). 
Conclusion: There was a significant relationship between age, attitude supervision, and 
compliance with PPE in nurses when performing their duties. 

Keywords: Compliance; Nurse; PPE  

INTRODUCTION 

The hospital is one of the health service facilities that provide services for the community in 
the form of treatment and care, both outpatient and inpatient; besides that, the hospital can 
be a source of infection for officers, patients, and other visitors.1 Infections in health facilities 

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are often called nosocomial infections or healthcare-associated infections (HAIS). These 
infections occur during the patient's treatment. Infections can also occur in health workers due 
to work done or actions given to patients. 2 Based on WHO data (2016), the incidence of 
nosocomial infections / HAIs as much as 9% or 4.1 million patients treated in all hospitals in 
the world, and the prevalence of infection in the United States every year is 1.7 patients per 
year while in Europe the incidence of nosocomial infections is 4-4.5 million annually.3 The 
Ministry of Health surveillance data (2015) shows the rate of nosocomial infection in patients, 
with an average of 9.8% in hospitalized patients.4 The risk of infection can also occur in staff 
when treating patients and in the hospital environment, so actions are needed to prevent the 
risk of infection.5 

Hospitals must protect health workers when providing services to prevent nosocomial 
infections in health workers. One protection measure requires all health workers to use 
Personal Protective Equipment (PPE) when carrying out risky actions.6 Personal protective 
equipment used by nurses functions to protect themselves and patients from the risk of 
exposure to dangerous materials such as chemical, physical, biological, and other infectious 
materials.7 PPE does not eliminate the risk of exposure to infectious materials but functions 
as a protector, barrier and reduces the risk of exposure to infectious sources.8 The Personal 
Protection Equipment often used by health workers are masks, gloves, dresses, eye or face 
protection, boots, and aprons.9 To protect health workers and patients from nosocomial 
infections, it is necessary to adhere to the use of PPE to get maximum benefit.10  

Based on Lawrence Green's theory, several factors affect PPE compliance, including 
presdiposising (knowledge, age, attitude, length of service, motivation), enabling (facilities), 
and reinforcing (training and supervision).11 Obedience is an officer's discipline or positive 
behavior to obey all established rules12. To maintain an officer's positive attitude, management 
support is needed through policies on PPE and routine supervision.13  With a positive attitude 
from officers and supervision carried out regularly to increase officer compliance in using PPE 
and reduce infection rates in health workers. 14  From the research results, there were 57.7% 
who did not comply with the use of PPE, which was caused by a lack of supervision carried 
out by the head of the room where the head of the room still assumed that the knowledge 
possessed by the head of the room was the same as other officers.15 

From the results of a preliminary study conducted by researchers in August 2022, data was 
obtained from April to June 2022 regarding the incidence of nosocomial infections that 
occurred in patients, namely phlebitis 2.09 ‰, UTI 0 ‰, VAP 0 ‰ and SSI 1.03% and the 
incidence of injury 0% risk of nosocomial infections such as needle sticks. Meanwhile, 
compliance with using PPE among nurses resulted in 67% compliance and 23% non-
compliance among 105 officers. Compliance when using masks is 100%, gloves 67%, boots 
100%, gowns 73%, face shields 25%, hats 45% and aprons 65%. Of the 70 officers who 
complied, 69% were female, and 31% were male. PPE is available in each unit at 95% and in 
the pharmacy at 100%; PPI training is carried out annually for all employees, while supervision 
has not been done optimally by the head of the room and IPCN (Infection Prevention Contro 
Nurses). This research contributes to determining the determinants of compliance with the use 
of PPE among nurses in preventing and controlling infections. 

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METHOD 

This was quantitative research with correlation using a cross-sectional design. The population 
was represented by permanent nurses hospitalized at PKU Muhammadiyah Bantul Hospital 
(130 people). The number of samples used was 100 nurses using the  Slovin formula, and the 
number of proportional random samplings was determined in 8 inpatient units. The research 
was conducted in October 2023 at PKU Muhammadiyah Bantul Hospital. The instruments 
used in this study were attitude questionnaires using the Likert scale that had been tested for 
validity and reliability testing with Cronbach's Alpha and observation sheets on the use of PPE 
in nurses at Universitas Islam Indonesia Hospital Bantul, Yogyakarta. Analysis was performed 
using univariate and bivariate with Chi–Square test. 

RESULTS 

Univariate analysis 

Table 1 shows that the characteristics of respondents based on gender are primarily women, 
with a total of 69 people (69%). The characteristics of respondents based on age are early 
adulthood (<40 years) with a total of 62 people (62%). The attributes of respondents based on 
the length of work were in the old category (> six years), as many as 63 people (63%). While 
the characteristics of respondents based on the most education are Diploma 3 with 75 people 
(75%). 

Table 1. Distribution of Respondent Characteristics 

Characteristics of respondents Frequency Percentage (%) 
Gender   
Male 31 31% 
Woman 69 69% 
Age   
Early Adulthood (< 40 years) 62 62% 
Advanced Adults (> 40 years) 38 38% 
Length of work   
< 6 years 37 37% 
> 6 years 63 63% 
Education   
Diploma  75 75% 
Bachelor 1 1% 
Profession 24 24% 

 

Table 2 shows the level of knowledge of nurses with good categories, as many as 64 people 
(64%), nurses who have a positive attitude, as many as 68 people (68%), nurses who state 
complete PPE facilities, as many as 58 people (58%), nurses who state that training is carried 
out regularly as many as 55 people (55%), nurses who state the implementation of routine 
supervision as many as 58 people (58%). 

Based on the results of direct observations of nurses when carrying out actions, it was found 
that 69 nurses (69%) were compliant with using PPE, and 31 nurses (31%) were non-
compliant out of 100 respondents (Table 3). 

 

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Table 2. Frequency Distribution of Respondent Determinants  

Characteristics of 
respondents 

Frequency Percentage (%) 

Knowledge   
Good 64 64 
Enough 36 36 
Attitude   
Positive 68 68 
Negative  32 32 
Facilities   
Complete 52 52 
Incomplete 48 48 
Training   
Routine 55 55 
Not routine 45 45 
Supervision   
Routine 58 58 
Not routine 42 42 

 

Table 3. Distribution of PPE Usage Observations 

Compliance Frequency Percentage (%) 
Obedient 69 69 
Disobedient 31 31  
Total 100 100  

    

Bivariate analysis 
According to the cross-tabulation results in Table 4, there is a relationship between age and 
compliance with PPE use with a p-value of 0.005  (α < 0.05) and a coefficient value of 0.289, 
which can be interpreted that the relationship between age and compliance with PPE use is 
low. In the category of working period, there is a relationship with compliance with the use of 
PPE with p - a p-value of 0.024 ( α < 0.05)  and a coefficient of  0.240, which can be interpreted 
that the relationship between working period and compliance with the use of PPE is low. 
Meanwhile, in the gender (α > 0.05) and education (α > 0.05) categories, there was no 
relationship with compliance with the use of PPE. Meanwhile, the gender and education 
categories did not show any relationship with the level of PPE compliance (α > 0.05).  
 
Table 5 shows is known that there is a relationship between attitude and compliance with the 
use of PPE with a p - p-value of 0.000 (α < 0.05) and a coefficient value of 0.351, which can 
be interpreted as meaning that the relationship between age and compliance with the use of 
PPE is low. In the supervision variable, there is a relationship between compliance with the 
use of PPE with a p - p-value of 0.016 (α < 0.05) and a coefficient of 0.253, which can be 
interpreted as meaning that there is a relationship between work life and compliance with the 
use of PPE is low. Meanwhile, in the categories of knowledge (α > 0.05), facilities (α > 0.05), 
and training (α>0.05), there was no significant relationship with compliance with the use of 
PPE. Meanwhile, the facilities and training categories did not show any relationship with the 
level of PPE compliance (α > 0.05). 

 
 

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Table 4. Cross-tabulation between respondent characteristics and PPE compliance 

Characteristic Compliance  Total P-Value 
Disobedient 

n (%) 
Obedient 

n (%) 
n (%)  

Gender     
Male 10 (10) 21 (21) 31 (31) 1,000 
Woman  21 (21) 48 (48) 69 (69)  
Age     
Early adult (<40 years ) 26 (26) 36 (36) 62 (62) 0,005 
Older adult (>40 years ) 5 (5) 33 (33) 38 (38)  
Length of work     
 < 6 years 17 (17) 20 (20) 37 0,024 
>6 years old 14 (14) 49 (49) 63  
Education      
Diploma 19 (19) 56 (56) 75 0,054 
Bachelor 1 (1) 0 (0) 1 (1)  
Profession 11 (11) 13 (13) 24 (24)  

 
    Table 5. Cross-tabulation between determinants and compliance with PPE use 

Determinant Compliance Status Total 
n (%) 

P-Value 
Disobedient 

n (%) 
Obedient 

n (%) 
Knowledge     
Good 16 (16) 48 (48) 64 (64) 0,170 
Enough 15 (15) 21 (21) 36 (36)  
Attitude     
Positive 13 (13) 55 (55) 68 (68) 0,000 
Negative 18 (18) 14 (14) 32 (32)  
Facilities     
Complete 20 (20) 38 (38) 58 (58) 0,505 
Incomplete 11 (11) 31 (31) 42 (42)  
Training     
Routine 16 (16) 39 (39) 55 (55) 0,811 
Not routine 15 (15) 30 (30) 45 (45)  
Supervision     
Routine 12 (12) 46 (46) 58 (58) 0,016 
Not routine 19 (19) 23 (23) 42 (42)  

 

Multivariate analysis 

Multivariate analysis was carried out to determine how much the independent variable affects 
the dependent variable. Based on the Chi–Square test results, four variables deserve to be 
included in the logistic regression test: age, length of service, attitude, and supervision (p–
value < 0.25) (Table 6). 

Table 6. Degree of influence on PPE compliance 
Variable Significance OR (Odd Ratio) 
Age 0,037 3,582 
Attitude  0,000 8,809 
Supervision 0,005 5,006 

          
Based on Table 6, age affects compliance with PPE use in nurses with a p-value of 0.037 (α 
< 0.05) with an odd ratio of 3.582, which means that age can increase nurse compliance in 
using PPE by 3.582. The attitude variable affects the compliance of PPE use with a p – p-
value of 0.000 (α<0.05) with an odd ratio of 8.809, so it can be concluded that attitude has the 

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opportunity to increase nurse compliance by 8.809. At the same time, supervision has 
compliance with the use of PPE with a p-value of 0.005 and an odd ratio of 5.006, so it can be 
concluded that supervision has the opportunity to increase nurse compliance by 5.006. 

DISCUSSION  

The frequency distribution of respondents' characteristics shows that most respondents are 
women, which is almost the case in all hospitals; this happens in nearly all hospitals due to 
the perception of a woman's feminine attitudes, such as nurturing or caring.16,17 Based on age, 
the most significant number in the early adulthood category is 25-40 years, which is the age 
with a high productivity level.18 At the same time, older adults will be more trusted because of 
their maturity in thinking and acting.19  While the length of the work period of respondents in 
the long category is the longer the work period, the higher the experience and ability to 
complete the work and the more excellent the opportunity to improve knowledge and skills 
through training held at the hospital. 20,21 Based on the respondents' education, the highest 
level of education was at the Diploma level. The level of education will influence the extent of 
knowledge and ability to accept new things and the education that can be obtained through 
formal and non-formal education.22 The results of observations of compliance with the use of 
PPE show that the most compliant nurses were, with the number of respondents being 69 
people (69%). Compliance in the health sector can be interpreted as when a health worker 
complies with the rules or procedures that have been established, especially in implementing 
standard precautions to prevent nosocomial infections.23  

About the Determinants of Compliance 

Nurse compliance is a positive behavior possessed by a nurse to comply with a rule or policy 
to maintain safety when providing health services to patients. A nurse's compliance in wearing 
PPE can begin with a compulsion to obey the rules when wearing PPE voluntarily and interpret 
the importance of using PPE rationally and according to indications to prevent nosocomial 
infections.24 

1) The relationship of knowledge to PPE compliance 
In this study, the level of knowledge was not related to PPE compliance among nurses 
(p-value 0,132). This research aligns with previous research, which states no relationship 
exists between knowledge and officer compliance using PPE (p-value 0.30).24 Previous 
research states a relationship exists between knowledge and nurse practice in preventing 
nosocomial infections (p-value 0.002).25 Knowledge is the result of knowing something 
that is manifested into reality so that there is no hesitation on the part of a health worker 
to comply with prevention and infection control measures.26  A person's level of knowledge 
is influenced by the officer's high exposure to information about preventing nosocomial 
infections with the use of PPE both formally and informally; information that is not full can 
create wrong perceptions in a nurse. Nurses who have good knowledge and data about 
infection prevention and control will influence behavior in using  PPE .27,28,29 Factors that 
influence nurses' knowledge about the use of PPE are increasing age, the length of work 
of nurses so that they are increasingly exposed to information about the importance of 
using PPE to prevent nosocomial infections when performing actions. To increase nurses' 

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knowledge, the hospital conducts socialization about infection prevention and control 
during the orientation of new employees and once a year as one of the routine activities.  

2) The relationship of attitude to PPE compliance 
The study results show a significant relationship between attitudes and compliance with 
using PPE in nurses (p-value 0,000). This study's results align with research on nurses at 
Dr. RM Pratomo Bagansiapiapi Hospital, which found that an officer's attitude is related 
to using PPE (p-value 0.004).30 In contrast, research conducted at Tuban Regency 
Hospital found no relationship between attitude and compliance in using PPE (p-value 
0.156). 6  Attitude is a mental response of an individual who will bring oneself in a good 
and honest direction or a potentially negative one.8 A health worker's attitude is a person's 
view of an object and the tendency to act according to the object.31 It can be concluded 
that a positive attitude from a nurse arises from a sense of confidence in the function of 
PPE to prevent nosocomial infections. On the other hand, nurses who have a negative 
attitude are based on distrust and discomfort when using PPE. Lack of knowledge and 
negative attitudes of nurses will affect compliance in the use of PPE so that it will increase 
the incidence of nosocomial infections and decrease the quality of hospitals; this is due 
to a lack of awareness that they work in an environment where there is a risk of disease 
transmission due to their work. According to Sigmund Freud, consciousness is the part of 
a person's soul that contains known things based on their knowledge.32,33 So, it can be 
concluded that awareness of using PPE is an awareness that arises from within to 
implement the use of PPE following regulations. 

3) Facility relationship to PPE compliance 
The research showed no relationship between facilities and PPE compliance (p–value 
0.505). This research is in line with previous research, which states that the availability of 
PPE (p-value 0.611) has nothing to do with officer compliance in wearing PPE.34 While 
another research states that the availability of facilities has a significant relationship with 
officer compliance in using PPE (p–value 0.000).35 The availability of complete PPE, 
which is easy to reach and comfortable, will encourage the good behavior of officers to 
comply with the use of PPE so that the procurement of PPE needs to be adjusted to 
needs.34,36 The researcher's observations showed that each treatment room had 
complete PPE facilities, was easy to access PPE, and was comfortable to use, which was 
a supporting factor in increasing nurses' compliance with PPE.  

4) Training relationship to PPE compliance 
The results of the analysis showed no relationship between training and compliance with 
PPE use (p-value 0.811). This research was in line with previous research that stated no 
significant relationship exists between PPE training and compliance with PPE use (p-
value 0.559).34 However, our result differed from another research study stating that there 
was a relationship between training and PPE compliance among nurses (p-value 0.003).35 

Training is an activity used to promote health, increase knowledge and skills, and 
determine attitudes toward using PPE to prevent nosocomial infections and as one of the 
guidelines given to an officer.5,34 Lack of training provided to officers can increase the risk 
of infection in the workplace and serve as a reminder of previously acquired 
knowledge.37,38 From the results of infection prevention and control training, interviews 
were given by all new employees and repeated regularly once a year. However, 
compliance with using PPE to prevent nosocomial infections still needs to improve. 

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5) Supervision relationship with PPE compliance 
The research results state a relationship between supervision and compliance with PPE 
(p–value of 0.016). This research is in line with previous research reported that there is a 
relationship between supervision and compliance with PPE use with a p-value - value of 
0.049,39, While an earlier study stated that there was no relationship between supervision 
and compliance with PPE use in health workers with a p-value of 0.148.40 Supervision is 
a continuous process of a job that begins with planning and ends with completing a job, 
which is initially authoritarian. Still, as time passes, supervisory activities are dynamic and 
function as motivators, supporters, and guidance in implementing regulations.41,42,43 

Supervision carried out is expected to increase officer compliance in wearing PPE44, and 
supervision carried out regularly will positively impact officer compliance compared to 
supervision not carried out routinely.45  From the results of interviews and observations, 
the implementation of supervision was carried out by the head of the room and the IPCN, 
where the implementation of supervision was not optimal because it was constrained by 
the number of IPCNs and the number of activities carried out by the head of the room. 

Level of relationship based on Multivariate analysis 

Based on the results of multivariate tests conducted by researchers, the results of p - p-
value age of 0.037 with an OR value of 3.582 so that it can be concluded that age can 
affect compliance with PPE use by 3.582 times, while in the attitude variable with p - value 
0.000 with an OR value of 8.809 which can be concluded the attitude of a nurse can affect 
the level of compliance with PPE use by 8.809 times. While the supervision variable p-
value of 0.005 with OR 5.006, it can be concluded that routine supervision activities can 
affect the compliance of PPE use in nurses by 4,615 times. The age of a nurse greatly 
influences the level of compliance with the use of PPE; this is because as age increases, 
the knowledge, insight, and experience in using PPE will increase so that it can prevent 
nosocomial infections.18,46  Age level will affect a nurse's attitude and behavior to obey 
the hospital's policies. 25 

Meanwhile, the attitude variable has a powerful influence on the level of PPE compliance; 
this is caused by a nurse's positive attitude about the importance of wearing PPE, which 
will be reflected in behavior to prevent nosocomial infections. A nurse who has a positive 
nature is more likely to comply with existing policies and vice versa.47  This result follows 
the attribution theory from Haider (1958), which states that each individual knows his 
attitude by inferring the situation, time, and method used. 48  The implication is that a nurse 
will be obedient in wearing PPE because of a positive attitude in her. To maintain a 
positive attitude in a nurse, supervision is needed to improve nurse compliance with 
wearing PPE. 

Regular supervision will impact increasing compliance with PPE use for nurses.30 
Supervision will provide external encouragement for nurses to comply with  PPE use7, 
which can increase work effectiveness and efficiency when using PPE.49 In addition, 
compliance in using PPE by an officer is also influenced by colleagues, so fellow nurses 
need supervision, and supervision carried out by a superior will affect attitudes and norms 
in practicing PPE according to regulations.50 In this study, researchers stated that a 

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positive attitude influences compliance with the use of PPE in nurses, which will impact 
behavior to comply with hospital policy. In addition, the factor that encourages compliance 
with PPE is the supervision carried out regularly by superiors or colleagues. With 
supervision, actions carried out regularly can maintain a positive attitude in a nurse in 
carrying out infection prevention and control while in the hospital. 

CONCLUSION 

Based on the research results conducted at PKU Muhammadiyah Bantul Hospital, the level of 
compliance with PPE is influenced by several factors, including age, attitude, and supervision. 
There is a significant relationship between age, attitude supervision, and compliance with 
using PPE on nurses when performing actions. 

Authors' contribution 

ASN was responsible for research design, data collection, analysis, and manuscript writing; 
DS and WH reviewed the analysis. All authors contributed to reviewing and evaluating this 
manuscript for publication. 

Funding 

This research has not received external funding. 

Conflict of interest 

There is no conflict of interest in this research.  

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