Volunteers, Contract Workers, and Other Nonemployees Who Interact with Patients

Vicki Allen, MSN, RN, CIC, FAPIC Director, Infection Prevention & Control

CaroMont Regional Medical Center
Gastonia, NC

Declarations of Conflicts of Interest:
  • Vicki Allen reports no conflicts of interest.


Many people who are not employees of the healthcare facility may interact with patients and organization personnel. In this chapter, nonemployees are individuals who are authorized by the facility to perform specific services but do not receive direct compensation or appointment recognition from the facility or hold direct care student status.

To protect patients’ safety, patients’ rights, and patients’ personal health information, it is vital for healthcare organizations to establish expectations and implement processes and protocols for nonemployees.Ref 104-1 Non-licensed non-employee individuals - Human resource requirements. The Joint Commission. https://www.jointcommission.org/standards/stan... - You do not have permission to view this object.  Nonemployees include volunteers and contract workers as well as other individuals not employed directly by the facility by authorized by them to provide services. This official nonemployee designation indicates that the facility is aware of and has approved their activities. Therefore, the healthcare facility has the responsibility to establish safe practice policies and procedures for these groups. For the purposes of this chapter, patient personal contacts, including family, friends, spiritual leaders, and others invited by an individual patient are excluded from the definition of nonemployee.

Healthcare industry representatives (HCIR), contracted sitters, contract construction workers, volunteer community clergy, pet therapists, and volunteers are examples of nonemployee individuals who may interact directly or indirectly with organization personnel as well as patients during their inpatient stay. These individuals provide a variety of necessary services, such as delivering mail, flowers, or personal care items to the patients’ bedsides; transporting patients within the facility; providing spiritual support or comfort; providing education or observation; and staffing the gift shop and visitor waiting areas. Other nonemployee examples include HCIR in the perioperative setting, who work directly with personnel to provide technical assistance to the surgical team, and contract construction workers, who may work inside or outside of the healthcare facility.

Nonemployee individuals working in the healthcare environment should receive orientation to include facility specific healthcare policies, procedures, and protocols that protect patients and personnel. Nonemployee personnel in the clinical setting must understand the transmission and prevention of disease within the framework of their duties to reduce the risk for exposure to potential pathogens. Each facility should establish a plan for protecting approved nonemployee individuals that includes a list of allowed and prohibited duties, evidence of an initial two-step tuberculosis skin test and annual tuberculin skin test guided by the facility’s annual tuberculosis risk assessment and individual state laws, as well as a personal health history that includes immunization status. Nonemployees should receive education and communication on facility policies, procedures and plans on topics including hand hygiene, standard and transmission-based precautions and isolation signage, as well as expectations regarding the utilization of personal protective equipment (PPE) and other measures to decrease the risk of exposure.