Foodservice Settings Research Articles

Training of food handlers on handwashing using a virtual reality environment is more effective than traditional training approaches in a randomized trial

ABSTRACT Handwashing is an essential prevention step in foodservice, This randomized comparative study assessed the effectiveness of three training methods -virtual reality (VR), Glo-Germ (GT), and traditional face-to-face training (CT)- in improving handwashing practices among foodservice workers (n = 129). Training focused on the World Health Organization’s 11-step handwashing process. Handwashing in the workplace was observed, in a pre- and post-test design, with microbiological swabs also taken. There was an increase in time spent on handwashing that was noticeable across all three groups (p < 0.05) with the highest in the VR group (50.16 ± 26.04 sec.). The mean number of handwashing steps increased across all groups, and the highest increase (8.91 ± 1.49 steps) was observed in the VR group. A statistically significant difference was observed among all groups regarding correctly performed steps, and the VR group showed the highest number of steps (p < 0.01). These findings suggest that VR-based training has value for enhancing hand hygiene practices in foodservice settings.

MedDietMenus4Campus: Integrating Views from Nutrition, Marketing and Psychology to Improve Diets

Abstract Food service is an important setting for public health interventions, educating consumers and modulating behaviours through the meals provided. Social Marketing is one of the strategies designed to promote behaviour change, which contributions to health and well-being of consumers are widely recognised. This project aims to identify the compliance of food service menus with the Mediterranean Diet (MD) in public high education institutes (HEI) canteens, pinpointing opportunities to intervene, namely: 1) promoting changes in the food offer addressing proximity to the MD, creating, and offering plant-based meals, with seasonable and local food products and 2) developing tailored social marketing strategies to engage stakeholders to encourage healthier and sustainable food habits. It gathers a team comprised of nutrition experts on public health and food service, food technologists, gastronomy experts, psychologists, and marketers. To achieve the objectives researchers will: 1) develop an index to evaluate compliance of menus with the MD; 2) define priority stakeholders and define a methodology for engagement; 3) evaluate perceptions, barriers and facilitators; 4) develop a meal plan framework; 5) develop a new food concept “student bag” (meal on the go) and test it for industry scale-up; 6) use previous diagnosis to develop social marketing strategies directed to stakeholders and consumers to achieve food behaviour change and 7) measure the impacts of the implemented strategies. This research intends to create and implement a new healthy and sustainable food service concept, expecting to define the standpoint to inspire other food service settings to achieve an effective and sustainable food offer change and positively influence food service consumers’ food pattern towards Mediterranean recommendations, while addressing the Sustainable Development Goals (3 - good health and 12 - responsible consumption and production; 17 - partnerships for the goals).

Do reusables pose greater infectious risks than disposables for consumer goods? A systematic literature review

Increased concern over climate change and the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus resulted in a clash of political directives around reusable and disposable food serviceware. Decreasing single-use items will likely reduce consumption and environmental emissions; however, improper cleaning of reusable items could result in greater risks of disease transmission. We sought to assess the risks of reusable and disposable food serviceware and document disinfection protocols by conducting a systematic literature review of articles that assessed materials or products that could be fomites to specific food-borne pathogens. After initial screening, the study team extracted data from 122 articles. The most common pathogens studied were E. coli (25% of included studies), general bacteria (24%), and Norovirus (16%). Thirteen studies (8%) focused on SARS-CoV-2. A majority of studies analyzed plastics (27%), stainless steel (22%), or porous surfaces such as paper and cardboard (12%). Forty seven of the studies (35%) were conducted in a food service setting, and 40 studies (30%) tested disinfection techniques. Despite a large body of related literature, there is very little evidence suggesting that either reusable or disposable food serviceware is safer for minimizing infectious risks. Pathogens can survive on various fomites, though greater surface porosity and higher humidity levels increase viability of most pathogens. There appear to be no major differences in pathogen viability on various fomites. There is a paucity of research that can specifically aid in developing policy or guidelines for appropriate use of reusable food serviceware. Though given recent studies on SARS-CoV-2, banning reusable bags and food serviceware is an inappropriate response to this particular pathogen, which is rarely spread through surface contact. Further research is needed that explicitly studies pathogen viability, transmission risks, and appropriate disinfection techniques for disposable and reusable food serviceware in order to devise effective sustainability policies.

Assessing the Validity of Front-of-Pack Nutrition Labels for Evaluating the Healthiness of Mediterranean Food Choices: A Global Comparison.

In response to growing public health concerns, governments worldwide have implemented various nutrition labelling schemes to promote healthier eating habits. This study aimed to assess the consistency and effectiveness of these labels in an out-of-home context, specifically focusing on restaurant, hospitality, and institutional food service settings. In total, 178 different dishes from Spain were analysed using labels from the Mazocco method, the UK's traffic light system, the Health Star Rating (Australia), Nutri-Score (France), multiple traffic lights (Ecuador), and warning labels (Chile and Uruguay). The results demonstrated a generally low level of agreement among these labels (K < 0.40), indicating notable variability and a lack of consensus, which could hinder consumers' ability to make informed food choices in out-of-home settings. Nutri-Score classified the highest number of dishes as unhealthy (38%). This study underscores the need for an easy-to-understand labelling system tailored to each country's culinary and socio-cultural contexts to improve consumer decision-making in various dining environments. Future research should focus on developing and testing qualitative methods to more accurately gauge the nutritional quality of cooked dishes in diverse out-of-home settings, thereby enhancing public health outcomes. By addressing the specific needs of the home, restaurants, hospitality, and institutional food services, tailored labelling schemes could significantly improve consumers' ability to make healthier food choices.

Antecedents and consequences of franchisee interaction in a food service setting

Antecedents and consequences of franchisee interaction in a food service setting

Mapping pre-consumer food waste in quick service restaurants on a university campus: Two Australian case studies

Mapping and monitoring the process of pre-consumer food waste generation in the foodservice sector is needed to fully understand food waste, identify hotspots, and strengthen the evidence-base in this sector of the food supply chain. The purpose of this study was to validate a tool for separation and quantifying pre-consumer food waste in a quick service restaurant (QSR) setting, and to map the food waste generation process using statistical process control methodology. This included consideration of food waste categories and edible versus inedible waste. The study also explored key foodservice and menu practices which may impact food waste production. Food waste audits were undertaken in two food outlets (FOs) in an Australian university campus over a two-week operating period for each outlet using a direct weighing method. Foodservice operation and menu practices occurring in the outlets during the audit period were also recorded. These observations validated practices reported by the owner-manager of the FOs during interviews. The amount of waste collected separately from each outlet was analysed using statistical process control methodology. While each FO was treated as a separate case study, the same methodology was applied to each, allowing some comparison between outlets. Despite differences in foodservice style and menus, the average daily pre-consumer food waste produced from all food waste categories was approximately 25 kg for both outlets, with about 60% from inedible waste. This equated to approximately 5.5–6.1 kg of pre-consumer waste per full-time-equivalent employee (FTE) per day. Used coffee grounds was the largest single contributor of total pre-consumer waste for both FOs. Both FOs demonstrated compliance with Australian best practice in foodservice operations and menu design. The study concludes that the method used to separate pre-consumer food waste into different categories and quantify this waste was a practical tool for these QSRs and allowed researchers to validate both the separation process and the amount of waste collected. Analysis of data using statistical process control allowed differentiation between common and special cause of variations. These findings can help inform processes which generate food waste in these types of foodservice settings and assist with the development of food waste reduction initiatives.

Limiting red meat availability in a university food service setting reduces food-related greenhouse gas emissions by one-third

Limiting red meat availability in a university food service setting reduces food-related greenhouse gas emissions by one-third

Dietitians as change agents for promoting healthy and sustainable food systems

Dietitians as change agents for promoting healthy and sustainable food systems

Campus food service users' support for nudge strategies for fruit and vegetable-rich items: findings from a large Canadian national sample.

Although customer support is critical to the wider uptake of nudging strategies to promote fruits and vegetables (FV) in institutional food service (FS) settings, empirical research is sparse and typically based on small convenience samples. An online survey was conducted to assess support, perceived effectiveness and intrusiveness of nine nudge types drawn from Münscher et al.'s Taxonomy of Choice Architecture. We focused on the setting of campus FSs across Canada. A national sample of post-secondary students regularly using campus FSs was used (N 1057). Support for changing the range of options (B3) was the highest, closely followed by changing option-related effort (B2) and changing option-related consequences (B4). Facilitating commitment (C2), changing default (B1) and providing a social reference point (A3) received lowest support. Furthermore, we extracted three clusters of respondents based on perceived effectiveness and intrusiveness of nudge types. Characterised by a relatively low level of perceived effectiveness and moderately high level of intrusiveness, Cluster 1 (61⋅7 % of the sample) reported the lowest support for nudges. Cluster 2 (26⋅6 %), characterised by intermediate effectiveness and low intrusiveness of nudging, reported a high level of support for nudges. Lastly, Cluster 3 (11⋅7 %), characterised by high perceived effectiveness of as well as high perceived intrusiveness, reported the highest level of support for nudges. Findings confirm overall support for FV nudging, with significant differences across nudge types. Differences in customers' acceptance and perception across nudge types offer campus FS operators initial priors in selecting nudges to promote FV.

Nudging greater vegetable intake and less food waste: A field experiment

Diet change and food waste reduction are key levers for meeting climate change goals, but little is known about pursuing policies to shape both behaviors simultaneously. In a between-subjects field experiment, we randomly assign distinct cognitive and behavioral nudges focused on increasing vegetable consumption and decreasing food waste among foodservice consumers. The individual and joint efficacy of nudges in changing the intake and waste of each meal component is measured by scale. We find increases in both vegetable consumption (effect size = 0.90) and wasted food (effect size = 0.96) among participants randomly assigned to meals with 50 % (vs 25 %) of the plate covered with vegetables (behavioral nudge). Information about the social costs of food waste (cognitive nudge) mitigated the increase in waste induced by the 50 % vegetable nudge by encouraging greater vegetable intake. However, these mitigation effects disappeared if participants also received information (a second cognitive nudge) recommending increased vegetable consumption to improve health. Displaying meals on a larger plate (behavioral nudge) significantly increased selection of larger portion sizes, which led to greater vegetable intake but no change in waste. These results highlight the need to understand interactions between nudges when pursuing policies to accomplish multiple behavioral changes in foodservice settings.

How to start a Focus Group: Using cartoons in adult focus groups to discuss consumers feedback expectations in food service settings

This article tests a novel method for starting focus groups quickly while ensuring that respondents understand the topic of interest for the study.To kick start the focus groups, a cartoon style illustration was developed. The cartoons depicted various food service experience from start to finish. Respondents first task was to indicate when it was natural for them to give feedback on the food service experience.The results show that the cartoons allowed respondents to quickly understand the topic, which in turn gave them confidence to contribute with relevant information from the start. In addition, respondents used the framework of the illustrations to keep the discussion focused on the topic throughout.We generally find that it is getting harder to find people who are willing to commit to 2 h focus groups after work. For us to find participants who are willing to take part, we are having to be much more time conscious, this method allows for shorter groups without losing valuable information.The method has a potential when it comes to testing food products as well as in the development of dishes for gastronomic experiences. It may also be a good tool to use in sensory focus groups.The use of comics to start off the focus group worked well in the context of a non-sensitive topic, in this case food service experiences. Further research could explore using this method for more sensitive topics.

Effectiveness of Strategies to Decrease Animal-Sourced Protein and/or Increase Plant-Sourced Protein in Foodservice Settings: A Systematic Literature Review

BackgroundEffective population-based strategies are required to move toward healthy sustainable diets that replace a proportion of animal- with plant-based protein. Food service can support this using a variety of strategies across the food supply chain. ObjectiveThis systematic review aimed to evaluate the effectiveness of strategies to decrease animal protein and/or increase plant protein in foodservice settings on uptake, satisfaction, financial, environmental, and dietary intake outcomes. MethodsSeven databases were searched in November 2020 with no restriction on study dates to identify peer-reviewed study designs conducted in commercial and institutional food services using any strategy to decrease beef, lamb, pork, poultry, eggs, fish, or seafood and/or increase legumes/pulses and legume/pulse-based meat substitutes or nuts and reported this review’s primary outcome, uptake by consumers, either quantitatively or qualitatively. Secondary outcomes were satisfaction and financial, environmental, and dietary intake outcomes. Titles/abstracts then full texts were screened independently by 2 authors. The Mixed Methods Appraisal Tool was used for quality appraisal. Results were described using a narrative synthesis by strategy type. The protocol is registered with PROSPERO (CRD42021235015). ResultsFrom 20,002 records identified, 38 studies met eligibility criteria, of which 16% were high quality. Strategies included forced restriction (n = 4), menu redesign (n = 6), recipe redesign (n = 6), service redesign (n = 4), menu labeling (n = 7), prompt at point of sale (n = 7), and multipronged strategies (n = 4). Menu labeling, prompting at the point of sale, and redesigning menus, recipes, and service increased uptake of target foods in most studies with the largest consistent changes in menu redesign. Few studies explored secondary outcomes. Recipe redesign, prompting at the point of sale, and menu labeling strategies that measured satisfaction found a positive or neutral effect. ConclusionsThe most promising strategies are likely in menu redesign, followed by menu labeling and service redesign. Satisfaction appears to not be negatively impacted by recipe redesign, prompting at the point of sale and menu labeling. More studies are needed to evaluate financial, environmental, and dietary outcomes.

Implementation of an organizational intervention to improve low-wage food service workers\u2019 safety, health and wellbeing: findings from the Workplace Organizational Health Study

BackgroundMany organizational interventions aim to improve working conditions to promote and protect worker safety, health, and well-being. The Workplace Organizational Health Study used process evaluation to examine factors influencing implementation of an organizational intervention. This paper examines the extent to which the intervention was implemented as planned, the dose of intervention implemented, and ways the organizational context hindered or facilitated the implementation of the intervention.MethodsThis proof-of-concept trial was conducted with a large, multinational company that provides food service through contractual arrangements with corporate clients. The 13-month intervention was launched in five intervention sites in October 2018. We report findings on intervention implementation based on process tracking and qualitative data. Qualitative data from 25 post-intervention interviews and 89 process tracking documents were coded and thematically analyzed.ResultsOver the 13-month intervention, research team representatives met with site managers monthly to provide consultation and technical assistance on safety and ergonomics, work intensity, and job enrichment. Approximately two-thirds of the planned in-person or phone contacts occurred. We tailored the intervention to each site as we learned more about context, work demands, and relationships. The research team additionally met regularly with senior leadership and district managers, who provided corporate resources and guidance. By assessing the context of the food service setting in which the intervention was situated, we explored factors hindering and facilitating the implementation of the intervention. The financial pressures, competing priorities and the fast-paced work environment placed constraints on site managers’ availability and limited the full implementation of the intervention.ConclusionsDespite strong support from corporate senior leadership, we encountered barriers in the implementation of the planned intervention at the worksite and district levels. These included financial demands that drove work intensity; turnover of site and district managers disrupting continuity in the implementation of the intervention; and staffing constraints that further increased the work load and pace. Findings underscore the need for ongoing commitment and support from both the parent employer and the host client.Trial registrationThis study was retrospectively registered with the Clinical Trials. Gov Protocol and Results System on June 2, 2021 with assigned registration number NCT04913168.

A systematic review of food waste audit methods in hospital foodservices: development of a consensus pathway food waste audit tool.

To understand, monitor and compare the scope of food waste in hospital foodservices, it is essential to measure food waste using a standardised method. The aims of this systematic review were to: (i) describe and critique the methodological features of waste audits used in hospital foodservice settings that measure aggregate food and food-related waste and (ii) develop a consensus tool for conducting a food waste audit in a hospital foodservice setting. Seven electronic databases were searched for peer reviewed literature, and 17 Google Advanced searches located grey literature that described food waste audit methods previously used or developed for hospital foodservices. Study selection and quality assessment occurred in duplicate. Data describing the audit method, its feasibility, and strengths and limitations were extracted and synthesised to develop a consensus tool. Eight peer reviewed and nine grey literature documents describing a variety of food waste audit methods were found. The most common practices were 2-week data collection (n=5), foodservice staff collecting data (n=6), measuring food waste only (n=11), measuring food waste at main meals (n=5) and using electronic scales to measure waste (n=12). A consensus tool was developed that proposes a method for preparing, conducting and analysing data from a food waste audit. This review used published evidence to develop the first ever food waste audit consensus tool for hospital foodservices to use and measure food and food-related waste. Future research is needed to apply and test this tool in practice.

P77 Evaluation of “Deciding on a Nontraditional Career Path: Networking Nutrition Students with Professionals”

<h3>Objective</h3> To evaluate the effectiveness of a seminar featuring a variety of nontraditional career opportunities available for nutrition majors. <h3>Use of Theory or Research</h3> Social Learning Theory suggests that individuals learn from observing others (models). Alumni can be models for students. <h3>Target Audience</h3> Undergraduate and graduate nutrition majors. <h3>Program Description</h3> Since many students are only exposed to traditional careers in hospital, community and food service settings as part of curriculum, nutrition faculty sought to expand students' perceptions of the nutrition field by highlighting nontraditional careers. Four alumni representing nontraditional careers in government, higher education, international work and business/website design were chosen to speak at a virtual panel. Each alumnus described their education/training, career path, lessons learned and words of wisdom. Prior to the program, a pre-event slideshow featured an additional 27 nutrition alumni in nontraditional careers including public relations, food policy, media, medicine, management and more. <h3>Evaluation Methods</h3> An IRB-approved survey was sent to participants via email immediately following the seminar. Before distribution, face validity and content were confirmed. <h3>Results</h3> Of the 203 seminar participants, 84% (n = 171) were students and 51% (n = 88) of the students completed the post-seminar survey. Of those responding, 87% (n = 77) were female, 78% (n = 69) were White and 91% (n = 80) were in a nutrition major. Of the 80 nutrition majors who finished the survey, 99% (n = 79) indicated they learned about new careers through the seminar and 96% (n = 77) stated they learned of resources to pursue a nontraditional career. Almost all, 95% (n = 76) responded their knowledge regarding the benefits of networking improved and 96% (n = 77) believed their knowledge of the role of nutrition professionals in nontraditional careers increased. <h3>Conclusion</h3> A seminar featuring alumni can be an effective way for faculty to expose students to nontraditional career options, the importance of networking and resources to navigate their future careers.

The Effectiveness of Interventions Delivered Using Digital Food Environments to Encourage Healthy Food Choices: A Systematic Review and Meta-Analysis.

Digital food environments are now commonplace across many food service and retail settings, influencing how the population orders and accesses foods. As such, digital food environments represent a novel platform to deliver strategies to improve public health nutrition. The purpose of this review was to explore the impact of dietary interventions embedded within online food ordering systems, on user selection and purchase of healthier foods and beverages. A systematic search of eight electronic databases and grey literature sources was conducted up to October 2020. Eligible studies were randomized controlled trials and controlled trials, designed to encourage the selection and purchase of healthier products and/or discourage the selection and purchase of less-healthy products using strategies delivered via real-world online food ordering systems. A total of 9441 articles underwent title and abstract screening, 140 full-text articles were assessed for eligibility, and 11 articles were included in the review. Meta-analysis of seven studies indicated that interventions delivered via online food ordering systems are effective in reducing the energy content of online food purchases (standardized mean difference (SMD): −0.34, p = 0.01). Meta-analyses including three studies each suggest that these interventions may also be effective in reducing the fat (SMD: −0.83, p = 0.04), saturated fat (SMD: −0.7, p = 0.008) and sodium content (SMD: −0.43, p = 0.01) of online food purchases. Given the ongoing growth in the use of online food ordering systems, future research to determine how we can best utilize these systems to support public health nutrition is warranted.

Consumer preferences for the use of an innovative digital menu solution in public food service settings in four European countries

Consumer preferences for the use of an innovative menu solution in public canteen services in the UK, Greece, France, and Denmark were investigated. Participants from both control and test groups were first introduced to the FoodSMART app through a video clip as well as verbal explanations. The control group filled a questionnaire evaluating their preferences for the use of a technical menu solution in public food services straight away, whereas the test group had the opportunity to experience the app adapted to a daily canteen menu in real-time before completing the questionnaire. The data collected was examined in both country-specific and collected manners. Participants in all four countries valued the canteen food quality the most, especially food hygiene, sustainability, safety, and freshness. Their preferences for other features such as app functions, information provision, and ethical issues varied in different countries. The knowledge gained from this study provides valuable lessons for the future design of a food-quality-focused digital menu solution in canteen services adapted to the specific country and population context to promote informed consumer food choices.

BOARDING SCHOOL HEALTHY EATING POLICY IMPLEMENTATION OPINIONS OF SCHOOL TEACHERS: A QUALITATIVE STUDY

The collaboration between the Malaysian education and health ministry introduced a school healthy eating policy, where there was a requirement for food and drinks provided within the boarding schools to conform to standards based on macronutrients and energy content. The aim of the present study was to explore the experience of implementing a school healthy eating policy to inform the compliance of such policies being implemented into practices in the boarding school foodservice setting. A qualitative approach was used, with in-depth interviews exploring informants' involvement in, experiences of, factors affecting, and perceived outcomes of policy implementation. Interviews were conducted with fifteen teachers involves in administering the implementation of the school's healthy eating policy. Results were analyzed using a thematic analysis approach. Perceived challenges to implementation of school healthy eating policy included: students’ eating preferences, students’ eating style, unchanged menu cycle selections, and unhealthy choices of canteen menu. Teachers’ recommendations for successful implementation of policy to be well-practiced in real situations included: enhancement in nutritional education, revise menu, create a conducive healthy eating environment and limit the hours to the canteen. Participants identified that successful policy implementation hinged on the provision of resources and support by the government to the school stakeholders. Implementing a healthy eating policy within the boarding school setting benefits from dedicated resourcing, investment in relationship building with various stakeholders, and introducing changes gradually with a long-term approach.

Dining at gas stations: an analysis of nonconventional fast-food outlets from a consumer behavior perspective

PurposeThe objective of this paper is to investigate the effect of the dining experience elements at gas stations foodservice outlets: (1) food quality, (2) service quality, (3) convenience and (4) atmospherics on customers' overall satisfaction and behavioral intention. This study also examines the mediating effect of overall satisfaction on dining experience elements and behavioral intention.Design/methodology/approachThis paper applies a quantitative approach, using partial least square-structural equation modeling for analysis. Survey data were collected online from 231 participants in the United States.FindingsConvenience and food quality are strong predictors of gas station food purchasing overall satisfaction and behavioral intention. Meanwhile, service quality and atmospherics were not statistically significant.Research limitations/implicationsThis study's survey was conducted online. Participants reflected on their dining experience at gas station dining outlets in the prior week.Practical implicationsThis study contributes to the existing foodservice literature by exploring dining at gas stations. It also provides a new insight into the importance of convenience in influencing overall satisfaction and behavior intention in a gas station foodservice setting.Social implicationsThis study helps with the understanding of consumer behavior and expectations of a fast-food setting. This study helps with enhancing convenience in order to improve the customers' experience and reduce their daily stress relating to wait time for purchasing fast-food meals.Originality/valueThis is the first study to examine consumer experience at a gas station food service setting.

Scientific Evidence Supports the Use of Alcohol-Based Hand Sanitizers as an Effective Alternative to Hand Washing in Retail Food and Food Service Settings When Heavy Soiling Is Not Present on Hands

Suboptimal food worker health and hygiene has been a common contributing factor in foodborne disease outbreaks for many years. Despite clear U.S. Food and Drug Administration (FDA) Model Food Code recommendations for hand washing and glove use, food worker compliance with hand washing recommendations has remained poor for >20 years. Food workers' compliance with recommended hand washing guidelines is adversely impacted by a number of barriers, including complaints of time pressure, inadequate number and/or location of hand washing sinks and hand washing supplies, lack of food knowledge and training regarding hand washing, the belief that wearing gloves obviates the need for hand washing, insufficient management commitment, and adverse skin effects caused by frequent hand washing. Although many of the issues related to poor hand washing practices in food service facilities are the same as those in health care settings, a new approach to health care hand hygiene was deemed necessary >15 years ago due to persistently low compliance rates among health care personnel. Evidence-based hand hygiene guidelines for health care settings were published by both the Centers for Disease Control and Prevention in 2002 and by the World Health Organization in 2009. Despite similar low hand washing compliance rates among retail food establishment workers, no changes in the Food Code guidelines for hand washing have been made since 2001. In direct contrast to health care settings, where frequent use of alcohol-based hand sanitizers (ABHSs) in lieu of hand washing has improved hand hygiene compliance rates and reduced infections, the Food Code continues to permit the use of ABHSs only after hands have been washed with soap and water. This article provides clear evidence to support modifying the FDA Model Food Code to allow the use of ABHSs as an acceptable alternative to hand washing in situations where heavy soiling is not present. Emphasis on the importance of hand washing when hands are heavily soiled and appropriate use of gloves is still indicated.